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.

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.

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.

Neuromuscular Dentistry

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.

Discovering GNEUROMUSCULAR Dentistry and the latest in Dental Continuing Education

Neuromuscular Dentistry - Measuring and Evaluating by Objective Analysis

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:

1. Make sure your orthotic is properly designed to accommodate lateral cuspid rise and posterior disclusion.
2. Anterior contact and posterior disclusion is an absolute requirement for these kind of cases (something most NM teachings overlooked).
3. Protrusive contacts must be properly balanced.
4. Retrusive contacts must be balanced, but not eliminated (especially in the supine laying down positions – night time wear).

Bottom line is that proper micro occlusal coronoplasty application must be implemented to get a proper result. The patient must be able to chew and function normally with a properly adjusted orthotic, if not the patient will not be comfortable and wear the appliance. Any interferences during functional jaw movements that remain will trigger unresolved clenching challenges and the patient will not resolve to the next level.
It has been my clinical experience that patients that present as so called “clenchers” will present with:

1. 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.
2. Arches appear well developed, but don't let that decieve you.
3. 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).
4. Inadequate disclusion of the posterior teeth during protrusive movements.
5. 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.

Common Clenching Symptoms Relating to the Bite - Dentist Need to Know
The following headaches can and should be resolved by the dentist:

1. Temporal headaches
2. Masseter facial pain
3. Tenderness and pain at the posterior lower border/corner of the jaw.
4. SCM tenderness
5. Cervical neck pain and tenderness
6. Pain in the occipital region
7. Pain on top of the head
8. Shoulder pain
9. Numbness and tingling in the arms, hands and fingers

Note: No matter how long you TENS and how many Myotrodes you place if you don't fix the bite to proper physiologic parameters, the dentist will be confused and will continue to search for the unobvious.
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.

Neuromuscular Dentistry

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.

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.

Neuromuscular Dentistry

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?

Neuromuscular Dentistry

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.

"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, NV

Dentistry 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.

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.

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!

"It's a curious thing that physical courage should be so common in the world and moral courage so rare." - Mark Twain

Neuromuscular Dentistry

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.

Neuromuscular Dentistry

MISSION AND GOALS

Occlusion Connections.com is a site that encourages open interaction by dental professionals wishing to further their learning and experience through internet communication and web interaction.

This blog is dedicated to those dentists and technicians desiring to take their dentistry to the "next level" in Physiologic Occlusion.

Neuromuscular and gnathologic concepts and philosophies are synthesized in the fields of TMD, restorative rehabilitation and orthodontic/orthopedics.

This site is dedicated to increasing the sophistication of the diagnosis and treatment we can offer our patients.

We believe in a community of dentists and technicians who want an honest exchange of answers to clinical questions and concerns regarding dental occlusion and its management issues.

Using involuntary muscle stimulus with the Myomonitor TENS to adjust the bite.

ADVANCING THE USE OF NM TECHNOLOGY CLINICALLY
One thing I realized is that using the J4/J5 Myomonitor TENS can work for you or against you if the dentist is not properly trained in such advanced technology! Using computerized mandibular scanning (CMS/ "Jaw Tracking") is also another high tech tool to effectively measure and quanitify the jaw position, but if not fully understanding its strengths and weaknesses can certainly lead the clinician down various paths of diagnosis and treatment. I am all for keeping it simple and effective. Jaw tracking is an amazing tool in dentistry to locate a jaw position combined with TENS (muscle relaxation) to speed up treatment resolution time and precision...Time Saver - YES! I wouldn't be where I am and couldn't do what I do without it! That is the KEY!

Electromyography is good for science, but lets get clinical and practical!

There are 2 SIMPLE KEY TECHNOLOGIES I use to get the results I get: TENS and TRACK THE JAW (CMS) position and THEN manage the occlusion to perfection!

Establishing a physiologic mandibular to cranial relationship has challenged the great minds of the dental profession, especially when it relates to TMD, orthodontic and complex prosthetic/restorative treatment. As we know, most of our profession has been trained to use anatomical bone and tooth references to establish a jaw position, but this may not always be effective especially when the TM Joint bones and or teeth structures are worn, degenerated and display dysfunction. Patient's who experience pain, joint derangement and muscular dysfunction challenge the minds of the dental and medical profession, searching for definitive answers to their muscle, occlusal and skeletal problems, desiring a better quality of life.

Obtaining a healthy (physiologic) comfortable "Bite" requires the clinician to understand what is not healthy (pathologic). Furthermore, how to determine a proper mandibular jaw position to establish precision in the bite also requires an appreciation of optimal micro-occlusal management to support an unhesitating healthy central nervous system response of the coming together of the teeth instantaneously confirming to the patient that the bite is comfortable and right to neuro-physiologic standards. Anything less than this, the body attempts to accommodate to some level of adaptability.

by Clayton A. Chan, D.D.S.

Mounting the Maxillary Dental Cast Using the Fox Plane

by Clayton A. Chan, D.D.S.
USING THE FOX OCCLUSAL PLANE - 3 STEPS
The task of orienting the maxillary cast is often given to the dental laboratory technician. The clinician usually has little awareness as to how the maxillary cast is technically mounted and often assumes it is being done correctly. In reality it is commonly being manipulated to position by the lab technician in the plaster room often with no accurate record or registration to go by. It is the lab that is deciding the maxillary cast orientation and mounting position. More often than most it is not the clinician. I see this as a huge problem for those clinicians wanting to take their cases to the next level. If so they need to take control and give the lab technician an accurate reference to mount the upper cast each and every time. In order to implement this simple technique it is imperative that the cervical neck is stable, if not the leveling of the Fox Occlusal Plane will challenge the clinician. This is what I do!

To orient my maxillary dental cast correctly as it relates to the patient's head orientation at level, I simply use a Fox Plane and a flat mounting table.

Sophisticated simplicity! My lab technician loves it's simplicity and accuracy.

Step 1: I record the maxilla's orientation in the patient's mouth using Dentsply's Trubyt Fox Occlual Plane. It is very simple! With the patient's head at level (eyes looking straight ahead at the horizon), I like to have the patient standing, I use a 30 second set Polyvinyl (PV) bite registration material and inject it on the bite fork. I then place the bite fork of the Fox Plane up against the anterior teeth keeping the Fox Plane level to the ground and level to the patient's leveled head. I do not press the PV Fox Plane up against the upper posterior teeth. If you do you are screwing up the occlusal plane indexing (OPI) record for your maxillary mount. Only the anterior central teeth should penetrate the PV material on the bite fork.


From the frontal view the Fox Plane is perpendicular to the long axis of the face. (I do not reference to asymmetric eye levels, neither distorted ears levels, but rather observe the overall long-axis of the face to establish a perpendicular level frontally). From the sagittal view I use an imaginary line from the corner of the eye (exocanthion) to the connecting line of the temple of the head and base of the anterior portion of the earfold (I call it the temporal helical fold). From the sagittal view I want this line level/parallel to the ground. The Fox Plane is also leveled parallel to this imaginary line when capturing this maxillary orientation record, I call the OPI - Occlusal Plane Index. Once it is set, I check for levelness both frontally and sagittally and remove it from the patient's mouth.

Step 2: I peel the set PV index from the Fox Plane bite fork and position the OPI to the flat mounting table, positioning it flat againsT the flat table in the anterior and middle of the table. [Any flat mounting table fitted to any articulator will work. There are a number of articulator companies that offer these tables (a growing trend in articulation it seems) and any table will work. I use Ivoclar's Stratos 200 Semi-Adjustable Articulator fitted with the "Flat set up table" and "Instrument carrier" (Stock #536394 and #536399)].

Step 3: Orient the maxillary cast into the PV OPI recording your took using the Fox Plane and mount the upper cast with mounting stone. You can stablize the OPI and stone cast with hot melt glue from Home Depot. It works great! Just wet the model first and blow dry the surface dampness quickly with compressed air and mount.

Note: The natural occlusal plane slant is simply transfer from the mouth accurately via the Occlusal Plane Index (OPI) record with fast set PV bite registration. (Read more to see the corresponding lateral cephalogram on "What Angle is the Occlusal Plane to the Horizon?) The maxillary cast mount is not accurately duplicated.

Now you have the maxillary cast mounted to level just as it was in the patient's mouth, with patient's head at a level position. Pretty simple! Anybody can do it! Most of you dentist all have a Fox Plane from dental school! Pull them out and use them. Your Lab Technicians will love you for this.

If you don't want to mount the upper cast yourself, then simply remove the PV OPI record from the Fox Occlusal Plane and mail it to your technician of choice. There are no moving parts to distort, more or shift during transportation or shipping to the lab. Make sure you send a frontal view photo of your patient so your lab can confirm the mounting visually.
For those clinicians not familiar with a proper head position and occlusal plant slant, what would appear as not natural may in actuality be physiologic once one learns what a proper head position is and how the position of the mandible effects head positioning and head tilt. Controlled studies have shown a normal "physiologic" occlusal slant is 6-14 degrees and not flat as many believe. Remember: If you are having difficulty in keeping the head level while recording the occlusal plane via this Fox Plane technique perhaps you may want to reconsider whether your patient's cervical neck posture is truly stable. An unbalanced cervical aligment will effect occlusal/mandibular stability.
If you would like to read more on the rationale, science and reasons why I choose to mount my complex cases in this simple way you can read my article "A Clinical Significance of the Occlusal Plane".

Anatomical Lower Or-tho'sis

by Clayton A. Chan, D.D.S.

The Science of Aligning Body Parts to Improve Function
"Pl. ortho'ses [Gr. orthosis making straight] an orthopedic appliance or apparatus used to support, align, prevent, or correct deformities or to improve the function of movable parts of the body." - Dorlands Medical Dictionary, 26th Edition.

This is what my Anatomical Lower Orthois looks like for most of my patient's. It is made from a 2.5 mm bisacryl clear shim base formed over a lower cast. It is then overlayed with a lab processed orthodontic acrylic and later hand carved anatomically to match the patient's occlusion. I usually do this myself. Fabrication Time: Approximately 4 hours.

Webster's dictionary defines a Splint as a "material or device used to protect and immobilize a body part". Masticatory muscle proprioception requires the most exquisite repositioning of any body part if optimal rest and function is to be achieved. Splinting implies an immobilization which is exactly opposite of the desired criteria for physiologic occlusion. A law of muscle physiology is that any obstacle to muscle action initiates excitement of muscle.

I am a firm believer of orthosis therapy, especially for any patient experiencing joint derrangement, masticatory muscle dysfunction and or pain. Most TMD pain comes from muscles that are restricted. A lower removable anatomically orthosis allows for freedom of entry to and from the established terminal contact position (myocentric) where the internal and external muscles of the jaw have freedom to move as well as rest properly. The anatomical lower orthosis specifically supports optimal disc and condylar positioning within the glenoid fossa, acknowledging the unwanted clicking and popping symptoms.

Indications for an Orthosis
Indications for an orthosis are many and are varied. "A fixed reconstruction is in a true sense a permanent orthosis." - Jankelson, R. In this blog, an orthosis is refered to as a lower anatomical removable appliance used to align and support the mandible in an occlusal position that sustains relaxed musculature and optimal function.

1. Provisional deconditioning of the TMD/TMJ/MSD symptomology of the patient. Deprogramming the muscle engrams via low frequency Myomonitor TENS allows the establishing of physiologic rest to identify a starting point to reference the neuromuscular bite registration.
2. Provisionally repositions the patient's jaw to identify both the anterior vertical as well as the posterior vertical dimension. Additionally, a very important aspect which is often overlooked is the anteroposterior relationship of the lower jaw to the upper jaw to anticipate final reconstruction and facial esthetics. It is essential that the orthosis be worn to establish muscle comfort to begin a pain free testing period of 3 months off medications prior to any finalizing restorative therapy. CMS (Computerized Mandibular Scanning/Jaw Tracking) and EMG (Electromyography) documenting jaw functioning ability and muscle status are objectively measured to determine a suitable occlusal position after 4-6 months or longer to prove stability and comfort.
3. An orthosis can be used as an intermediate holding appliance during orthodontic/orthopedic treatment of dysfunctional patients needing definitive orthodontic care. The appliance in those cases can be used as the "ORTHOPEDIC MATRIX" to help guide the clinician to the finalized treatment position via modification of the orthosis and verticalization techniques to assist in periodontal, bone, ligament and tissue remodeling and development.
4. The orthosis can be used for those patients who teeter on borderline dysfunction and are on the edge of clinical symptomology. Some of those patient's may decide to wear the appliance on an "as need basis" since orthodontics and or complex restorative treatment may pose an economic or emotional impossibility. Some may be able to wear the appliance at night time only and go about their daily activities symptom free.
5. The orthosis can also be used as a nightguard to reducing clenching and bruxing. Noctural stresses can be greatly reduced by providing a neuromuscular position free of any interferences and noxious proprioception. True clenchers are poor, high risk candidates for fixed reconstruction rehabilitation or orthodontics unless the pelvis and sacro-iliac region is properly aligned to support an aligned cervical neck (Atlas C1) with a balanced occiput. Any imbalance in the postural system will contribute to unresolved clenching actions and abnormal forces.

The orthosis is designed to distribute even forces through out the mouth to give balance and support to the complete body to allow it to function and rest optimally. It can be worn 24/7 with proper home care.

My Personal View
The lower anatomical orthosis is my appliance of choice! It is the one appliance I use for all my TMD patients who exhibit masticatory dysfunction,pain and joint derrangement. I keep it very simple, yet sophisticated! I don't use night time appliances or day time appliances to confuse the patient. My patients wear only one appliance, no day or night time appliance, just like they don't have day time teeth and or night time wearing teeth. I design the orthosis so it does what it is suppose to do both antomically and functionally in the mouth. My patient's love it, having tried numerous kinds of appliances (uppers, lowers, soft, hard, anterior positions, anterior discluders, jigs, shims, flat plane, even some so called NM appliances, etc. etc. and etc.). Another KEY is finding the correct bite position!


The Clincians Responsibility
If the clinician understands how to properly design, adjust, modify and deliver the orthosis appliance properly, the patient should report that the lower removable anatomical "orthosis feels better in than out!" Patient's that cannot wear the appliance comfortably will naturally take it out and not resolve optimally. I do not believe the patient has to get use to something that does not feel right in their mouth. The clinician must take the proper time to make the orthosis feel right. 


There are simple things that can be done by the laboratory and the dentist to make the appliance feel totally comfortable....but that is for another blog posting.... see Orthotic Central.

Occlusion 101

by Clayton A. Chan, D.D.S.

FIVE PRINCIPLES OF NEUROMUSCULAR OCCUSION
There are 5 fundamental principles of Neuromuscular Occlusion that dentist must recognize when treating patients comprehensively.

1. There exists numerous muscle-structural and bite related signs and symptoms that effect the jaw joints, contributes to abnormal jaw function resulting in abnormal occlusal form confusing the central nervous system (CNS).
2. Homeostasis must be established in the masticating system if the the position of the mandible to the cranium is to be "Physiologically and Anatomically" correct.
3. An isotonic mandibular closure pattern must exist to produce an optimal neuromuscular trajectory for proper joint function and tooth to tooth function.
4. A terminal contact position can be established with no interfering inclines that disrupts an isotonic movement of the mandibular system contributing to disabled "Happy Muscles".
5. The clinician can validate objectively muscle function, jaw positioning and joint sounds with measurable scientific technology.

Whenever we overlook these basic keys in our dentistry (diagnosis and treatment) we will relinquish our treatment to pathologic maintanence. Our patient's deserve better. Practicing dentistry with these key principles in mind have revolutionized many dentist, bringing value to the patient and confidence to the practicioner.

ASK US - You Got Questions? We Got Answers.

Your Questions Answered

If you have a question regarding neuromuscular dentistry or NM occlusion concerns, our group will do our best to answer them. Send it to clayton@drclaytonchan.com.

Don't Feel Embaressed
I have been practicing a Jankelson/Myotronics NMD (Neuromuscular Dentistry) mixed in with hard core gnathologics for over 13 years now. I have spent eight of those more recent years teaching extensively thousands of advanced dentist and specialist around the world who have sought serious answers to serious questions regarding the occlusal challenges that have haunted them since dental school training. Admit it! We never learned the science of occlusion adequately to meet the challenges we face in todays real world of clinical (in the trenches) dental practice. Don't feel embarressed. It's OK. I may have the answers you are looking for.

Some of you have educated yourselves in various programs and still desire to further your skills, awareness and understanding of NM and classical post graduate dental teachings. I believe the answers will slowly unveil themselves right here from this site as you stay tune and keep in touch as I continue sharing my passion and perspectives.

This Is a New Season ....!


How Many Times Do You Adjust the Bite Before Problems Erupt?
What do you do when your patient is returning back to your office numerous times after you equilibrated the bite? Do you keep adjusting more teeth or do you give them an elequent exiting referral and admit you don't understand their problem?

Are they beginning to complain of temporal headaches and facial/masseter and neck soreness that they did not formerly experience? Are they experiencing ear congesting/stuffy ear feelings and or clicking and popping in their jaw joints that did not previously exist? Guess what? There is a clear connection between the bite adjustments you performed, muscles and the condyle/disc positioning within the TMJ's.

The following are just some questions we have answers to to meet the demands of refined clinical dentistry.

How Do You Use the Myomonitor?
The sole purpose for the TENS Myomonitor is to relax the masticatory muscles. It is a non-invasive modality that either the patient, support team and or clinician can easily use. The J5 Myomonitor comes with 3 leads that connect silicone gel surface electrodes which are simply place bilaterally over the coronoid notch (ground leads) and in the middle of the upper neck (common lead). Synchronized bilateral pulse levels are usually around 4-6 on the amplitude dial, just enough to produce a 0.5-1.0 mm rise of the mandible. 45-60 minuets of TENS stimulation will begin to produce a therapeutic response of muscle relaxation.

Are EMG's Really That Important in Clinical Dentistry?
Although great emphasis has been placed on electromyography to scientifically validate objectively physiologic muscle activity in the scientific community, I have found that it is not always required when establishing a physiologic bite relationship "Clinically". I use habitual resting EMGs to document the base line status to assist in my overall "diagnosis" and use functional EMGs to validate "treatment" effectiveness. I do not rely on resting EMGs to determine my bite position since they do not give me the definitive location to establish a bite. CMS jaw tracking is a far better tool to visualize a specific position and location of the bite then resting EMGs.


Where Can I Learn More About NMD?
Where Can I Learn More Advanced TMJ Problem SolvingTechniques?
Stay tune and connected! We will post locations and dates in the future, but for now if you have questions, don't hesitate to comment and blog your thoughts.


How Do I Coronoplasty the Bite?
Hands on demonstration is really the best way to visualize and see how I do it. But for now, first establish the myocentric bite position, land the dots as I have instructed in previous courses in the past.

Note the bilateral point contact DOTS that are balanced to the neuromuscular position. Precision is required in order to calm the hypertonic muscle activity of those patients with high level of detailed proprioception (ie. clencher/bruxers, TMD paining patients).


QUESTIONS:

Are You Accommodating Your Dentistry to Worn Down Dentition?

Is Worn Down Dentition Dictating Your Type of Dental Practice and Are You Accommodating Your Style of Practice to Routine Dentistry vs. Optimal Care?

What is the Difference Between Equilibration, Coronoplasty and Micro-Occlusion Management?

What is the Significance of Proper Head Balance and the Occlusal Plane?

Pathologic or Physiologic Occlusal Plane? How Do You Relate the Maxillary Cast to the Articulator to Avoid Long Term Pitfalls in Your Full Mouth Reconstructions?

Why is TENSing Important Before Taking a Bite Registration?

How Do You Properly Use the K7 To Capture a Myobite? Is it Necessary?

How Do You Take A Proper "Chan Scan" 4/5? Ask Chan
Designing a Comfortable Orthosis and How to Properly Fabricate the Orthosis?

How to Properly Deliver the Orthosis to Your Patient for Optimal Resolution?

Can the Dentist Orthopedically Verticalize the Posterior Teeth Without Surgery and Correct a Skeletal Class II Relationship?

The answers to all these questions area answered at my Advanced Courses. (Click Advanced Neuromuscular Clinicians - "Advanced Problem Solving for the Complex Cases" and “Micro-Occlusion/Coronoplasty – Level II” ) for course dates and location.

Relaxing the Muscles with TENS

by Clayton A. Chan, D.D.S.

When patient's come to me for help regarding their TMJ problems I always use low frequency muscle stimulation (J5 Myomonitor, Myotronics, Inc, Kent, WA) to relax the muscles that are in spastic tension. After a thorough evaluation and comprehensive work up, I will use this simple non-invasive modality to help me find and establish a more physiologic jaw/bite relationship for lower orthotic laboratory fabrication. Relaxing all the muscles of mastication first is the first fundamental principle that is missed among dental professionals when therapeutically treating these kind problems. Without establishing the mandible to a more neutral state as it relates to the cranial base, the dentist will not effectively be able to calm the many head and neck pains that trigger the Central Nervous System and back to the jaw, teeth, head and neck region. This is a key principle that more and more clinicians are now recognizing.