Neuromuscular Dentistry
Showing posts with label Neuromuscular Dentistry. Show all posts
Showing posts with label Neuromuscular Dentistry. Show all posts
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, 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.
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.
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
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?
Thursday, September 11, 2008
Jaw Tracking Technology Is NOW Being Realized in Dentistry
by Clayton A. Chan, D.D.S., M.I.C.C.M.O.
The leaders in the dental profession are finally recognizing the importance of objective occlusal measurement instrumentation four decades after Dr. Bernard Jankelson’s pioneering work. In 1966, Dr. Jankelson risked his professional reputation for what he believed would change the future of dentistry.
Myotronics-Noromed's computerized electro-diagnostic technology has shown a history of consistency and innovation in producing quality jaw tracking technology that measures the movements of the human jaw (circa 1970). It is with this technology that the dentist can determine an optimal physiologic bite position. It is an occlusal/bite position that provides a starting point of occlusal treatment for all treating clinicians. Without a specific bite position, all measuring diagnostic aids are only aids to diagnose, but what about the occlusal treatment position, especially those restorative dentists who take that next step beyond initial diagnosis?
CMS Sensor Array by Myotronics-Noramed, Inc., Kent, Washington
Objective diagnostics are a critical component to the overall examination process before any mode of treatment begins. Joint vibration/sound can measure joint sounds. EMGs can measure muscle activity, but what about the bite position? Once the diagnostic process has been completed it should lead the treating dentist to a basic conclusion as to where a jaw position should relate to the upper cranial base (maxilla). Recording EMGs may record the amplitude activity of muscles, but is not definitive enough for the dentist to determine a therapeutic condylar/disc position for the mandible, especially for those cases with joint derangement problems.
Certain diagnostic aids are more meaningful to me than others when it comes to specific occlusal treatment in both a phase I (stabilization) or a phase II (finishing) mode of treatment, i.e. restorative dentistry. Today, electrosonography (ESG)/joint vibration analysis (JVA) has been a favorite to many who have focused their attention on joint sound analysis. Although, ESG/JVA technology has validity in identifying joint sounds it has its limitations from a clinical treatment perspective.
Another area of recent focus has been on electromyography (EMGs). This modality has been around since 1980, but few wanted to acknowledge its significance in the early years. Surface EMG is now endorsed and accepted by leaders of all philosophies of occlusion as a valid technology to measure muscle activity and muscle function.
Computerized Mandibular Scanning (CMS) K7 instrumentation, by Myotronics, Inc., is the hallmark of objective measurement devices that has consistently shown credible accuracy in mandibular tracking, allowing the dentist to visualize the jaw position in space. This incredible visualization tool is what I want serious restorative dentists to recognize above all other devices as the modality of choice, giving them the ability to quickly recoup their investment by providing occlusal dental care. This technology has positively changed my professional life for the better and is also changing the landscape of dentistry. ESG and EMG are good diagnostic aids which I also use. TENS is a must to relax spastic muscles. CMS is a must for any clinician serious about optimizing the patient's bite position prior to completing a full mouth /TMD rehabilitation.
Our dental profession is taking notice!!!
Disclosure Note: Dr. Chan does not have any financial interest in, and is not paid by Myotronics-Noromed, Inc. to write his views about their technology.
The leaders in the dental profession are finally recognizing the importance of objective occlusal measurement instrumentation four decades after Dr. Bernard Jankelson’s pioneering work. In 1966, Dr. Jankelson risked his professional reputation for what he believed would change the future of dentistry.
Myotronics-Noromed's computerized electro-diagnostic technology has shown a history of consistency and innovation in producing quality jaw tracking technology that measures the movements of the human jaw (circa 1970). It is with this technology that the dentist can determine an optimal physiologic bite position. It is an occlusal/bite position that provides a starting point of occlusal treatment for all treating clinicians. Without a specific bite position, all measuring diagnostic aids are only aids to diagnose, but what about the occlusal treatment position, especially those restorative dentists who take that next step beyond initial diagnosis?
CMS Sensor Array by Myotronics-Noramed, Inc., Kent, WashingtonCertain diagnostic aids are more meaningful to me than others when it comes to specific occlusal treatment in both a phase I (stabilization) or a phase II (finishing) mode of treatment, i.e. restorative dentistry. Today, electrosonography (ESG)/joint vibration analysis (JVA) has been a favorite to many who have focused their attention on joint sound analysis. Although, ESG/JVA technology has validity in identifying joint sounds it has its limitations from a clinical treatment perspective.
Another area of recent focus has been on electromyography (EMGs). This modality has been around since 1980, but few wanted to acknowledge its significance in the early years. Surface EMG is now endorsed and accepted by leaders of all philosophies of occlusion as a valid technology to measure muscle activity and muscle function.
Our dental profession is taking notice!!!
Disclosure Note: Dr. Chan does not have any financial interest in, and is not paid by Myotronics-Noromed, Inc. to write his views about their technology.
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