Neuromuscular
What is Neuromuscular Dentistry?
Let me ask you a question, have you ever been to the dentist
and had a filling (crown) placed and then afterward the tooth or teeth or the
jaw hurt afterwards? It may not be a high filling or an abscessing tooth.
Sometimes you can't even tell where it is actually hurting.
In dental school we were taught that the teeth were attached
to the jaws that were part of the head and neck. There are also muscles, joints,
nerves and blood vessels that make up this whole head and neck complex. . .
somewhere along the line some of us forgot that.
Neuromuscular dentistry goes beyond not only the hard tissues
but also the soft tissues - muscles and nerves. We understand that there is a
balance between the bodies ability to adapt to imperfection and the stresses
placed on its physiologic range of motion and body posture. Thus our office
relies on having the ability to objectively measure muscle function and
correlate it to a proper jaw posture and its movements in function.
When the harmony of the teeth, the facial muscles, and the
temporomandibular joints no longer exists symptoms of what has been identified
as TMJ/ TMD (Temporomandibular Joint Dysfunction) arises. Here are the symptoms
that we see most often:
- Headaches
- Sensitive and sore teeth
- Facial pain
- Neck and shoulder aches
- Ringing in the ears
- Jaw pain
- Ear congestion
- Clicking/ Popping in the joints
- Worn down teeth
- Clenching &/or Bruxing
- Limited opening of the mouth
- Cervical/ Neck problems
- Loose teeth
- Tingling in the fingertips
- Forward head posturing
Call The Center for Exceptional
Cosmetic Dentistry and Adult Dentistry in Toms River today @ 732.341.8500
or E-mail us at drrotem@comcast.net. If you’d prefer to fill
out our online form for NJ dentist information, please click
here.
WHAT'S THE POINT?
In our office, Neuromuscular Dentistry emphasizes the need
to establish an occlusion based upon:
- the most stable position and function of the
temporomandibular joints
- the most relaxed resting posture and function of the
masticatory (chewing) muscles.
This is achieved by:
1) using electrical stimulation (TENS) to relax the
masticatory muscles
2) bio-instrumentation to correctly measure the muscles and
jaw position in "real time".
This approach differs greatly from the common dentistry
approach that treats the teeth and assumes the teeth, active muscles,
and the jaw joints will accommodate to the treated occlusion. Treating
teeth by restorative procedures (crowns, bridges, and fillings) or
common orthodontics (straightening teeth) are most often done without
accurately determining a correct jaw posture and a proper vertical
dimension.
A Neuromuscular Dentist can determine a proper resting jaw position
that effects the facial head and neck muscles, the teeth as well as
the joints. A physiologic resting position and body posture is often
overlooked and not even considered as an important part of the whole
dental system.
Our success is in the philosophy of taking a neuromuscular approach
in all facets of our dentistry including orthodontics, TMJ/ Myo-facial
pain problems and all areas of restorative and aesthetic treatments.
WHAT IS BIO-INSTRUMENTATION?
= COMPUTERIZED DIAGNOSTICS
In this day of technology and computerization, Dr. Ronen Rotem and his team use
state of the art technology to find a correct and accurate jaw posture
substantiated by objective measurable data of the muscles in function and at
rest.
BEFORE
The above recording depicts a "PATHOLOGIC JAW POSITION" that
is contributing to this patients TMJ pain symptoms. The diagnostic test indicate
that the jaw should be 2.1 mm forward (physiologic path of closure). Dotted line
indicates the ideal physiologic path of closure both frontally (green lines) and
sagittally (blue lines).
AFTER
Same patient is now able to function at a natural unstrained
position (the normal opening/ closing path is equal to a physiologic opening and
closing path). Notice that the 2.1 mm discrepancy is no longer present. The blue
and green lines verify that the jaw is properly aligned to a "Neuromuscular"
position. This patient is comfortable and free of myofacial pain.
Computerized diagnostics make it possible to accurately
find a physiologic position that meets the parameters of each individual
patient, not some old unjustified established norm.
If you are seeking "state of the art" care and treatment,
[especially for those of you that find yourselves in the difficult to complex
category (top 5-15%)] and are tired of educated guesses, trial and error
treatment protocols then you owe it to yourself to see how:
Computerized jaw tracking instrumentation - is used to record
jaw movements, range of motion, path of closure, protrusive guidance, rest
positions, habitual centric occlusion, and determine freeway space.
- Electromyography -is used to monitor the muscles in
function.
- Sonography - records jaw joint sounds and helps detect
abnormalities.
- Myo-monitor (low frequency TENS) - is used to relax the
hyperactive facial muscles.
- Transcranials - are special x-rays of the jaw joints to
evaluate the jaw joint condition and position.
Now you can see why it is paramount to find your
neuromuscular jaw position before a final restorative/ orthodontic phase is
started to prevent muscular imbalances that would lead to instability of the
teeth, supporting bone and compromised posture. A comprehensive analysis and
evaluation is highly recommended to assist the doctor in accurately diagnosing
and developing a treatment plan that can best meet your needs for long term
optimal dental health and comfort! “Subjective feelings and educated guesses
when treating the mandible, masticatory muscles of the head and neck, and the
temporomandibular joints will not produce cost effective results and treatment
times.”
"If you can measure something, it is a
fact; if not, it is an opinion." -US Supreme Court Justice Benjamin Cardozo
Computerized
Diagnostics
ADVANCED TECHNIQUES FOR PRECISION AND ACCURACY
  
COMPUTERIZED DIAGNOSTIC INSTRUMENTATION
A variety of other techniques have been developed to
diagnose TMJ diseases and disorders including mandibular jaw tracking, surface
electromyography and sonography. The use of computerized electro-diagnostics is
a more sophisticated approach to accurately and objectively define and treat TMJ/
TMD. In the past these technologies were not available thus resulting in
erroneous conclusion, misdiagnosis, and misguided treatments.
Although there are some opponents that say that there is inadequate evidence to
support the use and effectiveness of such diagnostics instrumentation, it is
clear that they are misinformed and do not understand how the instrumentation
can be used and implemented to aid in the diagnosis and treatment of TMJ.
1.
Computerized Mandibular Scanning (CMS)
1a. Computerized Mandibular Scanning is a more complex assessment
of mandibular function using biomedical instrumentation which measures
the rotational movement in the frontal and sagittal planes, thus confirming
a neuromuscular dysfunction. The computerized mandibular scanner measures
jaw movement (both qualitatively and quantitatively in several dimensions)
to within 0.1 millimeters of accuracy. With a magnetic tracking device
and sensor array, it projects the data on a calibrated computer monitor.
The CMS measures jaw movement far more accurately
than the eye, making it possible to document characteristics of mandibular
motion considered significant to evaluate jaw function. It also identifies
the amount of free space, the swallowing pattern, and the quality
of the occlusion, and substantiates the presence of disc derangements
and their prognosis for reduction. It is a multi-dimensional assessment
of torquing movements used to differentiate between contributing factors
of a pathologic position to a non-pathologic position on opening and
closing of the mandible. It is used in conjunction with EMG recordings.
Graphic recording of opening/ closing paths of jaw movements
from the side and front views can be analyzed to assess abnormal mandibular
paths of movement. The speed at which the jaw can open and close is also
simultaneously recorded.
1b. The literature supports the efficacy of mandibular
tracking in the diagnosis and treatment of TMJ/ MSD.
- There are over 22 controlled published studies that further
support the rationale for mandibular jaw tracking.
- There are 25 additional supporting referenced studies
confirming the same.
- There are numerous other studies that document the clinical
efficacy and validity of computerized mandibular scanning.
2.
Electromyography (EMG)
2a. Surface electromyography is a series of tests to more specifically delineate
and define hypertonic musculature in the compromised TMJ patient. These series
of tests are necessary to differentially diagnose between intra-capsular
interference (mensical or otherwise) and extra-capsular interference (influence
of the surrounding hypertonic muscular matrix) so as to determine the
predominant dysfunctions. Surface electrodes are placed over the muscles which
in turn send impulses to the recording instrument. Defining the etiology of the
TMJ patient's predominate neuromuscular dysfunctions will preclude misdirected
palliative treatment regimens.
Surface electromyography (EMG) utilizes eight channels
monitoring the right and left posterior temporalis muscles, right and left
anterior temporalis muscles, right and left masseters, and right and left
anterior digastric muscles. A clinical hands-on muscle palpation examination is
not able to quantify and objectively record muscle hypertonicity with out
subjective intervention.
Muscles of the face and jaw can be recorded to determine
hyperactive muscle activity and/ or resting muscle activity. A strained jaw
position can effect muscle activity. The objective is to determine the optimal
resting jaw position at physiologic rest that harmonizes with resting EMG
levels.
2b. There is a broad body of literature that supports the physiologic basis for
using surface EMG as an aid in assessment of muscle function/ dysfunction. (38 +
studies support this ending with Lynn et al, 1992).
- There is substantial evidence based upon controlled studies
that confirm that surface EMG is reliable and reproducible. (18 studies ending
with Dean et al., 1992).
- 87 studies verifying the use, safety, and efficacy of EMG
to monitor masticatory muscle function/ dysfunction.
"In summary, based on well controlled empirical and
clinical studies that have been conducted in several universities over the past
three decades throughout the world, there is unequivocal evidence to strongly
support the use of EMG for the evaluation and diagnosis of temporomandibular
disorders." - Robert Jankelson, D.D.S.
3. Sonography
Sonography utilizes a kinesograph to measure
intracapsular TM Joint sounds against normalized data, duration of these sounds,
exact location of the occurrence of these sounds during jaw opening/ closing, or
lateral excursions, and a spectral frequency analysis of the sound. Without this
information, one could not restore function free of intracapsular interference
resulting in decreased muscle tenderness on palpation, an increased range of
motion free of restrictions and resolve patient complaints of pain). A pair of
ultra sensitive transducers are held in place by a lightweight headset over the
temporomandibular joints. Vibrations from each joint during opening and closing
of the mandible are monitored by the transducers, amplified and inputted into a
computer for display, analysis and data storage. The joint sounds are analyzed
by the computer in terms of amplitude and frequencies present relative to
occurrence in the opening and closing cycles. It is a valuable adjunct used in
conjunction with other clinical diagnostic modalities to confirm such conditions
of joint pathology.
Sound vibration recordings when the jaw is opened and closed.
4.. TENS (Transcutaneous Electro Neural Stimulation)
Transcutaneous electrical nerve stimulation is a specific therapy for the
treatment and resolution of pain related to neurological and myofacial
conditions. It does this by delivering a mild electronic impulse through the
nerves that control the masticatory and facial muscles. The rhythmic pulsing
relaxes the muscles and therefore allows us to determine the correct relation of
the mandible to the cranium. It also relieves pain and trismus of the muscles of
the face caused by spasms and tension. In addition, it propels the mandible
through space to a position which is most compatible with a relaxed musculature.
This procedure involves the placement of electrodes bilaterally in the
preauricular area anterior to the right and left ears, just lateral to the
coronoid notch. The current emanating form the electrodes stimulate the motor
divisions of the fifth and seventh cranial nerves. The TENS pulse rate is once
every 1.5 seconds (low frequency). It mimics the natural pulsing action of the
body somewhat like a massage. The effectiveness of the TENS therapy is
documented by EMG recordings.
Although the use of TENS is a mode of treatment it can be used
most effectively when used in conjunction with CMS and EMG recordings
simultaneously in objectively documenting and diagnostically gathering
information before, during and after treatment.
The efficacy of low frequency TENS in the diagnosis and
treatment of TMJ/ MSD has been clearly confirmed in the published literature. It
is clear and unequivocal that low frequency TENS (.05 Hz - 10 Hz) is both safe
and efficacious for muscle relaxation and pain control. It is clear that low
frequency TENS has a high degree of specificity when utilized for craniofacial
pain. (Over 44 internationally published studies support and confirm this
fact).
There is more than adequate confirming
evidence to support the effectiveness of such diagnostic instrumentation as
verified and confirmed by the American Dental Association (ADA) and the Food and
Drug Administration (FDA).
The American Dental Association’s Council on Scientific
Affairs has awarded surface electromyography (SEMG), Computer Mandibular
Scanning (CMS), and Sonography its "Seal of Acceptance", as diagnostic aids in
the management of temporomandibular disorders.
(Report on Acceptance of TMD Devices, ADA Council on
Scientific Affairs, JADA, Vol. 127, November 1996).
The U.S. Food and Drug Administration has granted 510k
status to each of these mentioned devices for use in the diagnosis and
management of TMD in my practice.
This reflects that the U.S. Government and the dental profession
acknowledges the safety and efficacy of the devices as recording and
measuring devices used in the diagnosis and management of TMD and
orofacial pain.
Call The Center for Exceptional
Cosmetic Dentistry and Adult Dentistry in Toms River today @ 732.341.8500
or E-mail us at drrotem@comcast.net. If you’d prefer to fill
out our online form, please click here.
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