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TMJ/ MSD is a group of separate, but related disorders of the temporomandibular joint and all the associated muscles, ligaments, nerves and supportive structures. Unfortunately, TMJ/ TMD are one of the most misdiagnosed of the medical/ dental conditions. There are two factors that account for this sad state of affairs.

First, few central New Jersey dentists (or physicians, chiropractors, osteopaths, etc.) have proper training in the diagnosis and treatment of TMJ/ MSD.

Secondly, these disorders have many overlapping symptoms which mimic many other conditions.

Misdiagnosis is the rule rather than the exception with MSD. Patients wander from one specialist to another, and from one New Jersey dentist to the next, depending on the type of pain and problems they experience. Symptoms focusing on ear, sinuses, or swallowing problems are referred to an Otolaryngologist. Limitations of jaw movement are referred to an Orthopedist. Persistent head pains are referred to a Neurologist, and the list goes on.

As the wanderers are told by uninformed doctors and NJ dentists that there seems to be no organic basis for their pain, and that the cause is psychogenic, their anxiety mounts. When physical findings remain obstinately in abeyance, patients may begin to suspect a brain tumor, turn to drugs to alleviate their symptoms, or on rare occasions, even contemplate suicide.

Anatomy of Temporomandibular Joint:

The Temporomandibular Joint is the joint connecting the jaw (mandible) to the skull (temporal bone).

The two bones are held together and function via a complex group of muscles, ligaments and other soft tissue. The temporal bone has a concavity, called the glenoid fossa in which the head of the jawbone (the condyle) sits. A cartilage disc, called the articular disc, separates the two bones. The articular disc slides in conjunction with the mandible to provide smooth quiet movement and acts as a cushion against heavy forces generated by the strong jaw muscles. The right and left TMJ joints do not act as separate joints, but must move in coordination with one another.

The TMJ joints are considered the most complex joints in the human body because they must provide for rotational movements, sliding movements and an infinite range of combined movements and functions, unlike any other joint in the body.

The lower jaw (Mandible) has a relationship to the upper jaw (Maxilla). If this relationship is altered, the muscles of mastication (chewing muscles) go into spasm. This causes the muscles that have the same nerve intervention to also go into spasm. The resulting stresses may radiate throughout the head, neck, and even involve the back. The pain may be constant or intermittent, lasting minutes, hours, days, or even years. Many patients describe the pain as a migraine headache. Eventually a patient may demonstrate clicking, grating, snapping, or popping sounds in the joint.

This joint pops upon opening. A grating sound may occur here.

Mechanics of Temporomandibular Joint Dysfunction:

The lower jaw may be over closed (too close to the upper jaw), and /or distally displaced (too far back in the joint or socket). Also, the lower jaw may deviate to one side due to interfering tooth cusps (points on the chewing surfaces of teeth that do not meet properly with the opposing teeth).

The cause is multifaceted, i.e., loss of teeth, poor alignment or natural wear of teeth, grinding or clenching of the teeth day and night, poor tongue position, a muscle imbalance in the tongue and the facial muscles, chronic mouth breathing, osteoarthritis, rheumatoid arthritis, trauma, etc.

To determine if an improper relationship exists between upper arch and the lower jaw, it is necessary to relax the muscles of mastication (chewing muscles), then close the relaxed lower jaw on a trajectory that is not strained. In other words, the mouth closes were the muscles are most comfortable.

To relax the muscles of mastication, a gentle pulsating stimulus is applied to the skin for approximately one hour. Multi-channel electromyography (EMG) is used to verify the degree of muscular relaxation.

Dr. Rotem, a top dentist in NJ, will tell you that MSD is not a rare condition. Every patient has some degree of Musculoskeletal dysfunction. It is when symptoms are manifested that people seek help. Many patients tend to clench and/or grind their teeth in response to unconscious stress, creating muscular dysfunction. This usually occurs during sleep, but it may also occur during a stressful daily experience. Resolution of unconscious stress which cause symptoms indicated on the Screening questionnaire may require stress counseling. Subconscious stress must be controlled for successful resolution of clenching and /or grinding of teeth.

Posture and Airway

Posture has an effect on the relationship of the lower jaw to the cranium and can result in a malocclusion (improper bite). If body symmetry is not within normal limits, physical therapy may be necessary to correct body symmetry during treatment.

Airway obstruction must be cleared as it will result in constant mouth breathing. Allergy is a primary cause of chronic mouth breathing. If nasal obstruction is evident, consultation with an allergist and/or Otolaryngologist will be recommended during treatment. All chronic mouth breathers develop an improper bite (malocclusion).

Initial Treatment for TMJ:

New Jersey dentists may recommend three approaches, or a combination thereof, as initial therapy:

1. Occlusal correction or coronoplasty (reshaping teeth to remove interferences that cause abnormal jaw displacement).
2. Construct an orthotic to orthopedically align the lower jaw to the cranium in three dimensions providing there is an over closure. If symptoms subside after wearing the appliance for three months, crowns may be recommended to maintain the orthopedic position established by the orthotic. Orthodontics may be recommended to avoid crowns. Possibly a combination of orthodontics and crowns will be recommended. When posterior (back) teeth are missing, dentures and /or partials may be recommended. For more details, see Our Treatment Protocol.
3. Surgery is the last and least recommended when irreversible damage has occurred in the joints and is beyond natures healing.

"Key to Success"

Skill, knowledge, paying attention to detail, & Computerized Diagnostics leads to precision and accuracy = Desired Results! The key to our success is in "the Neuromuscular Approach" we take. Consistent predictable results is what allows our patients to experience the long over due relief from their agonizing pain.

One of the many reasons Dr. Rotem is considered preeminent among central New Jersey dentists is the meticulous and systematic way he goes about treating his TMJ patients. He leaves nothing to chance. He realizes that rushing and hurriedness will not lead to predictability. His approach takes time when the patient is under his care at each diagnostic and treatment visit. Precision, accuracy and attention to detail is what is necessary to get the desired results for each patient he treats.

Because he is committed to seeing results for his patient's, he takes the time to methodically address each area of the diagnostic work up in order to gain optimal results in the shortest recovery time possible.

Attention to Detail Takes Time

When adjusting the lower arch orthotic appliance, Dr. Rotem does more than just hand the patient their new appliance and wish them the best.

A series of four (4) meticulous steps are taken to detail and adjust the appliance to assure that he gets positive-timely results.

• An initial adjustment implementing TENS is used to assure that the orthotic is adjusted to be in harmony with the physiologic closing path of the muscles and jaw joints.
• A further refinement is made to the orthotic to remove all interferences in the chewing movements - thus further minimizing spastic muscle activity that could trigger pain.
• A more detailed refinement is again checked and rechecked using TENS to assure the balance, comfort and evenness of the appliance.
• A final finishing adjustment is then made using computerized electro-diagnostics and EMG read-outs that test the balance/ symmetry of muscle activity when clenching with the orthotic in place.
• Dr. Rotem is able to accurately determine specific point contact imbalances on the biting surfaces of the appliance by means of electromyography to refine the bite to balanced muscle activity in function and at a physiologic resting jaw position.

Dr. Rotem's approach implements all three diagnostic and treatment modalities "simultaneously":

• Computerized Mandibular Scanning (CMS)
• Electromyography (EMG)
• Transcutaneous Electro-Stimulation (Low frequency TENS)

To try to implement one or two of the modalities without the utilization of the third modality will result in limited and unpredictable outcomes.

Anticipated Office Visit Time to Accurately Adjust the Neuromuscular Orthotic

At the delivery appointment of the neuromuscular orthotic, one can expect to be with Dr. Rotem and his neuromuscular assistant for approximately 2-3 hours.
At completion of this visit the appliance should feel comfortable! Most patient's are surprised how normal the appliance feels when accurately and properly adjusted to a "physiologic rest position".

DETAILS, DETAILS, DETAILS. That is the reason we get results!
*written by Clayton Chan, DDS, reprinted and modified with his permission

Objective Instrumentation
How does raising the standard of care help me?

Evidence Based Treatment and Care

In this age of evidence-based treatment and diagnosing it is imperative that objectivity is used by the treating clinician when addressing TMJ/ TMD. Due to the variety of symptoms and patient complaints, it is imperative that objective gathering techniques be used rather than subjective, educated guesses when all else has failed.

By implementing technology when appropriate in gathering measurable quantifiable data, as a part of a prudent protocol to verify objectively the true condition of the paining patient, one can begin to accurately diagnose, present a mode of treatment and treat effectively these types of problems reliably and consistently.

Radiographs of the Jaw Joints:
When treating the temporomandibular joint and it's accompanying symptoms, it is imperative that radiographic imaging of the jaw joints be used to visualize and ascertain: the joint position (posture), bony surface anatomy and abnormalities of the surrounding structures. Diagnostic radiographs (Tomography) of the joints are the most accurate in most cases. Other modalities to visualize the jaw joints can be used to enhance further understanding, when needed.

It is important to realize that radiographs are a "static" reproduction of three dimensional structures. Radiographs are helpful but should not be considered the only tool to access living, moving and functioning structures, especially when they are compromised and injured.

Computerized Electro-diagnostic Instrumentation:
This type of diagnostic modality tests muscle function and stability of jaw movements in real time (dynamic). Computerized electro-diagnostics are able to record, measure and track jaw movements in three dimensions (horizontal, vertical and sagittal). Radiographic imaging techniques are not able to do this! The following are examples of two recordings (scans or tracings) that are implemented. There are ten different jaw recordings/ scans that can be used in diagnosing and treating TMJ disorders effectively.

From the recorded data produced by the recording instruments, the doctor is able to distinguish between normal verses abnormal and pathologic verses physiologic movements of the jaw. Muscle activity is simultaneously recorded, thus enhancing the understanding of the dynamic living human anatomy (the mandible, the surrounding muscles, the jaw joints and posture of the head and neck).

Scientific Innovation Verses Tradition

In spite of the confused medical/ dental profession the suffering patient has to face the ravages of this harsh disease/ disorder. The merciless and often illogical criticism from those who would not or could not renounce their obsolete convictions regarding traditional notions about the pathophysiolgy of head, neck and masticatory apparatus only promotes further confusion. Dr. David Jones is well versed in the controversies of treatment methods and protocols. He is strongly aware of the varying views as well as the flawed research that many clinicians based their strong views, treatments and recommendations.

Realizing the short comings of the present medical and dental profession, it is even the more necessary to take a scientific, methodical approach and lay aside biased views and old paradigms. As Dr. Bernard Jankelson, the Father of Neuromuscular Dentistry, so intuitively stated, "If it has been measured, it is a fact; if it has not been measured, it is an opinion." This concept corresponds amazingly well to one of the basic postulates of Galileo Galilei, the father of modern scientific philosophy.

AUTOMOBILE VICTIMS AND CHRONIC PAINING PATIENT'S

It is highly appropriate to use objective diagnostic procedures and therapeutic modalities on patients that fall victims to auto accidents, chronic paining patients in distress that have often sought help and treatment from numerous clinicians that have already implemented their subjective evaluations and treatments with limited help. For this reason it is imperative to stop this cycle of subjective treatment and rising costs due to lack of proper implementation of objective diagnostic procedures and protocols that would contain the costs and decrease treatment times of those victims.

The use of objective, quantifiable diagnostic procedures, especially those with automobile accidents, should be implemented to quantify and qualify a patient's dysfunction. This certainly adds essential accurate information in the effective diagnostic and treatment process, especially with patients with trauma episodes to the head/ neck and cervical regions. 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.

Confirming and Supportive Evidence

for the use of Computerized Electro-diagnostic Instrumentation

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 misguided as to their understanding of how computerized electro-diagnostic instrumentation can be used and implemented to aid in the diagnosis and treatment of TMJ.

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 (ADA) 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)

U.S. Food and Drug Administration (FDA) 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.

LITERATURE REVIEW SUPPORTS

the use of Computerized Electro-diagnostic Instrumentation:

Efficacy of Mandibular Tracking in the Diagnosis and Treatment of TMJ/ MSD

• Over 22 controlled studies that further support the rationale for mandibular jaw tracking.
• 25 supporting referenced studies.
• Numerous other studies that document the clinical efficacy and validity.

Efficacy of Surface Electromyography in Dentistry-

• 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.

Efficacy of Low Frequency TENS in the Diagnosis and Treatment of TMJ/ MSD-

• The literature is clear and unequivocal - 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 studies internationally).

Efficacy of Sonography (Spectral Analysis) in the Diagnosis and Treatment of TMJ/ MSD-

• There is a broad body of literature that supports the use and efficacy of sonography in the diagnosis of temporomandibular joint disorders. (Over 30 studies ending with Bracco, et al in 1997).

*written by Clayton Chan, DDS, reprinted and modified with his permission

Self Referral

TMJ Self-Diagnostic and Self-Referral Program

• Do you have a grating, clicking or popping sound in either or both jaw joints when you chew or open and close your mouth?
• Do you have sensations of stuffiness, pressure or blockage in your ears? Is there excessive war wax production?
• Do you ever have ringing, roaring, hissing or buzzing sound in your ears?
• Do you ever feel dizzy or faint?
• Is your jaw painful or locked when you get up in the morning? Does is get stuck?
• Are you ever nauseous for no apparent reason?
• Do you fatigue easily or consider yourself chronically fatigued?
• Are there imprints of your teeth on the sides of your tongue?
• Is it difficult or impossible to swallow quickly five times in a row with the last swallow being as easy as the first swallow?
• Does your tongue go between your teeth when you swallow?
• Do your fingers sometimes go numb?
• Do you have pain or soreness in any of the following areas: jaw joints, upper jaw or teeth, lower jaw or teeth, side of neck, back of head, forehead, behind eyes, temples, tongue or chewing muscles?
• Is it hard to move your jaw from side to side or forward and backward?
• Do you have difficulty in chewing your food?
• Do you gulp your food, swallowing it whole or almost whole?
• Do you have any missing back teeth?
• Have you had extensive dental crowns and bridgework that were painful afterwards?
• Do you clinch your teeth during the day?
• Do you grind your teeth at night? (Ask your family)
• Do you ever awaken with a headache?
• Have you ever had a whiplash injury?
• Have you ever worn a cervical collar or had neck traction?
• Have you ever experienced a blow to the chin, face or head?
• Have you reached the point where drugs no longer relieve your symptoms?
• Does chewing gum start or worsen your symptoms?
• Is it painful, or is there soreness when you press your jaw joints or the cheek just below them?
• Is it painful to stick your "pinky" fingers into your ears with your mouth open wide and then close your mouth while pressing forward with your "pinky" fingers?
• Does your jaw deviate to the left or right when you open wide? (Look in a mirror.)
• Are you unable to insert your first three fingers vertically into your mouth when it is opened wide?
• Is your face crooked and not symmetrical?

TMJ Protocol

The following is a brief summary of our office treatment protocol for those patients who desire treatment.

TMJ CONSULT (Visit 1)

This visit will be about one hour long. The following is what one can anticipate at that consultation.

• Meeting the Doctor and discuss the problem.
• A brief screening muscle palpation will be done.
• The doctor's assistant will complete an initial screening sonography recording of the joints.
• The doctor will present a treatment method and options
  

COMPREHENSIVE EXAMINATION (Visit 2)

• This visit will take on average 3 1/2 hours, over half that time will be with the doctor. The following will give you some idea of what will be accomplished at this visit.
• Diagnostic Casts and Necessary Photographs will be taken.
• Thorough review an complete history of the problem.
• Medical/dental history.
• Thorough review of all previous doctors and health care providers recommendations and treatment outcomes.
• Head and neck examination - including muscle palpation and postural.
• Occlusal evaluation.
• TMJ evaluation - sonography (joint sound recordings) reviewed.
• Periodontal examination.
• Taking of all necessary radiographs and partial review of all radiographs (panoramic, transcranials, cephalometric, AP coronal townes).
• Recording of pre-existing dental conditions.
• A further discussion and interaction with the doctor of treatment options.

NEUROMUSCULAR ANALYSIS (Visit 3)

This visit takes approximately 4 hours. It involves the recording of jaw movements at rest, in function, before and after TENS. Data is gathered from EMG recordings and coordinated with CMS recordings. A "myo-bite" registration that records accurately that physiologic resting position that is unique to each patient is recorded and verified with the objective data. The following is a brief outline of the recordings that will be taken.

• Computerized Mandibular Scan (CMS) - Scan 2, 3, 13.
• Electromyographic (EMG) Analysis with low frequency TENS - Scan 6, 9, 10, 11.
• Sonography Analysis/ Range of Motion Analysis - Scan 15, 16.
• Computerized Neuromuscular (Myo-Bite) registration to determine neuromuscular jaw rest position - Scan 4, 5.

PHASE I THERAPY (Visit 4)

Orthosis Therapy with TENS
This visit usually takes on average 3 hours. This visit comprises the delivery of the neuromuscular orthotic appliance. The neuromuscular orthotic is custom designed to the exact jaw recordings specification that was accomplished at the previous visit. The computer diagnostics and TENS are also implemented in the refining of the appliance to the patients physiologic resting and functioning musculature.

Very little doubt is left as to the accuracy, precision and what this protocol accomplishes. It is able to stabilizing the jaw and muscles to their physiologic rest position which is confirmed by the diagnostic data gathered. This data is then recorded to confirm a proper physiologic rest, jaw posture and cranium to mandible relation.

FOLLOW UP VISITS will be monitored to access the progress of each case.

Treatment Rational

How Dr. Rotem differs from other central Jersey dentists

In the process of consultation, evaluation, examination and gathering evidence and data, there should be a consistent sequelae and flow to the rationale for recommended diagnostics which would lead toward a specific treatment protocol. Without objective data gathering, misguided conclusions toward a particular mode of treatment, especially when dealing with the cranio-mandibular/ temporomandibular/ cervical complex, will result in confusion and frustration to both the clinician and patient. The sequence of fact-finding, verification and confirmation of what is observed and known should help lead the clinician toward understanding the problem as a whole. If certain pieces of evidence do not correspond and are not consistent with other findings, further study in that area of the unknown must be investigated before treatments is rendered.

Understanding the neuromuscular pathophysiolgy of this living system is a must for any treating clinician to effectively begin to consider treatment, especially in dealing with the complex.

Computerized Electro-Diagnostic Instrumentation

This multi-dimensional means of observing typical signature patterns confirming injury incorporates several of our senses, exponentially enhancing our spatial visualization and conceptual grasp of the functioning or dysfunctioning of the body parts, organs, and neurovasomuscular systems, while utilizing to the fullest the physical findings from clinical examination of the patient.

EMG accurately measures the activity in muscles in micro volts.
CMS accurately measures the motion and range of movement of the mandible in function in the frontal and sagittal planes as well as velocity of jaw movements.
SONO accurately measures and locates TM Joint sounds in function.
TENS relaxes the muscles of the face, including the muscles of mastication and therefore allows us to determine the correct relation of the mandible to the cranium.

EMG
As a result of pain elicited in palpating muscles and areas of the craniomandibular complex, and in consideration of the patient's complaints, an electromyography (EMG) series is recommended to more specifically delineate and define hypertonic musculature in this compromised patient. This series is necessary in order 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. Defining the etiology of the patient's predominate neuromuscular dysfunctions will preclude misdirected palliative treatment regimens.

CMS
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. 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. Used in conjunction with EMG recordings.

SONOGRAPHY
Sonography utilizes a Myo-tronics K6-I, measuring 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. This is the first initial non-invasive diagnostic test to verify if there is joint pathology

TRANSCRANIALS
Transcranials are x-rays of the TM Joint that have proven to be reliable imagery in the diagnosis of patients suffering form Temporomandibular dysfunction and Craniofacial pain.

TM Joint transcranials yield a tremendous amount of even subclinical information about the fossa/ condylar relationship and the integrity of the TM Joint mechanism.

TENS
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 from 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.

By gathering this data objectively, one is able to effectively determine a resting physiologic position of the mandible in relation to the cranium. Resting modes of the musculature are clearly identified and the parameters by which to record the optimal jaw to cranium relationship can be accomplished scientifically without subjective interference of bias and guessing.

ORTHOPEDIC APPLIANCE (ORTHOTIC)
Treatment, utilizing a neuromuscular orthotic, is directed toward orthopedic realignment of the mandible to the cranium, stabilizing the temporomandibular joints and restoring them to normal physiological function while concomitantly reducing contracted (spastic) craniofacial and cervical musculature and developing functional and resting modes within normal physiological parameters.

Tests are required for the placement of an orthotic that was designed and constructed using data derived from EMG recordings and range of motion data. The purpose of this orthopedic appliance is to align the mandible to the craniomaxillary complex optimally in three dimensions thereby relieving muscle, ligament, nerve and vascular impingement. It serves to maintain the stomatognathic musculature at the optimal resting length from origin to insertion thus decreasing pain and improving function.

The orthotic is a custom made removable acrylic appliance designed for the patient and placed over the mandibular teeth. To be worn 24 hours per day.

*written by Clayton Chan, DDS, reprinted and modified with his permission

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.

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).

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.