Neuromuscular Dentistry
Friday, July 8, 2011
Dental Continuing Education
To discover the latest and most up to date information on GNEUROMUSCULAR Dentistry and the latest in Dental Continuing Education CLICK:
Neuromuscular Dentistry
Neuromuscular Dentistry
Sunday, September 26, 2010
Fox Occlusal Plane Angulation Questioned
by Clayton A. Chan, D.D.S., M.I.C.C.M.O.
Lateral Ceph taken after final restorative was completed at optimized mandibular position. Note occlusal plane and normalized level head position unposed at time ICAT image (raw) was taken. Occlusal plane in the mouth is the same occlusal plane angle as articulated cast mounting above.
If the occlusal plane is flatter relative to horizontal due to slight upward head tilt what kind of occiput to C1 axis relationship would occur? How would that effect head movements?
I had a wonderful conversation with a doctor who had serious interest as to my method of establishing the occlusal plane using the Fox plane. He was analyzing a case I posted on our www.occlusionconnections.com/Blog in the article/blog I posted titled, "What Angle is the Occlusal Plane Relative to Horizon". He couldn’t quite envision the root angulation and position of my articulated mounted case.
So I decided to post the finished ceph to show the actual root position of the "actual" case. He was worried that I had atlas/C1 restrictions in my finished case. The patient has excellent range of motion (side bending, flexion/extension and side bending). See the actual radiographs confirm that the patient has normalized occipital-C1 space (no restricted). This Occiput to C-1 is well within normalized limits with an unposed angled occlusal plane as nature intended. Remember form follows function. Also note the root angulations, occlusal plane orientation and head postion as they relate to a level horizontal.
One cannot look at models and assume roots are out of line as they relate to an unposed horizontal level head position. Patient is symptom free with no headaches, no neck aches and no TMD pain problems as previous. Numerous cases have proven this.
Clinicians need to start get use to seeing what a normal occlusal plane looks like relative to a normalized head posture at horizontal level!
I know many can’t comprehend the angle of this occlusal plane mounting, since flat has been considered normal among some occlusal teachings and philosophies…..A new perspective and understanding of wha is "Physologic" is needed!
Lateral Ceph taken after final restorative was completed at optimized mandibular position. Note occlusal plane and normalized level head position unposed at time ICAT image (raw) was taken. Occlusal plane in the mouth is the same occlusal plane angle as articulated cast mounting above.
I know I have a reputation of not knowing anything about Occlusal Planes…what can I say….I just don’t want to reproduce pathology if I have an opportunity to bring the human body toward homeostasis - health!
To discover the latest and most up to date information on GNEUROMUSCULAR Dentistry and the latest in Dental Continuing Education CLICK:
Tuesday, July 20, 2010
Expanding Occlusion Connections-Blog
We're excited to launch the new blog under the Occlusion Connections domain. To read more posts, CLICK on the NEW Occlusion Connections Blog. Keep up to date with Dr. Clayton Chan's teachings.
Tuesday, June 1, 2010
HIP (Hamular Notch Incisive Papilla) MOUNTING: IMPORTANT POINTS TO RECONSIDER
By Clayton A. Chan, DDS
The mandibular and cervical head mechanism PROPRIOCEPTIVELY responds to subtle occluding contacts (distal facing or mesial facing) of the teeth. The occlusal plane and its orientation to the cervical neck and base of the skull also proprioceptively responds to each individual occlusal form and incline plane in total as well as how the occlusal plane is designed in an attempt to seek a balance of forces between the teeth, joints and musculature of the temporalis, masseters and even more so with the suprahyoid/digastricus and the semispinius cervicalis, capitus, trapezius, scalene, levator scapula muscles. Teeth and the occlusal plane do not function independently from the supporting musculature.
1) They fail to recognize that when asked to exccentuate the curve of Spee with the HIP mount that they are just excentuating the negative proprioceptive responses of the mandible to function posteriorly off the neuromuscular trajectory. As the maxillary posterior first and second molar occlusal tables begin to tip posteriorly they begin to act as distalizing forces to the opposing mesially facing lower occlusal tables of the opposing dentition.
2) When building the case to HIP, the lab technicians all admit that the upper posterior crowns are shorter with longer looking lower posterior crowns. This is not just against golden proproptional crown to root ratio principles, but further contributes to abnormal vector of musculo-occlusal forces (abnormal form leads to abnormal function) since the occlusal plane tends to be flatter and does effectively support an isotonic perpendicular closure path of the mandible to support a normalized head posture, thus…
3) A relapse of the closing path will naturally occur over time posterior of an optimized NM trajectory with an accompanying upward head tilt tendency further confirming a level occlusal plane with accompanying relapse of musculo-occlusal signs and symptoms (UNRESOLVED)!
The laboratory technicians all know the truth about the mounting problems and occlusal plane design problems they have with HIP! They admit that it produces odd crown length ratios for years. But may not realize the impact it has on the patients subtle proprioceptive responses to the musculature of the mandible and head and neck posture.
Since they fail to openly admit this to doctors they knowingly and or unknowingly contribute to confusion to the learning dentist, thus confusion in the ranks of our dental profession.
Every doctor has choices and will chose what is best for themselves as well as for their patients. I can only share what I am aware of. Perhaps it may make a difference to some.
Time is a real tester of concepts and principles. It is unrelenting and the TRUTH WILL PREVAIL. You don’t have to take my word for it. Your patients will let you know and the evidence will become obvious in time. It’s a matter of one’s awareness.
For further reading see: Fox Plane and HIP Mounting Considerations Blog
The mandibular and cervical head mechanism PROPRIOCEPTIVELY responds to subtle occluding contacts (distal facing or mesial facing) of the teeth. The occlusal plane and its orientation to the cervical neck and base of the skull also proprioceptively responds to each individual occlusal form and incline plane in total as well as how the occlusal plane is designed in an attempt to seek a balance of forces between the teeth, joints and musculature of the temporalis, masseters and even more so with the suprahyoid/digastricus and the semispinius cervicalis, capitus, trapezius, scalene, levator scapula muscles. Teeth and the occlusal plane do not function independently from the supporting musculature.
Classic HIP mount with fence post and incive pin.
Many technicians still don’t get it, thinking that it doesn’t matter if the doctor Rx/presribes a case for HIP or Fox plane mounting, because they believe they are artists and can customize any occlusal plane to any orientation of the maxillary case with a curve of Spee and make it look esthetic. That may seemly be true superficially, but they fail to realize the clinical outcomes dentist may or may not be aware of. Here are just a few important factors:
2) When building the case to HIP, the lab technicians all admit that the upper posterior crowns are shorter with longer looking lower posterior crowns. This is not just against golden proproptional crown to root ratio principles, but further contributes to abnormal vector of musculo-occlusal forces (abnormal form leads to abnormal function) since the occlusal plane tends to be flatter and does effectively support an isotonic perpendicular closure path of the mandible to support a normalized head posture, thus…
3) A relapse of the closing path will naturally occur over time posterior of an optimized NM trajectory with an accompanying upward head tilt tendency further confirming a level occlusal plane with accompanying relapse of musculo-occlusal signs and symptoms (UNRESOLVED)!
The laboratory technicians all know the truth about the mounting problems and occlusal plane design problems they have with HIP! They admit that it produces odd crown length ratios for years. But may not realize the impact it has on the patients subtle proprioceptive responses to the musculature of the mandible and head and neck posture.
Since they fail to openly admit this to doctors they knowingly and or unknowingly contribute to confusion to the learning dentist, thus confusion in the ranks of our dental profession.
Every doctor has choices and will chose what is best for themselves as well as for their patients. I can only share what I am aware of. Perhaps it may make a difference to some.
Time is a real tester of concepts and principles. It is unrelenting and the TRUTH WILL PREVAIL. You don’t have to take my word for it. Your patients will let you know and the evidence will become obvious in time. It’s a matter of one’s awareness.
For further reading see: Fox Plane and HIP Mounting Considerations Blog
Tuesday, May 11, 2010
Divine Proportions (Golden Proportions)
Phi is in Art, Nature and Science. It is comprised of null and 1. The Fibonacci sequence, 0, 1, 1, 2, 3, 5, 8, 13….are intrinsically related to the Divine Proportions (1.6.1803…). The divine proportions of a rectangle is 5:8 was found to be the average ratio that was close to the φ and was preferred by most people in regards to its proportions.
Phi simply describes the relationship in perfect proportions of the whole to its parts. It is a relationship so perfect that its parts are to each other as the whole is to its larger part. The Logarithmic Spiral - Golden Proportions = Divine Proportions
The POWER OF PHI creates harmony and a unique capacity to unite different parts of a whole so that each preserves its own identity, yet blends each into a greater pattern of a single whole. My desire is that Occlusion Connections be a living and dynamic entity to assist the greater pattern of a single whole.
We can only be our best when we align ourselves with the Greater null and 1.
The regenerative principle we have all inherited within our DNA allows us to reflect natures intended design and keeps us on trajectory and at physiologic rest within.
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Wednesday, May 5, 2010
Skull Orientation, Fox Plane vs. HIP Occlusal Plane Relationships
by Clayton A. Chan, DDS
When considering the “HORIZONTAL GAZE” for each of these skulls one will note that picture “A” skull could have the head tipped slightly more downward to improve a level eye gaze which would increase the occlusal plane angle relative to the horizontal table approaching what I would consider a better more anatomical relationship.
The pictures of the 2 skulls with both physiologic and pathologic head postures will go a long way to clarify the issues of the relevance of the Optimized use of the Fox Plane vs. the HIP mount.
Seeing the bigger picture and correlating these key principles to earths gravitational forces and cervical muscular balance works best and compliments the clinician's cosmetic treatment when a clear and balanced understanding of these foundational occlusal plane concepts are presented in an unbiased manner.
We cover the clinical and laboratory aspects more extensively in our Level 6 Occlusion Connections training. I hope many of you would consider coming to our OC courses to learn "why and what I do" to help my esthetic/TMD cases. It is impossible to convey all these great concepts in just a short posting.
When considering the “HORIZONTAL GAZE” for each of these skulls one will note that picture “A” skull could have the head tipped slightly more downward to improve a level eye gaze which would increase the occlusal plane angle relative to the horizontal table approaching what I would consider a better more anatomical relationship.
Seeing the bigger picture and correlating these key principles to earths gravitational forces and cervical muscular balance works best and compliments the clinician's cosmetic treatment when a clear and balanced understanding of these foundational occlusal plane concepts are presented in an unbiased manner.
We cover the clinical and laboratory aspects more extensively in our Level 6 Occlusion Connections training. I hope many of you would consider coming to our OC courses to learn "why and what I do" to help my esthetic/TMD cases. It is impossible to convey all these great concepts in just a short posting.
To discover the latest and most up to date information on GNEUROMUSCULAR Dentistry and the latest in Dental Continuing Education CLICK:
Tuesday, April 20, 2010
Fox Plane and HIP Plane Mounting Considerations
by Clayton A. Chan, DDS
The leveling of the maxilla, the managing of the maxilla relative to a proper oriented head and cervical neck, and the concern of a proper occlusal plane are steps toward idealizing the finishing of the restorative case in a phase II treatment. Leveling of the maxillary plane relates to both function and esthetics.
Red dots = HIP reference line. Depending on how the clinician and technician chooses to mount the maxillary cast (classic HIP with fence post and Incisive pin (level) or Modified Fox Plane (angled)) will affect how much tooth reduction is necessary to accommodate the same curve of Spee.
Managing the GAP on an optimized trajectory regardless of cants and roller coaster occlusal planes either on the upper or lower arches using an orthotic based on a HIP or Fox plane technique is of little significance in phase I treatment. All that is basically required to assist in bringing normalacy to the dysfunctional head and neck system is the agreed upon physiologic GAP that is established on a proper trajectory. A lower orthotic placed between two distorted and skewed arches certainly fills in the missing components of occlusion to help relate the upper and lower arches together and with good anatomical occlusion has shown to help in maintaining the neuromuscular myo-trajectory, improving head levelness (from pathologic upward tilt to a physiologic leveled head tilt).
Many clinicians have observed these head re-orienting responses with their patients regardless of Fox Plane or HIP techniques, because the Fox and or HIP does not come into play during the Phase I stabilization phase. It becomes a factor when moving into the Phase II level of esthetic restorative finishing of the case as it relates to crown root ratios and smile lines. If the lab “truthfully and honestly” managed and maintained the classic HIP mounting position from start to finish of the case, the dentist will routinely see shorter upper posterior crowns and longer lower posterior crowns. This is not anatomically correct. This will often cause the labs to cheat the upper crown fabrication, by reorienting the maxillary cast, since the upper posterior preps will not have sufficient occlusal reduction (based on this mount) especially in the second molar regions. Because of this lack of occlusal prep height reduction the lab is forced to remount and alter the cast from the original HIP mount to accommodate the lack of occlusal height reduction. (This is what the labs don’t tell the dentist!) The lower crowns will show, routinely, a longer (higher) crown (crown root ratio) and does not reflect proper golden proportional relationships. We strive for golden proportioned anteriors (tooth width ratios and gingiva to gingiva relationships), yet the posterior uppers and posterior lowers are distorted in crown lengths ratios (a failure of the classic HIP concept!) and not evenly balanced in their upper to lower posterior crown lengths (another failure).
With the Fox plane technique the crown to root ratios in the upper and lower posterior regions are more proportional and reflect a better even distribution of crown to root ratios of both upper and lower posteriors (closer to golden proportions) due to a proper maxillary cast orientation due to a proper occlusal plane set up (see picture above).
Consider the same curve of Spee used in both situation. Different crown root ratios of upper and lower teeth will result depending on which method is used to mount the maxilla.
If you choose HIP, make sure you reduce the prep sufficiently so the lab doesn’t have to alter the maxillary mounting occlusally! Don’t be surprised if the lower posterior crowns look longer, the upper posterior crowns shorter and the upper first molar to second bicuspid region looks a bit more toothier.
If the HIP is the method of choice in Phase II restorative, make sure the lab doesn’t alter your mount during the finishing of the case. Over the years they all tend to cheat this step and don’t tell dentist that they altered the mount to accommodate the occlusal plane. The clinician can always confirm the HIP mount by telling the lab that you will be checking the maxillary prepped cast with the finalized porcelain crowns on the prep dies in place at the HIP mount referenced to the table before crowns delivery! Make sure they don’t change or alter the HIP mount if you chose to do so!
The dividing of the crown ratios between the upper and lowers (as seen in the diagram above) will vary depending on the maxillary cast orientation technique. Doctors and technicians have choices! We all need to understand these concepts thoroughly to make the proper choices for our patients.
For more information read Fox Plane Mount, Occlusal Plane
Neuromuscular Dentistry
The leveling of the maxilla, the managing of the maxilla relative to a proper oriented head and cervical neck, and the concern of a proper occlusal plane are steps toward idealizing the finishing of the restorative case in a phase II treatment. Leveling of the maxillary plane relates to both function and esthetics.
© 2009 Clayton A. Chan, DDS. All Rights Reserved.
Red dots = HIP reference line. Depending on how the clinician and technician chooses to mount the maxillary cast (classic HIP with fence post and Incisive pin (level) or Modified Fox Plane (angled)) will affect how much tooth reduction is necessary to accommodate the same curve of Spee.
Managing the GAP on an optimized trajectory regardless of cants and roller coaster occlusal planes either on the upper or lower arches using an orthotic based on a HIP or Fox plane technique is of little significance in phase I treatment. All that is basically required to assist in bringing normalacy to the dysfunctional head and neck system is the agreed upon physiologic GAP that is established on a proper trajectory. A lower orthotic placed between two distorted and skewed arches certainly fills in the missing components of occlusion to help relate the upper and lower arches together and with good anatomical occlusion has shown to help in maintaining the neuromuscular myo-trajectory, improving head levelness (from pathologic upward tilt to a physiologic leveled head tilt).
Many clinicians have observed these head re-orienting responses with their patients regardless of Fox Plane or HIP techniques, because the Fox and or HIP does not come into play during the Phase I stabilization phase. It becomes a factor when moving into the Phase II level of esthetic restorative finishing of the case as it relates to crown root ratios and smile lines. If the lab “truthfully and honestly” managed and maintained the classic HIP mounting position from start to finish of the case, the dentist will routinely see shorter upper posterior crowns and longer lower posterior crowns. This is not anatomically correct. This will often cause the labs to cheat the upper crown fabrication, by reorienting the maxillary cast, since the upper posterior preps will not have sufficient occlusal reduction (based on this mount) especially in the second molar regions. Because of this lack of occlusal prep height reduction the lab is forced to remount and alter the cast from the original HIP mount to accommodate the lack of occlusal height reduction. (This is what the labs don’t tell the dentist!) The lower crowns will show, routinely, a longer (higher) crown (crown root ratio) and does not reflect proper golden proportional relationships. We strive for golden proportioned anteriors (tooth width ratios and gingiva to gingiva relationships), yet the posterior uppers and posterior lowers are distorted in crown lengths ratios (a failure of the classic HIP concept!) and not evenly balanced in their upper to lower posterior crown lengths (another failure).
With the Fox plane technique the crown to root ratios in the upper and lower posterior regions are more proportional and reflect a better even distribution of crown to root ratios of both upper and lower posteriors (closer to golden proportions) due to a proper maxillary cast orientation due to a proper occlusal plane set up (see picture above).
Consider the same curve of Spee used in both situation. Different crown root ratios of upper and lower teeth will result depending on which method is used to mount the maxilla.
If you choose HIP, make sure you reduce the prep sufficiently so the lab doesn’t have to alter the maxillary mounting occlusally! Don’t be surprised if the lower posterior crowns look longer, the upper posterior crowns shorter and the upper first molar to second bicuspid region looks a bit more toothier.
If the HIP is the method of choice in Phase II restorative, make sure the lab doesn’t alter your mount during the finishing of the case. Over the years they all tend to cheat this step and don’t tell dentist that they altered the mount to accommodate the occlusal plane. The clinician can always confirm the HIP mount by telling the lab that you will be checking the maxillary prepped cast with the finalized porcelain crowns on the prep dies in place at the HIP mount referenced to the table before crowns delivery! Make sure they don’t change or alter the HIP mount if you chose to do so!
The dividing of the crown ratios between the upper and lowers (as seen in the diagram above) will vary depending on the maxillary cast orientation technique. Doctors and technicians have choices! We all need to understand these concepts thoroughly to make the proper choices for our patients.
For more information read Fox Plane Mount, Occlusal Plane
Neuromuscular Dentistry
Saturday, April 17, 2010
What Angle is the Occlusal Plane Relative to the Horizon?
by Clayton A. Chan, DDS, MICCMO
Nature has amazingly design the masticatory system in such a manner to meet the functional demands in a very physiologic manner. Our occlusal, cervical, airway and postural system has been pre-determined genetically to function optimally relative to earth’s gravitational forces. An angled or slanted occlusal plane is natures design when the head is properly supported by balanced muscles.
Because of gravity, the muscles of the structural system as well as the masticatory system allows the human being to function with the head in properly balanced manner to avoid strains and fatigue to the overall postural system. A person with a forward neck posture will accommodate to maintain the flow of oxygen into his/her body. This forward neck and head posture tendency is indicative of an upward head tilt with a resulting flatter occlusal plane. The upward head tilt contributes to TMD and accommodative pathologic issues (e.g., shoulder pain, neck pain, temporal headaches). This upward head tilt is the bodies way to accommodate due a mal-aligned bite which tries to defy natures gravitational vertical forces, resulting in a flatter more leveled occlusal plane which does not represent what nature originally intended in its design.
The SN (Sella-Nasion) Plane is noted in the dental literature as a standard objective leveling reference. What you see in the lateral ceph below is one of one of my patients, male age 47 who presented with former TMD cervical neck problems. Symptoms were resolved with an orthotic. The previous upward head tilt responded positively to the orthotic therapy allowing nature to correct it's head posture including and an improved occlusal plane. Based on this corrected and more normalized occlusal plane orientation as seen in the below lateral cephalogram I want to transfer this occlusal plane orientation to a flat analyzing table on my articulator to fabricate the upper and lower restorations for FM rehab esthetically and anatomically.
It seems to me that if SN plane is level, symptoms are gone, and patient’s head is now balanced. Recording this position is the most logical to communicate with the lab to mount the case.
My patient is very pleased, no neck cervical TMD problems. The bite is awesome. After gneuromuscular esthetic dentistry the patient no longer reports cervical pain, no shoulder pain, nor any TMD issues. The patient is stable and very happy. He is a public speaker and is on streaming internet video weekly and has a great pleasing smile. You can view him at: http://www.iclv.com/ or spiritflow.net on Sunday mornings and Sunday evenings.
Although, there is some dental literature that tries to indicate that the occlusal plane is parallel to certain boney references as the hamular notch and incisive foramen) they often do not realize that cervical bones from C1 to C7 are not perpendicular, thus misleads and confuses the reader as to which horizontal they are refering to. Dental literature both in the orthodontic, restorative and prosthetic arena clearly have reported on average an occlusal plane angle of 6-14 degrees when the horizontal gaze is parallel to earth's horizontal level. Any dental referencing technique that advocates an occlusal plane horizontal to earth's horizontal plane certainly is contributing dental failure and postural/occlusal instability.
Dentists have ignored physiology far too long and have destroyed much with their hands, what nature has spent years growing and developing. A flat occlusal plane relative to horizontal level represents mal-alignment and dysfunction contributing to body fatigue. Neuromuscular science supports normalize occlusal form. If clinicians ignore what nature intends they WILL be building fatigue into their cases. You cannot fool physiologic and anatomical science, especially when it is tested amongst thousands of great clinicians who understand the realities of conservative, ethical and thoughful judicious "gneuromuscular/neuromuscular" treatment for their patients.
As you all know I take a lot of records and this is just a small sampling of what many have been privately emailing me to show what I do. Some may not agree, but I am fine with that. My patient is extremely happy and satisfied.
The occlusal plane should look natural and balanced with the smile (that is how it should appear)…the mount is what tweaks our minds…the lateral ceph objectively confirms the reality, but it may be a need for a paradigm shift in occlusal thinking and re-evaluate whether your occlusal plane mount is too flat or not. It's worth investigating.
Conclusion:
1) We ultimately desire the cervical neck muscles balanced, thus we observed that the head tilts downward from an upward pathologic TMD position which TMD patients present with (flatter occlusal plane relative to horizontal level), 2) we desire optimal esthetics smiles lines and our patients to be asymptomatic. We observe on lateral cephalograms that the occlusal plane is angled – no symptoms and 3) we simply desire to reproduce what we actually see in a stable, symptom free system – angled occlusal plane, and not have our lab technicians guess or alter the mounts, thus the Fox plane method we advocate as many recognize as simple and logical is easily transfered via the Fox Plane method indicated at Occlusion Connections.
To read more: The Science of Aligning Body Parts To Improve Function - Part I
© 2009 Clayton A. Chan, DDS. All Rights Reserved.
Neuromuscular Dentistry
Nature has amazingly design the masticatory system in such a manner to meet the functional demands in a very physiologic manner. Our occlusal, cervical, airway and postural system has been pre-determined genetically to function optimally relative to earth’s gravitational forces. An angled or slanted occlusal plane is natures design when the head is properly supported by balanced muscles.
Because of gravity, the muscles of the structural system as well as the masticatory system allows the human being to function with the head in properly balanced manner to avoid strains and fatigue to the overall postural system. A person with a forward neck posture will accommodate to maintain the flow of oxygen into his/her body. This forward neck and head posture tendency is indicative of an upward head tilt with a resulting flatter occlusal plane. The upward head tilt contributes to TMD and accommodative pathologic issues (e.g., shoulder pain, neck pain, temporal headaches). This upward head tilt is the bodies way to accommodate due a mal-aligned bite which tries to defy natures gravitational vertical forces, resulting in a flatter more leveled occlusal plane which does not represent what nature originally intended in its design.
The SN (Sella-Nasion) Plane is noted in the dental literature as a standard objective leveling reference. What you see in the lateral ceph below is one of one of my patients, male age 47 who presented with former TMD cervical neck problems. Symptoms were resolved with an orthotic. The previous upward head tilt responded positively to the orthotic therapy allowing nature to correct it's head posture including and an improved occlusal plane. Based on this corrected and more normalized occlusal plane orientation as seen in the below lateral cephalogram I want to transfer this occlusal plane orientation to a flat analyzing table on my articulator to fabricate the upper and lower restorations for FM rehab esthetically and anatomically.
It seems to me that if SN plane is level, symptoms are gone, and patient’s head is now balanced. Recording this position is the most logical to communicate with the lab to mount the case.
© 2009 Clayton A. Chan, DDS. All Rights Reserved
to record this maxillary occlusal plane orientation I use the Fox plane as indicated in the blog articles and other publications I have written. It takes the guess work away from the laboratory as long as you implement the process properly like anything. Errors can occur during the following steps:
(These are real time pictures that I routinely take during my clinical work up to document what I actually observed).
- During the bite registration stage. If one use computerized mandibular scanning (jaw tracking - eg. scan 4/5 with TENS) and does not have adequate training to accurately interpret and record this kind of neuromuscular bite registration error can occur before the case is even started.
- If the EMG interpretation is not correct and one implements erroneous EMG diagnostic protocols (unable to decipher the differences between fatigued EMG patterns vs. normalized EMG patterns or does not monitor the cervical group EMGs believing that these EMG recordings are the same as SCM EMG recordings one will be greatly mistakened.
- Subjective interpretation in these areas of diagnostics will also lead to failed treatment results.
(These are real time pictures that I routinely take during my clinical work up to document what I actually observed).
© 2009 Clayton A. Chan, DDS. All Rights Reserved
Note how the maxillary recording is simply recorded at level using fast set PV on the bite fork of the Fox Plane and the transferred to a level table. This nicely correlates with the lateral ceph occlusal plane which objectively confirms the mounting and occlusal plane transfer.
© 2009 Clayton A. Chan, DDS. All Rights Reserved
The maxillary cast is simply transferred to the table via the OPI (occlusal plane index) from the Fox Plane recording. (Read more on Mounting the Maxillary Cast Using the Fox Plane and Occlusal Plane ).
This is the actual photo that some skeptics have tried to alter to disparage the modified Fox Plane technique I have been advocating. (Important Note: In the background the level counter and bottles sitting on top shows that my patient's head is leveled. The bottles and level counter top are not slanting and or angled as some scrupulous "instructor/teachers" have tried to convey in their lectures by altering this image in their lectures to distort the truth of my Fox Plane recording). Level = Level!
This is the actual photo that some skeptics have tried to alter to disparage the modified Fox Plane technique I have been advocating. (Important Note: In the background the level counter and bottles sitting on top shows that my patient's head is leveled. The bottles and level counter top are not slanting and or angled as some scrupulous "instructor/teachers" have tried to convey in their lectures by altering this image in their lectures to distort the truth of my Fox Plane recording). Level = Level!
In a purposeful attempt to disparage and misconstrue the facts of my published article, a dentist instructor "teacher" of a "cosmetic NM teaching center" used this picture and altered and flipped it in an attempt to discredit my teachings during during his lectures. What is amazingly wrong with his attempt is that he failed to fully read and comprehend the article that was published in the ICCMO Anthology (Chan, CA: A Review of the Clinical Significance of the Occlusal Plane: Its Variation and Effect on Head Posture: Optimizing the Neuromuscular Trajectory – a Key to Stabilizing the Occlusal-Cervical Posture. International College of Craniomandibular Orthopedics (ICCMO) Anthology VIII, 2007). His biased publicized lecture subtitle shown in the below power point slide shows his unscrupulous dishonest disregard for scientific and academic teaching integrity and is in itself a "contradiction". Additionally, it shows his lack of knowledge and understanding of basics in lateral cephalograms.
This is the altered and flipped picture by this "occlusion teachers" with the accompanying text.
Below is the unscrupulously altered photo by the same dentist (instructor "teacher" of an institute) who purposely altered my photo again in a second power point slide (by rotating and altering the above photo) and used it without permission in a manner to give a misleading and false impression to the attending listening doctor audience about my occlusal plane teachings and understanding of how I advocate the use of the Fox Plane. One of my dentist colleagues discovered and reported this poorly mishandled power point slide exposing this doctor/ "teacher's" credibility as an "occlusion instructor" by pointing out in the background the tipped bottles that were positioned on a counter in the background. The unethical teacher/lecturer purposely rotated the photo to mislead, misguide and convey a false teaching about me and what I believe about head posture, the maxillary occlusal plane orientation and what I consider as horizontal level.
The lecturer/ "occlusion teacher" has exposed his credibility and lack of academic honor. Such stupidity does not go unnoticed by those who have astute eyes to see beyond what is obvious. Postural balance is maintained best when the head, neck, shoulders, pelvis and feet are leveled to Earth's horizontal level. Dentists and the viewing audience clearly recognize what level is and realize that the angled human occlusal plane is simply determined when the dentist can clearly see things from a balanced perspective - not from a distorted biased and altered view).
The unposed head posture clearly shows the natural angled occlusal plane of the same patient in this lateral cephalogram.
Lateral cephalogram (ICAT) after comprehensive restorative treatment. Note: unposed natural head position and natural angled occlusal plane. Images have not be altered or modified. (You decided ...is the occlusal plane angled or flat?)
© 2009 Clayton A. Chan, DDS. All Rights Reserved
The wax up was done to match the mount using the maxillary transfer table. Restorations were fabricated to the same mount without alterations to the mount. (Dr. Chan proudly gives recognition for outstanding ceramic and waxing to Las Vegas Esthetics Lab, Ray Foster and Team).
© 2009 Clayton A. Chan, DDS. All Rights Reserved
I check the crown ratios (they shouldn’t look funny)…reconfirm my AP…check my patient’s subjective responses. Many dentist and I have discover that when the correct occlusal plane is properly managed, the patient doesn't experience any neck, cervical and shoulder pain problems. If one uses the classic HIP (hamular notch and incisive papilla) method to manage the case too completion that many are discovering that this can lead to unresolved TMJ/occlusal problems. If everything seems to line up I go for it!
© 2009 Clayton A. Chan, DDS. All Rights Reserved
I mount my cases and check my cases from the lab to see if they maintained the correct maxillary orientation before delivery (labs are not allowed to cheat or change the mount unless it is wrong). I check my mount. I check the photos, I check and compare what is in the mouth, I check how the angle and slant is…I analyze and re-analyze and confirm with my lateral ceph, check my EMG data (making sure my patients are comfortable and stable), I check my Scan 4/5, scan 2’s, scan 8’s, etc. and decided that this orientation got to be right from the frontal and lateral views….then a re-check the patient and I re-check at the lab bench…. Seems right to me!
© 2009 Clayton A. Chan, DDS. All Rights Reserved
I am happy…that He is happy…. "Don’t lose sight of the Power of the Bite!” I have no regrets about the Fox…because I know it works for me and it works for all the talented clinicians who understand this concept. These pictures are immediately after lower seat, before any adjusting of any crowns….I had the patient come back the next day to TENS and refine the bite.My patient is very pleased, no neck cervical TMD problems. The bite is awesome. After gneuromuscular esthetic dentistry the patient no longer reports cervical pain, no shoulder pain, nor any TMD issues. The patient is stable and very happy. He is a public speaker and is on streaming internet video weekly and has a great pleasing smile. You can view him at: http://www.iclv.com/ or spiritflow.net on Sunday mornings and Sunday evenings.
Although, there is some dental literature that tries to indicate that the occlusal plane is parallel to certain boney references as the hamular notch and incisive foramen) they often do not realize that cervical bones from C1 to C7 are not perpendicular, thus misleads and confuses the reader as to which horizontal they are refering to. Dental literature both in the orthodontic, restorative and prosthetic arena clearly have reported on average an occlusal plane angle of 6-14 degrees when the horizontal gaze is parallel to earth's horizontal level. Any dental referencing technique that advocates an occlusal plane horizontal to earth's horizontal plane certainly is contributing dental failure and postural/occlusal instability.A physiologic occlusal plane, determined by balanced cervical neck, shoulder and masticatory muscles of the head is routinely angled by natures design to be perpendicular to a normalized lordotic curvature of the neck from C1 to C7. This orientation is physiologically sound according to natures proportional design for optimal function of the pharyangeal airway (breathing), optimal head posture for physiologic functioning and positioning of the lower jaw, and proper shoulder posture. Proper mandibular positioning relative to the cranium does effect and impact body balance, flexion, extension and rotational movements.
Dentists have ignored physiology far too long and have destroyed much with their hands, what nature has spent years growing and developing. A flat occlusal plane relative to horizontal level represents mal-alignment and dysfunction contributing to body fatigue. Neuromuscular science supports normalize occlusal form. If clinicians ignore what nature intends they WILL be building fatigue into their cases. You cannot fool physiologic and anatomical science, especially when it is tested amongst thousands of great clinicians who understand the realities of conservative, ethical and thoughful judicious "gneuromuscular/neuromuscular" treatment for their patients.
As you all know I take a lot of records and this is just a small sampling of what many have been privately emailing me to show what I do. Some may not agree, but I am fine with that. My patient is extremely happy and satisfied.
The occlusal plane should look natural and balanced with the smile (that is how it should appear)…the mount is what tweaks our minds…the lateral ceph objectively confirms the reality, but it may be a need for a paradigm shift in occlusal thinking and re-evaluate whether your occlusal plane mount is too flat or not. It's worth investigating.
Conclusion:
1) We ultimately desire the cervical neck muscles balanced, thus we observed that the head tilts downward from an upward pathologic TMD position which TMD patients present with (flatter occlusal plane relative to horizontal level), 2) we desire optimal esthetics smiles lines and our patients to be asymptomatic. We observe on lateral cephalograms that the occlusal plane is angled – no symptoms and 3) we simply desire to reproduce what we actually see in a stable, symptom free system – angled occlusal plane, and not have our lab technicians guess or alter the mounts, thus the Fox plane method we advocate as many recognize as simple and logical is easily transfered via the Fox Plane method indicated at Occlusion Connections.
To read more: The Science of Aligning Body Parts To Improve Function - Part I
© 2009 Clayton A. Chan, DDS. All Rights Reserved.
Thursday, March 25, 2010
10 Occlusal Factors that are often Overlooked in Every Day Dentistry
10 Occlusal Factors that are often Overlooked in Every Day Dentistry
by Clayton A. Chan, DDS
Founder/Director Occlusion Connections - Center of Neuromuscular Dentistry & Orthopedic Advancement
1. Ignoring the status of both left and right temporomandibular joints – condyle/disc relationship within the glenoid fossa. Most within our dental profession do not have a complete grasp of proper condyle/disc relationship, let alone how to optimized the disc if it was in the wrong position (e.g. anteriorly or medially displaced). Clinicians must recognize that occlusion doesn’t start with the status of the TMJ condition, but rather with what is the status of the masticatory muscle system that contributes to the ills of joint degeneration.
3. Vertical Dimension of occlusion is often ignored during routine clinical examinations and or overly emphasized when recognized. Most clinicians do not realize how to optimally find the proper vertical position, even if they were faced with a severely overclosed bite. On the flip side, many don’t know how to find the proper vertical dimension of occlusion if they were faced with an anterior open bite case problem. The Physiologic Rest Position CAN be effectively used to establish a reproducible VDO. The challenge is that our dental profession doesn’t understand how to establish physiologic rest as it relates to condyle/disc relationships and correlate it to proper muscle posture in 6 dimensions, thus they don’t believe it is possible to use Physiologic Rest as a determined in establishing a proper vertical dimension.
4. Proper transpalatal width dimension is another misunderstood and or highly unrecognized problem within the dental profession. Without a clear understanding of muscle health as it relates to proper mouth breathing and tongue postural dynamics the so called neutral zone cannot be established. If muscles are not measured, neither are they properly relaxed prior a diagnosis (establishing a proper maxillary to mandibular cast relationship), how can proper clinical treatment begin for either orthodontic or restorative therapy? How can any clinician proceed to a finalizing phase without proving the final end game and expect a stable neuromuscular result?
5. Establishing Myocentric is one of the most challenging of all. Where is it? What vertical should be used to establish a proper myocentric? And what jaw closure pattern (NM trajectory) should be used to establish a proper myocentric? If a trajectory closure path is not properly identified while at the same time the hidden joint dysfunction is present, then it makes it more difficult for the clinician to remedy the occlusal/muscle/joint problems. Myocentric can be achieved without manual manipulation techniques of the jaw and or having to lay the patient back in a supine position. Gravity, condyle/disc, occlusal and muscle dynamics all play a role in establishing a proper terminal contact position (the bite) even if one is using the K7 or whatever method or bite technique. The bite must be placed in neutral.
6. In the neuromuscular community we shouldn’t have to worry about long myocentric problems. If ones experience has been to observe the patients jaw to shift down and forward during occlusal adjustments after a TENS bite or K7 bite was taken, perhaps a re-evaluation of the techniques learned will help move one forward to appreciate what it means to “optimize” the NM trajectory or optimize the TENS bite. The use of the term Optimized is now being used to give the impression that the bite is being taken correctly, but the fact of the matter is if the clinician has to verbally coach the patient to a particular position (move up….let the jaw float back….more to the left or more to the right, etc. etc. etc.) even if using the K7 Scan 4/5 is a clear indication that the bite is in actuality being forced and may not really be optimized. The clinical application, methods and or techniques presented must be questioned and re-evaluated. At OC the clinicians are discovering that when the bite condyles, disc and muscles are truly optimized on a proper trajectory very little verbal coach needs to be used and one finds that finding the isotonic optimal trajectory takes on a different meaning.
7. Anterior contact and disclusion is a gnathologic concept that must be acknowledged, when you have established an optimal trajectory/closure pattern. To ignore and or dismiss the need to have anterior contact (especially in restorative dentistry) is an admittance of a lack of neuromuscular occlusal understanding, especially if one is seeking optimal occlusal posture and dynamics. Determining the angle of disclusion during protrusive, retrusive as well as the various lateral movements is crucial and significant to any student of occlusion, thus a need to learn GNEUROMUSCLUAR OCCLUSION.
8. The envelop of physiologic function cannot be achieved if the basics to proper VDO, muscles rest, condyle/disc optimization, head and mandibular postural balance is not acknowledged clinically.
9. The angle of the Occlusal Plane is significant and does make a difference as to long term maxillary to mandibular occlusal stability as well as skeletal/structural balance. To ignore what nature has designed as a template and insist that the occlusal plane is to be leveled (flat) relative to horizontal level is a masking of how the stomatognathic system really works. How to determine a proper occlusal plane must be learned and or re-learned in certain cases. Why the occlusal plane is angled is important, because it relates to the anterior teeth and posterior disclusion and functional occlusal dynamics as well as head, neck and shoulder posture.
10. Lastly, occlusal contact management is often under estimated among clinicians today. The power of micro occlusion and its relationship to proprioceptive response as it relates to the central nervous system is tremendous. It does take time, skill and a clear understanding of how the body works. Thank goodness for patient adaptive capacities, but one the adaptive capacity of patients are sick and dysfunctional it now is in the hands of the treating clinicians abilities to try to meet those demands placed on him or her to meet those occlusal challenges in a time, efficient manner. Taking the Psychosomatic route is another means to mask and ignore the real issues of being a physician of the mouth. Taking the route of treating the Somatopsychic takes knowledge, understanding, patience and skill. It can be learned and properly implemented.
by Clayton A. Chan, DDS
Founder/Director Occlusion Connections - Center of Neuromuscular Dentistry & Orthopedic Advancement
1. Ignoring the status of both left and right temporomandibular joints – condyle/disc relationship within the glenoid fossa. Most within our dental profession do not have a complete grasp of proper condyle/disc relationship, let alone how to optimized the disc if it was in the wrong position (e.g. anteriorly or medially displaced). Clinicians must recognize that occlusion doesn’t start with the status of the TMJ condition, but rather with what is the status of the masticatory muscle system that contributes to the ills of joint degeneration.2. The status of the masticatory musculature is often overlooked and rarely considered a significant factor when it comes to evaluating the existing occlusal condition of the mouth. Worn dentition, facets, chipping, broken or missing teeth, are indicators that have direct correlation to muscle imbalance problems. How to recognize muscle problems is often ignored and not understood by most clinicians. The fact that even the most astute clinicians do not understand how to resolve cervical neck imbalances, masseter facial pain complaints as well as occipital pain problems at the base of the back of the head is a clear indicator that most may talk about muscle problems, and may even use TENS, etc, but don’t know how to clinically address these problems effectively, shows a significant lack and necessity to learn the proper principles of occlusion.
6. In the neuromuscular community we shouldn’t have to worry about long myocentric problems. If ones experience has been to observe the patients jaw to shift down and forward during occlusal adjustments after a TENS bite or K7 bite was taken, perhaps a re-evaluation of the techniques learned will help move one forward to appreciate what it means to “optimize” the NM trajectory or optimize the TENS bite. The use of the term Optimized is now being used to give the impression that the bite is being taken correctly, but the fact of the matter is if the clinician has to verbally coach the patient to a particular position (move up….let the jaw float back….more to the left or more to the right, etc. etc. etc.) even if using the K7 Scan 4/5 is a clear indication that the bite is in actuality being forced and may not really be optimized. The clinical application, methods and or techniques presented must be questioned and re-evaluated. At OC the clinicians are discovering that when the bite condyles, disc and muscles are truly optimized on a proper trajectory very little verbal coach needs to be used and one finds that finding the isotonic optimal trajectory takes on a different meaning.
7. Anterior contact and disclusion is a gnathologic concept that must be acknowledged, when you have established an optimal trajectory/closure pattern. To ignore and or dismiss the need to have anterior contact (especially in restorative dentistry) is an admittance of a lack of neuromuscular occlusal understanding, especially if one is seeking optimal occlusal posture and dynamics. Determining the angle of disclusion during protrusive, retrusive as well as the various lateral movements is crucial and significant to any student of occlusion, thus a need to learn GNEUROMUSCLUAR OCCLUSION.
8. The envelop of physiologic function cannot be achieved if the basics to proper VDO, muscles rest, condyle/disc optimization, head and mandibular postural balance is not acknowledged clinically.
9. The angle of the Occlusal Plane is significant and does make a difference as to long term maxillary to mandibular occlusal stability as well as skeletal/structural balance. To ignore what nature has designed as a template and insist that the occlusal plane is to be leveled (flat) relative to horizontal level is a masking of how the stomatognathic system really works. How to determine a proper occlusal plane must be learned and or re-learned in certain cases. Why the occlusal plane is angled is important, because it relates to the anterior teeth and posterior disclusion and functional occlusal dynamics as well as head, neck and shoulder posture.
Wednesday, February 3, 2010
A Re-evaluation of the Meaning of NMD
"GNEUROMUSCULAR" DENTISTRY - What It Is and What It's Not
by Clayton A. Chan, DDS, MICCMO
by Clayton A. Chan, DDS, MICCMO
I am posting this to clear up confusion as to what Neuromuscular Dentistry and NM Occlusion is about. Because there are some who profess to be "Neuromuscularly" trained, but in reality have very little understanding and appreciation for the Gnathologic occlusal concepts which are the foundation to neuromuscular dentistry. NMD is not only about scans, EMGS and jaw tracking data, it is about occlusion and it’s relationship to the trigeminal system as it relates to postural system. Let’s not forget that it relates to CLINICAL applications of TMD, restorative/prosthetics and orthodontics. It’s not an academic exercise of knowledge, but rather it should be a display of how the teeth, muscles and joints are functioning (HEALTH not dysfunction) in relationship to the bio-physiology, neurology and their impact to the masticatory system.
The concept of NMD is not new, neither should it relate to marketing exploits in the name of post graduate dental education. It is a "discipline" in dentistry that requires attention to detail to the core principles that every dental student has learned in their dental training. It is certainly not about an overuse of technological advancements for the learning student to convey to their patients that what they understand about EMGs, jaw tracking and orthotics is to over ride the actual patient responses of ill feeling bites, imbalance of musculature as it relates to restorative reconstruction. LEARNING THE BASICS IN OCCLUSION IS KEY! The proper application of the GNM principles as taught at OC is key!
When doctors who begin to use these advanced techniques in manners and cannot properly interpret the EMG and jaw tracking data correctly or apply the micro occlusal management principles from a complete clinical perspective, even though in their mind that the data may appear to be normal or correct as per their understanding, it behooves all to assess their training and understanding of scan interpretation, especially when restoring patients through the various phase of reconstruction or restorations (phase I removables, phase I fixed orthotic, phase I porcelain orthotics and or phase II restorative). If the scans appear to be normally low EMGs and the trajectory looks like it is right on trajectory sagittally and frontally and the patient is complaining that they don’t have a bite, then perhaps a reassessment as to one’s understanding of scan interpretation is in order (Level 5 Advanced NM Bite Refinement/K7 Training and Interpretation). If the EMG and jaw tracking data as per one's understanding shows a balanced occlusion, yet the central nervous system is not calm or neutralized then one's understanding of GNM (gneuromuscular) and or NM (neuromuscular) needs to be reassessed.
If the patient is having a difficulty with the dentistry provided even if it was performed in the name of GNM or NM and one is not sure what to do….don’t tell the patient that all the scans appear normal and that there is nothing wrong with the dentistry. They are not whiners and complainers for no reason. They have a legitimate concern that needs further investigation, occlusal understanding and another level of skill sets may be required. It is wrong to tell the patient that there is nothing wrong when the Scans appear to be OK to cash this patient to the waste heap of “NM” failures. Let’s reconsider what we have been taught. (Of course the TMD patient must also realize there are no guarantees, when TMD involves multiple layered factors that involved not just structural/anatomical postural issues, but even more the emotional/psychological stressors as well as biochemical issues that often patients rarely want to acknowledge with their dentist). Learn from those who really practice what they preach. Use your knowledge, skills and good judgment to help your patients and find a resolution to the problem. Be patient, compassionate, respectful of others work and listen to your patients carefully…sometimes they know more than the treating doctors…why because some of them are experienced and have read, learned educated themselves amongst the numerous practitioners they have visited, have been the recipients of many doctors treatments and therapies, yet continue to seek for real answers to real problems.
As long as Neuromuscular clinicians continue to pretend to hide under the covering of their scans (not really understand OCCLUSION management principles and the importance that microns matter) not fully comprehending the GNM principles what they mean as they relate to CLINICAL TMD pain treatment, restorative occlusal therapy problems and orthodontic/orthopedic issues, then scan interpretation is only a lopsided perspective of what NMD and GNM really advocates.
Orthopedic Dentistry, Orthopedic Occlusion, GNEUROMUSCULAR Occlusion or Gneuromuscular Dentistry is perhaps an updated means to convey the full package of what NMD originally intended. It shouldn’t convey something less than a complete understanding of both neuromuscular and gnathologics…it is really plain dentistry that requires self discipline.
Neuromuscular Dentistry - Measuring and Evaluating by Objective Analysis
by Clayton A. Chan, DDS, MICCMO
by Clayton A. Chan, DDS, MICCMO
I am posting this to clear up confusion as to what Neuromuscular Dentistry and NM Occlusion is about. Because there are some who profess to be "Neuromuscularly" trained, but in reality have very little understanding and appreciation for the Gnathologic occlusal concepts which are the foundation to neuromuscular dentistry. NMD is not only about scans, EMGS and jaw tracking data, it is about occlusion and it’s relationship to the trigeminal system as it relates to postural system. Let’s not forget that it relates to CLINICAL applications of TMD, restorative/prosthetics and orthodontics. It’s not an academic exercise of knowledge, but rather it should be a display of how the teeth, muscles and joints are functioning (HEALTH not dysfunction) in relationship to the bio-physiology, neurology and their impact to the masticatory system.
The concept of NMD is not new, neither should it relate to marketing exploits in the name of post graduate dental education. It is a "discipline" in dentistry that requires attention to detail to the core principles that every dental student has learned in their dental training. It is certainly not about an overuse of technological advancements for the learning student to convey to their patients that what they understand about EMGs, jaw tracking and orthotics is to over ride the actual patient responses of ill feeling bites, imbalance of musculature as it relates to restorative reconstruction. LEARNING THE BASICS IN OCCLUSION IS KEY! The proper application of the GNM principles as taught at OC is key!
When doctors who begin to use these advanced techniques in manners and cannot properly interpret the EMG and jaw tracking data correctly or apply the micro occlusal management principles from a complete clinical perspective, even though in their mind that the data may appear to be normal or correct as per their understanding, it behooves all to assess their training and understanding of scan interpretation, especially when restoring patients through the various phase of reconstruction or restorations (phase I removables, phase I fixed orthotic, phase I porcelain orthotics and or phase II restorative). If the scans appear to be normally low EMGs and the trajectory looks like it is right on trajectory sagittally and frontally and the patient is complaining that they don’t have a bite, then perhaps a reassessment as to one’s understanding of scan interpretation is in order (Level 5 Advanced NM Bite Refinement/K7 Training and Interpretation). If the EMG and jaw tracking data as per one's understanding shows a balanced occlusion, yet the central nervous system is not calm or neutralized then one's understanding of GNM (gneuromuscular) and or NM (neuromuscular) needs to be reassessed.
If the patient is having a difficulty with the dentistry provided even if it was performed in the name of GNM or NM and one is not sure what to do….don’t tell the patient that all the scans appear normal and that there is nothing wrong with the dentistry. They are not whiners and complainers for no reason. They have a legitimate concern that needs further investigation, occlusal understanding and another level of skill sets may be required. It is wrong to tell the patient that there is nothing wrong when the Scans appear to be OK to cash this patient to the waste heap of “NM” failures. Let’s reconsider what we have been taught. (Of course the TMD patient must also realize there are no guarantees, when TMD involves multiple layered factors that involved not just structural/anatomical postural issues, but even more the emotional/psychological stressors as well as biochemical issues that often patients rarely want to acknowledge with their dentist). Learn from those who really practice what they preach. Use your knowledge, skills and good judgment to help your patients and find a resolution to the problem. Be patient, compassionate, respectful of others work and listen to your patients carefully…sometimes they know more than the treating doctors…why because some of them are experienced and have read, learned educated themselves amongst the numerous practitioners they have visited, have been the recipients of many doctors treatments and therapies, yet continue to seek for real answers to real problems.
As long as Neuromuscular clinicians continue to pretend to hide under the covering of their scans (not really understand OCCLUSION management principles and the importance that microns matter) not fully comprehending the GNM principles what they mean as they relate to CLINICAL TMD pain treatment, restorative occlusal therapy problems and orthodontic/orthopedic issues, then scan interpretation is only a lopsided perspective of what NMD and GNM really advocates.
Orthopedic Dentistry, Orthopedic Occlusion, GNEUROMUSCULAR Occlusion or Gneuromuscular Dentistry is perhaps an updated means to convey the full package of what NMD originally intended. It shouldn’t convey something less than a complete understanding of both neuromuscular and gnathologics…it is really plain dentistry that requires self discipline.
Neuromuscular Dentistry - Measuring and Evaluating by Objective Analysis
Wednesday, October 21, 2009
Orthotic Managment, Clenching and BNS 40 TENS
Clayton A. Chan, DDS Response
QUESTION:Has anyone had experience with their patients using the BNS-40 at home? I just got one to give to a chronic headache pt for home use. The patient is a 49 yr. old female with a 25 year history of headaches, usually 2-3 per week, and she reports she clenches every night. I made her an orthotic and have done 3 adjustment appts. I am considering having her TENS with the BNS-40 every day for two weeks then run more scans and another adjustment for the orthotic. I'm doing this because therapy with the orthotic has given only slight impovement in her condition. Does anyone have alternate methods/protocols they might offer?
Thanks!
JO
RESPONSE:
The chronic paining clencher is one of the more challenging type of cases the clinician will face. Although the use of the BNS-40 Myomonitor TENS is known to be an effective means to relax the masticatory muscles the treating clinician must also recognize that there are other factors involved beyond delivering an orthotic and relaxing muscles. The true clencher will usually show hypertrophy of the masseter muscle extra-orally, a well developed dental arch without depression of the Curve of Spee, and an unfaceted dentition with good anatomic morphology.
The reality is that many patients are a combination bruxer-clenchers. The typical bruxer shows a significant faceting and wear of the dentition, bicuspid drop-off with depression of the Curve of Spec, inadequate arch development with lingual inclination of the lower posterior teeth.
Regardless of whether a patient is a clencher or bruxer there exists an heighten noxious proprioceptive input feeding into the CNS-reticular loop, resulting in a greatly accentuated motor hyperactivity. This means that occlusal therapy must be successfully controlled to reduce the noxious influences which in turn reduces the level of bruxing/clenching in most of our patients. The clencher appears to have a more patterned or engrammed central nervous system component to their noxious occlusal habit. Biofeedback is often a helpful adjunct for the chronic clencher.
Here are a few pointers to consider:
It has been my clinical experience that patients that present as so called “clenchers” will present with:
The following headaches can and should be resolved by the dentist:
I believe that clenching problems can be resolved with effective a comprehensive craniomandibular cervical structural approach which goes against what most literature and teachers may say, relinguishing this problem to the CNS emotional psychosomatic stressor department rather than acknowledging the physiologic somatopsychic issue.
We know we can help you!
If you have further questions please don't hestitate to contact me at: clayton@claytonchan.com
Clayton A. Chan, D.D.S.
QUESTION:Has anyone had experience with their patients using the BNS-40 at home? I just got one to give to a chronic headache pt for home use. The patient is a 49 yr. old female with a 25 year history of headaches, usually 2-3 per week, and she reports she clenches every night. I made her an orthotic and have done 3 adjustment appts. I am considering having her TENS with the BNS-40 every day for two weeks then run more scans and another adjustment for the orthotic. I'm doing this because therapy with the orthotic has given only slight impovement in her condition. Does anyone have alternate methods/protocols they might offer?
Thanks!
JO
RESPONSE:
The chronic paining clencher is one of the more challenging type of cases the clinician will face. Although the use of the BNS-40 Myomonitor TENS is known to be an effective means to relax the masticatory muscles the treating clinician must also recognize that there are other factors involved beyond delivering an orthotic and relaxing muscles. The true clencher will usually show hypertrophy of the masseter muscle extra-orally, a well developed dental arch without depression of the Curve of Spee, and an unfaceted dentition with good anatomic morphology.
The reality is that many patients are a combination bruxer-clenchers. The typical bruxer shows a significant faceting and wear of the dentition, bicuspid drop-off with depression of the Curve of Spec, inadequate arch development with lingual inclination of the lower posterior teeth.
Regardless of whether a patient is a clencher or bruxer there exists an heighten noxious proprioceptive input feeding into the CNS-reticular loop, resulting in a greatly accentuated motor hyperactivity. This means that occlusal therapy must be successfully controlled to reduce the noxious influences which in turn reduces the level of bruxing/clenching in most of our patients. The clencher appears to have a more patterned or engrammed central nervous system component to their noxious occlusal habit. Biofeedback is often a helpful adjunct for the chronic clencher.
Here are a few pointers to consider:
- Make sure your orthotic is properly designed to accommodate lateral cuspid rise and posterior disclusion.
- Anterior contact and posterior disclusion is an absolute requirement for these kind of cases (something most NM teachings overlooked).
- Protrusive contacts must be properly balanced.
- Retrusive contacts must be balanced, but not eliminated (especially in the supine laying down positions – night time wear).
It has been my clinical experience that patients that present as so called “clenchers” will present with:
- Anterior open bite tendency – They may appear with normal occlusion with seemingly higher Golden Vertical values in the anterior region, but in reality are previous ortho or post surgical cases.
- Arches appear well developed, but don't let that decieve you.
- Posterior teeth contact in lateral excursive movements contributing to mandibular jaw torque (culprits to clenching. Relieve posterior interferences, if left the patient will continue to clench).
- Inadequate disclusion of the posterior teeth during protrusive movements.
- Maxillary arch can be retrognathic relative to an optimized NM position and trajectory when evaluating with K7 Scan 4/5, an optimized TENs bite and or cephalometrics.
The following headaches can and should be resolved by the dentist:
- Temporal headaches
- Masseter facial pain
- Tenderness and pain at the posterior lower border/corner of the jaw.
- SCM tenderness
- Cervical neck pain and tenderness
- Pain in the occipital region
- Pain on top of the head
- Shoulder pain
- Numbness and tingling in the arms, hands and fingers
I believe that clenching problems can be resolved with effective a comprehensive craniomandibular cervical structural approach which goes against what most literature and teachers may say, relinguishing this problem to the CNS emotional psychosomatic stressor department rather than acknowledging the physiologic somatopsychic issue.
We know we can help you!
If you have further questions please don't hestitate to contact me at: clayton@claytonchan.com
Clayton A. Chan, D.D.S.
Wednesday, September 30, 2009
Myo-Trajectory and the NM Clinicians Focus
by Clayton A. Chan, DDS - Director of Occlusion Connections
A more optimal trajectory can be observed with computerized mandibular scanning (CMS) and low frequency Myomonitor TENS alone by following an effective bite taking Scan protocol. Understanding how to interpret the scans and what they mean is also very important, before conclusions are made. That is the essence and beauty of understanding NM at the next level. At the next level the trained NM clinician is aware of the elevators and depressor issues, but also realizes that it is not the key focus to optimization of the NM trajectory along an isotonic path/zone or tunnel as it CLINICALLY relates to establishing a bite for TREATMENT. That is the academic exercise of questioning the NM occlusal paradigm to convince oneself whether NMD is correct or not (no problem with questioning). Certainly we desire and want low EMGs, that is one of the clinical objectives.
A more optimal trajectory can be observed with computerized mandibular scanning (CMS) and low frequency Myomonitor TENS alone by following an effective bite taking Scan protocol. Understanding how to interpret the scans and what they mean is also very important, before conclusions are made. That is the essence and beauty of understanding NM at the next level. At the next level the trained NM clinician is aware of the elevators and depressor issues, but also realizes that it is not the key focus to optimization of the NM trajectory along an isotonic path/zone or tunnel as it CLINICALLY relates to establishing a bite for TREATMENT. That is the academic exercise of questioning the NM occlusal paradigm to convince oneself whether NMD is correct or not (no problem with questioning). Certainly we desire and want low EMGs, that is one of the clinical objectives.
Note: the above CMS jaw tracking scan shows various sagittal trajectories all of which present with calm low EMG activities (not shown). Reproducibility of mandibular position can be shown in real time when observing the sagittal and frontal cursors (not seen in above scan).If the clinician tries to focus on the end point (trying to establish neuromuscularly calm muscles first using EMGs as the tool of choice to find the bite, rather than aim for a optimal occlusal bite position using CMS as the first choice to later establish the calm muscles second, the dentist will get frustrated in the NM teachings and lose confidence that NM truly an effective approach. Working extra hard to determine low EMGs, for example, on a paining TMD patient to establish a bite will cause the clinician to realize that calm muscles are not going to happen until a proper positioning (location with an established bite (myocentric) is first established. Muscles don’t want to become isotonically calm when they know there is pathologic form (a wrong bite). We want to get good bites, but if you are using EMGs to observe proprioceptive cranio-mandibular responses, the NM bite taking methods classically taught will lead you down the path of bewilderment and wonder searching for the calm zone of both diagastric/suprahyoids, temporalis anterior, masseter and cervical group calmness with varying degrees of vertical, AP and frontal positioning.
Where does the clinician set the bite when cervical groups are hyperactive? Where to set the bite when temporalis are hyperactive? One may get one area calm, but the other areas may not be calm….if we keep searching and hoping that the EMGs is the key to establishing the best bites, then why doesn’t the NM minded clinician just use EMGs alone to establish the bite and don’t depend on CMS!?
It is obviously clear that CMS is a superior and very important tool to see what is happening spatially with the mandibular position for any and all NM clinicians. It also becomes further clear in Level 5 NM Bite Refinement/Advanced K7 teaches how to properly interpret scan 4/5 and refine the bite taking protocol so the clinicians realize what is significant in implementing the instrumentation tools to do NM dentistry practically and in what order of importance as to TENS, CMS, EMG and ESG.
Sunday, July 12, 2009
Use of the Orthotic
by Clayton A. Chan, D.D.S., M.I.C.C.M.O.
There are several different aspects to consider regarding the use of orthotics.
1) Medico-legal – standard of care is that occlusal therapy be reversible as per ADA statement, removable orthotic appears to fit this criteria better. Especially, to the non NM clinician. It looks more mainstream to the traditional clinician. Much less likely to damage the patient’s own structures when the appliance is removed, whether the patient takes it off or we dentists take it off. Which would make you feel more comfortable if your TMD pain patient ever decided to leave your practice for whatever reason…Leaving your practice with a fixed orthotic in the mouth or with a removable?
2) DOT Occlusal Management – Significantly easier to adjust the bite outside the mouth than in the mouth, especially with paining TMD patients that are not yet committed to phase II treatment.
3) When patient not yet committed to phase II level therapy, removable is less likely to cause a more permanent joint change, because of the capability to remove the appliance when the patient wants to. With fixed the patient has no control of the situation and you own the bite (patient now controls you)! If patient is having difficulties with their bite using fixed on a weekend you have to go in and help, if removable they can take it, see them on Monday. Harder to divorce from a patient who has been in fixed vs. a patient in removable.
4) Removable is safer for the doctor in patient management: The patient can always pull it out of the mouth if the bite is bothering them, with the fixed orthotic the patient can’t do that and will require doctor help and assistance. Haven’t we all had a patient who told us that they could not tolerate their new bite?
5) After 30 day fixed orthotic trial period and patient is not ready to proceed forward with finalizing treatment, what do you do then?
6) Paining TMD patient is not always prepared to move forward with a phase II finalizing mode of treatment after 3 months of orthotic therapy. Most of my TMD pain cases are not ready for phase II for at least 1 year, I don’t want the liability for hygiene issues or any other things that would happen underneath the fixed orthotic.
7) Bite Management is much easier and simpler when setting up the case to transition into Phase II. (Any mandibular shift/change that occurs during the course of treatment is easily transferred without the worries of having to cut off the fixed orthosis to get a lower arch wax up. You don’t have the worries to cut off orthotic, maintain and record the bite for the lab, and then place another fixed orthotic which must be exactly and identical to the same orthotic position you just cut off.
8) Removable orthotic is less hard work vs. fixed orthotic with TMD pain patient. Do you like to adjust bite in a laying down position intra orally or a sitting up position extra orally? Is coronoplasty/ micro occlusion easier intra orally or extra orally?
9) When you need to resurface the orthosis. Which is easier fixed intra orally or removable extra orally?
10) After resurfacing how much energy is required to coronoplasty intra orally or extra orally? Think of the emotional stresses on yourself when dealing with a high proprioceptive paining TMD patient?
Ask yourself several questions:
Why do many prefer the removable orthotic rather than a fixed orthotic?
Is it really easier to manage the TMD paining case with a removable or fixed orthotic?
Why does the dental profession (as a Standard of Care) recommend conservative and reversible therapy especially amongst TMD/occlusal philosophies?
There are several different aspects to consider regarding the use of orthotics.
1) Medico-legal – standard of care is that occlusal therapy be reversible as per ADA statement, removable orthotic appears to fit this criteria better. Especially, to the non NM clinician. It looks more mainstream to the traditional clinician. Much less likely to damage the patient’s own structures when the appliance is removed, whether the patient takes it off or we dentists take it off. Which would make you feel more comfortable if your TMD pain patient ever decided to leave your practice for whatever reason…Leaving your practice with a fixed orthotic in the mouth or with a removable?
2) DOT Occlusal Management – Significantly easier to adjust the bite outside the mouth than in the mouth, especially with paining TMD patients that are not yet committed to phase II treatment.
3) When patient not yet committed to phase II level therapy, removable is less likely to cause a more permanent joint change, because of the capability to remove the appliance when the patient wants to. With fixed the patient has no control of the situation and you own the bite (patient now controls you)! If patient is having difficulties with their bite using fixed on a weekend you have to go in and help, if removable they can take it, see them on Monday. Harder to divorce from a patient who has been in fixed vs. a patient in removable.
4) Removable is safer for the doctor in patient management: The patient can always pull it out of the mouth if the bite is bothering them, with the fixed orthotic the patient can’t do that and will require doctor help and assistance. Haven’t we all had a patient who told us that they could not tolerate their new bite?
5) After 30 day fixed orthotic trial period and patient is not ready to proceed forward with finalizing treatment, what do you do then?
6) Paining TMD patient is not always prepared to move forward with a phase II finalizing mode of treatment after 3 months of orthotic therapy. Most of my TMD pain cases are not ready for phase II for at least 1 year, I don’t want the liability for hygiene issues or any other things that would happen underneath the fixed orthotic.
7) Bite Management is much easier and simpler when setting up the case to transition into Phase II. (Any mandibular shift/change that occurs during the course of treatment is easily transferred without the worries of having to cut off the fixed orthosis to get a lower arch wax up. You don’t have the worries to cut off orthotic, maintain and record the bite for the lab, and then place another fixed orthotic which must be exactly and identical to the same orthotic position you just cut off.
8) Removable orthotic is less hard work vs. fixed orthotic with TMD pain patient. Do you like to adjust bite in a laying down position intra orally or a sitting up position extra orally? Is coronoplasty/ micro occlusion easier intra orally or extra orally?
9) When you need to resurface the orthosis. Which is easier fixed intra orally or removable extra orally?
10) After resurfacing how much energy is required to coronoplasty intra orally or extra orally? Think of the emotional stresses on yourself when dealing with a high proprioceptive paining TMD patient?
Ask yourself several questions:
Why do many prefer the removable orthotic rather than a fixed orthotic?
Is it really easier to manage the TMD paining case with a removable or fixed orthotic?
Why does the dental profession (as a Standard of Care) recommend conservative and reversible therapy especially amongst TMD/occlusal philosophies?
Monday, February 2, 2009
The Occlusal Plane
Which Occlusal Plane Do You Undestand? Don't Get Confused
by Clayton A. Chan, DDS, MICCMO
Read my scientific article: "A Review of the Clinical Significance of the Occlusal Plane: Its Variation and Effect on Head Posture" - published in the International College of Craniomandibular Orthopedics Anthology, 2007.
Read my scientific article: "A Review of the Clinical Significance of the Occlusal Plane: Its Variation and Effect on Head Posture" - published in the International College of Craniomandibular Orthopedics Anthology, 2007.
"If you don't stand for anything you will fall for anything...."
Establishing the occlusal plane is an important aspect for every clinician and laboratory technician who desires to create beautiful soft smile lines, stable occlusion and supported normalized head and neck posture. Many of the dental goals and objectives for dental health correlate to esthetics as well as the physiologic function of natures dynamic masticatory system. The artistry and design of the smile is often subjective in nature and does not always lend itself to a cookbook receipe of hard fast numbers and values, but often is visualized by the designers and creators of dental occlusion. So it is the same with establishing the occlusal plane.
Reconstruction by Clayton A. Chan, DDS and Mike Milne, CDT & Team Sunrise Dental Laboratory, Las Vegas, NVDentistry is both an art as well as a science. Combining the artistry of tooth position, orientation, embrasure spaces (open or closed), occlusal plane position and arch shape development are all examples of the subjective clinical decision making ("non science", yet scientific) that must conform to good principles and universal laws of form and function. Implementing one's judgment, clinical experience in addition to a keen visual eye does not lessen ones position of being objective and clinically sound, especially in the arena of neuromuscular occlusion, orthodontics and restorative/prosthetic care.
There are basic laws in nature and science to support such and so it is the same when establishing the occlusal plane. There is nothing wrong neither is it any less than scientific with using leveling tools (e.g Fox Occlual Plane Analyser, face bows, leveling tables and photos) to help the clinician and technician visualize and capture the maxillary occlusal plane with a normalized head position as long as they are used properly. Subjective is certainly required when it comes to the art of dentistry, yet balanced with the physiologic neuromuscular sciences that can measure muscle function using EMG and CMS technology. I like to use all the scientific tools available in dentistry in addition to applying my artistic mind to create postural form for healthy function.
Note the various occlusal plane references as noted in dental literature.
Depending on boney landmarks alone as references to establish maxillary relationships is almost similar to using jaw joints to reference the mandible/bite. The astute clinician recognizes that neuromuscular and physiologic paradigms reference to healthy muscles not bones which often present with distortions, torques, skews and asymmetries. Repeated studies have shown that relaxed muscles can change the profile and soft tissue architecture over the hamular notch regions. Studies have also shown that relaxed cervical neck musculature with isotonic mandibular muscles will effect head posture and the occlusal plane, thus testing the occlusal plane teaching paradigms as to how these boney landmarks are actually referenced to horizontal level in a physiologic position, not pathologic ("level"). After studing numerous cephalometrics and lateral cervical spine films of patients it is clearly evident that the hamular notch and incisive papilla (HIP) landmarks actually are more closely parallel to the the Ala-Tragus plane, and Campers Plane, NOT parallel to horizontal level as some teach. This is a big misnomer! True HIP of the maxilla in a true physiologic head and cervical relationship actually angles or slants at a 6 to 10 degrees (average) relative to horizontal (see literature references in above article).
Key Point: The lab technicians are challenged when mounting the maxillary casts by artistically guessing because dentists fail to sending the necessary recordings that are essential to reliably fabricate the aesthetic restorative case. They do not rely on stick bites, inaccurate impressions, inadequate photos, distorted models (hamular notches) and wrong fox plane recordings. The artistic eye often comes into play regardless of advocated techniques.
Key Point: The lab technicians are challenged when mounting the maxillary casts by artistically guessing because dentists fail to sending the necessary recordings that are essential to reliably fabricate the aesthetic restorative case. They do not rely on stick bites, inaccurate impressions, inadequate photos, distorted models (hamular notches) and wrong fox plane recordings. The artistic eye often comes into play regardless of advocated techniques.
Clinical and laboratory studies have shown when using the boney landmarks of the maxilla to mount the maxillary cast is in fact incorrect and will simulate an unnatural upward head tilt position with the maxillary cast displaying an anterior upward cant 57.6% of the time. That is why most labs ultimately do not complete the restorative cast to these references, but may use it as a guide. Anyone who honestly questions this can check for themselves by mounting the final restorations on the solid mounted maxillary cast to see the type of occlusal plane and what mounting position was actually used.
Labs will say they mount the case to HIP, but will often not dare finish the case to these references because of their experience and realization that this mount will lead to long toothy looking smiles. The technicians realize that the maxilla is not naturally oriented in that manner, thus they make the decision to change the cant of the cast purposely to avoid remakes and an undesirable result for the dentist. The maxillary cast mount should be determined by the dentist, but reality shows that the lab technicians will subjectively and artistically alter the doctors HIP recording to one that is more subtable for finishing the restorative case.
A flat/level HIP mount leads to a pathologic referenced position. A slanted/angled HIP mount is what nature designed physiologically. I advocate the second HIP mount (slanted or angled) which nature intends and is similar to Campers plane or ala tragus plane. This will lead to golden proportions not only in the anterior regions, but also will result in a more idealized crown to root ratio of both the upper to lower posterior molar regions. (Interesting to note that with the classic HIP mount it is often observed that the upper posterior molar crowns will typically look short (staulky) with longer looking lower molar crowns (This is not gold proportions, but results when the maxilla is erroneously mounted to a pathologic relationship). Neuromuscular science supports natures golden proportions and recognizes pathologic distortions! I prefer not to use the fence post and incisive pin as my mounting references to orient the HIP. I use the Fox Plane as indicated in the previous blog titled "Mounting the Maxillary Dental Cast Using the Fox Plane".
Note: A)Pathologic neck posture: Kyphosis resulting in a more flatter occlusal plane. B) Physiologic neck posture: Lordosis resulting in a normalized occlusal plane (angled slant).
If we were to establish boney maxillary cast references such as the hamular notch and incive papilla as some prefer to dogmatically advocate as scientifically objective and mount the maxillary cast to those references the dentist and technician will ultimately be reproducing an undesireable relationship (often resulting in a maxillary cast occlusal plane that appears level and often with the anterior incisal edges vertically upward relative to the posterior teeth). This does not truly represent what nature intended as dental health. Although this idea may appear to be simple to learn and easy to teach this maxillary cast mounting method is in fact one that ignores natures isotonic neutral head position. What we clinicians want to do is replicate healthy relationships of the head, neck and mandible as it relates to the cranum and not pathologic relationship when treating our patients occlusion.
The Fox Plane technique I advocate is a simple means to subjectively analyze and capture what nature intended (an angled HIP mount not flat or level). This is well supported by literature and the orthodontic and prosthetic community. It is a convenient way to capture a proper maxillary recording when the patient is stable and ready to move to the next phase of restorative dentistry. (The classic face bow also works, but is historically more complex and involved and not laboratory friendly). Objective science will always advocate healthy form to support healthy function. The neuromuscular minded clinician needs to learn to use their best judgement skills and understanding and not rely solely on pathologic boney references as their guide. "Nature does not think in mechanical terms". We need to learn from nature, its beauty,design, form and how it functions.
Labs will say they mount the case to HIP, but will often not dare finish the case to these references because of their experience and realization that this mount will lead to long toothy looking smiles. The technicians realize that the maxilla is not naturally oriented in that manner, thus they make the decision to change the cant of the cast purposely to avoid remakes and an undesirable result for the dentist. The maxillary cast mount should be determined by the dentist, but reality shows that the lab technicians will subjectively and artistically alter the doctors HIP recording to one that is more subtable for finishing the restorative case.
A flat/level HIP mount leads to a pathologic referenced position. A slanted/angled HIP mount is what nature designed physiologically. I advocate the second HIP mount (slanted or angled) which nature intends and is similar to Campers plane or ala tragus plane. This will lead to golden proportions not only in the anterior regions, but also will result in a more idealized crown to root ratio of both the upper to lower posterior molar regions. (Interesting to note that with the classic HIP mount it is often observed that the upper posterior molar crowns will typically look short (staulky) with longer looking lower molar crowns (This is not gold proportions, but results when the maxilla is erroneously mounted to a pathologic relationship). Neuromuscular science supports natures golden proportions and recognizes pathologic distortions! I prefer not to use the fence post and incisive pin as my mounting references to orient the HIP. I use the Fox Plane as indicated in the previous blog titled "Mounting the Maxillary Dental Cast Using the Fox Plane".
Note: A)Pathologic neck posture: Kyphosis resulting in a more flatter occlusal plane. B) Physiologic neck posture: Lordosis resulting in a normalized occlusal plane (angled slant).
If we were to establish boney maxillary cast references such as the hamular notch and incive papilla as some prefer to dogmatically advocate as scientifically objective and mount the maxillary cast to those references the dentist and technician will ultimately be reproducing an undesireable relationship (often resulting in a maxillary cast occlusal plane that appears level and often with the anterior incisal edges vertically upward relative to the posterior teeth). This does not truly represent what nature intended as dental health. Although this idea may appear to be simple to learn and easy to teach this maxillary cast mounting method is in fact one that ignores natures isotonic neutral head position. What we clinicians want to do is replicate healthy relationships of the head, neck and mandible as it relates to the cranum and not pathologic relationship when treating our patients occlusion.
The Fox Plane technique I advocate is a simple means to subjectively analyze and capture what nature intended (an angled HIP mount not flat or level). This is well supported by literature and the orthodontic and prosthetic community. It is a convenient way to capture a proper maxillary recording when the patient is stable and ready to move to the next phase of restorative dentistry. (The classic face bow also works, but is historically more complex and involved and not laboratory friendly). Objective science will always advocate healthy form to support healthy function. The neuromuscular minded clinician needs to learn to use their best judgement skills and understanding and not rely solely on pathologic boney references as their guide. "Nature does not think in mechanical terms". We need to learn from nature, its beauty,design, form and how it functions.
Students in a recent Level 6 course at Occlusion Connections mounted their maxillary casts using the Fox Plane technique. Note the natural angles that resulted and are represented in this series of mountings. This is key to dental aesthetics.
My View and Opinion: Use the Fox Plane technique to reference a physiologic occlusal plane, not depending on maxillary boney references. Capture a correct maxillary slant or angled HIP (Physiologic) keeping the Fox Occlusal Plane Analyzer level and parallel to the ground. Make sure the head is level (see Fox Plane Mount blog for technique). This will allow the clinician to easily capture a proper occlusal plane, not a flat or "level" occlusal plane (pathologic). Frontally the fox plane is perpendicular to the long axis of the face. I am sure the laboratory technician understands these techniques and the esthetic significance better then most clinicians since they actually have first hand experience of mount your dental casts daily!
Not all clinicians have comprehended these simple teachings of the Fox Plane concept and its significance to the head, neck and mandibular physiology. Not all teachers teach from a TMD/orthodontic-orthopedic/restorative perspective. Not all clinicians take cephalograms and cervical neck films to understand and see the relationship of the neck and occlusal plane as it relates to a leveled balanced head position, thus limiting their understanding of the significance of these occlusal plane concepts that are importantly related to head position, mandibular positioning and mandibular trajectory closing paths. Clinicians who have a scientific inquiring mind will have the maturity and desire to pursue these truths with certainty and apply the common sense techniques that naturally become logically apparent. We don't have time to waste when doing clinical dentistry on live patient's using wrong and misleading concepts. We need to take the opportunity and learn proper occlusal concepts that will lead our profession toward bring health to our patients, not for ease and convience of teaching.
"Clinicians and dental laboratory technicians have found it important to DIAGNOSTICALLY identify HIP plane so that the dentist does not restore to a distorted cranial base. Since the patient poplulation with chronic TMD and postural problems obviously has a higher than normal HIP plane variance from normal base plane parameters, it is important that the clinician does not replicate this distorted base. Ergo Hoc Proctor Hoc, if clinicians restore this patient using the HIP reference it will only replicate the anatomic manifestations of the etiologic problems." - Robert Jankelson, Summer 2005 .
Some may laugh, jeer and criticize me for my passion and beliefs of my occlusal plane perspectives as they relate to clinical dentistry, but one day those critics will quiet themselves when our profession begins to further mature to the next level to see that our application of neuromuscular dentistry brings the science as well as the art together. Don't be confused. Change is in the making! Let's be tolerant, thoughtful and respectful of another point of view!
Some may laugh, jeer and criticize me for my passion and beliefs of my occlusal plane perspectives as they relate to clinical dentistry, but one day those critics will quiet themselves when our profession begins to further mature to the next level to see that our application of neuromuscular dentistry brings the science as well as the art together. Don't be confused. Change is in the making! Let's be tolerant, thoughtful and respectful of another point of view!
"It's a curious thing that physical courage should be so common in the world and moral courage so rare." - Mark Twain
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