Neuromuscular Dentistry
WHAT is Neuromuscular Dentistry?
Occlusion is the foundation of dentistry. It is of key importance in the success of every major dental procedure. Occlusion is affected by a triad of factors - the teeth, the muscles and the temporomandibular joints. Traditional dentistry has focused on the teeth - what might be called 'one-dimensional' dentistry. Neuromuscular Dentistry (NMD) is a term that has been applied to the additional consideration of the 'second & third dimensions' - muscles and TM joints.
Neuromuscular Dentistry is the science of dentistry that embodies accepted scientific principles of patho-physiology, anatomy, form and function. NMD objectively evaluates the complex relationship between teeth, temporomandibular joints and the masticatory muscles in order to achieve an occlusion that is based on the optimal relationship between the mandible and the skull. It is the science of occlusion that is based on a premise of relaxing the muscles to establish an optimal occlusal position. In summary, NMD is the science of occlusion that objectively measures the physiologic functions affected by occlusion to achieve the desired treatment goal.
WHY is Neuromuscular Dentistry Important?
The limited time in the dental curriculum makes if difficult enough for schools to prepare dentists to deal with the teeth. Muscles and joints typically get a cursory once-over. As dentists go into practice, it is not uncommon to hear them say that they have done procedures 'by the book' and yet have less than satisfactory results. Or, that a case is so complex they refer the case out rather than treat it themselves. Neuromuscular dentists commonly report that taking muscle and joint status into consideration aids them in optimizing treatment, minimizing the times that they are 'surprised' by less than ideal outcomes, and gives them the added insight needed to treat complex cases.
WHAT is TENS (Transcutaneous Electrical Neural Stimulation)?
Neuromuscular Dentistry begins with the true relaxation of the muscles through the use of TENS. TENS is a widely used term, but as used in Neuromuscular Dentistry it is more properly called ultra-low frequency electrical muscle stimulation. This safe, battery operated device delivers a mild electrical stimulus to the muscles via neural pathways. The stimulus induces involuntary contraction of the muscles controlled by the facial (7th) and masticatory (5th) cranial nerves.
WHAT Use TENS?
Muscles of the face and neck are often 'programmed' (propriocepted) to control head and mandibular posture in a way that accommodates occlusion, even though that particular occlusion may be less than ideal. The Neuromuscular Dentist wants to relax these often tense muscles to find their true resting state and establish the occlusion at that position. It is extremely difficult to voluntarily overcome this proprioception, so 'TENS' is used. A secondary use of low frequency stimulation is to achieve drug-free pain relief of pain of muscular origin.
WHY Use Myotronics TENS?
Myotronics TENS products, the Clinical Myomonitor and the Home Treatment unit are backed by a history of safe, effective use since 1966. The only fixed-rate device of its kind that provides true bilateral, simultaneous stimulation, the Myotronics products provide stimulus at a fixed rate of once every one and one-half seconds (or 40 times per minute).
The Myomonitor's '3d electrode' ensures safe and simultaneous stimulation of masticatory muscles. In addition, the stimulation of the Myomonitor propels the mandible upward from rest position and registers a physiologic occlusal position with ease and accuracy. Fail-safe circuitry and the fixed low frequency rate provides the ultimate in safety.
WHY is Evaluation of Physiologic Function Important?
The state of the teeth and the joints very often cause the muscles to accommodate. Evaluation of the hard tissue alone does not provide insight to the true status of the occlusal system. This is why the Neuromuscular Dentist uses objective, scientific documentation methods in the comprehensive evaluation of occlusion. Through the use of jaw tracking, electromyography and joint sound recording, a complete analysis of the function (or dysfunction) of the masticatory system is accomplished.
Grinding the Teeth
Some people habitually grind their teeth - often as a way of releasing stress. Dentists call this 'bruxing'. Both children and adults can do this, almost always at night. Bruxing can deform the natural shape of teeth, but there are several things that can be done to restore the damage.
Grinding speeds the ageing process
Grinding makes the teeth less effective for chewing. It also makes the face look prematurely old. Teeth naturally wear as you age, but nervous grinding accelerates this habit and can make people look years older than they really are. When dentists restore the form and shape of teeth, they instantaneously rejuvenate both the smile and face.
What signs suggest that you are a 'grinder'?
Your teeth look worn down
Look at the biting surfaces of your teeth, particularly the upper and lower front teeth. Have they become short, 'stubby' and flat? Do the front teeth look the same length? If so, they are wearing down prematurely.
Your jaw muscles are sore
If you sometimes wake up with painful or sore jaw muscles, you may be grinding your teeth at night. If you are a habitual and continuous grinder, your jaw chewing muscles will become unduly prominent (which is called the 'Schwarzenegger' effect).
Your teeth are unusually sensitive
In some cases your teeth will be rather sore and oversensitive to hot or cold temperatures. The pressure on the roots has sensitised them.
Grinding noises disturb your sleeping partner
The sound of grinding teeth during the night can be very off-putting to your sleeping partner and prevent him or her from getting proper rest. This can be one of your first indications that something is wrong.
The consequences of tooth grinding
Destruction of tooth enamel
The enamel on your teeth is hard, but will wear down when rubbed against itself - just as diamonds will abrade other diamonds. Your teeth are naturally different in length but tooth grinding wears them down to similar length.
Loss of protection
The pointy 'canine' teeth protect your other teeth. When you move your teeth sideways across each other (as in a grinding motion), the lower canines ride up onto the tips of the upper canines and create distance for other teeth. Canine teeth that are the same length as all others cannot prevent tooth friction and wear.
A prematurely aged look
Unusually even and flat teeth make the smile look much older than it should.
What are the possibilities for treatment?
If you think that you grind your teeth, talk to a stress management counsellor to deal with the causes of your stress. Sometimes an unbalanced bite contributes to the problem. We are experienced at recognising this and will perform a NeuroMuscular examination once you've filled our specially developed evaluation forms. Sometimes a simple correction or intervention can suffice. A customized tooth-guard, to be worn at night or in stressed situations like intense sports or work can instantly ease the damage caused by grinding.
Can you turn back the clock?
Definitely! Restoring your teeth's form and shape to their natural proportions will instantly rejuvenate your face and smile. It is done in several steps:
Plan out the treatment
The dentist diagnoses and evaluates the extent of tooth wear, its prime causes and aesthetic effects.
Before shape and function
A colour-matched material (quartz composite) is temporarily bonded onto the worn teeth to restore their function, form and aesthetics. This procedure, called a Dental Mock-Up, can be left in place for a few weeks to establish comfort and appearance.
Restore hard-wearing qualities
Once the patient confirms that everything feels and looks good, the mock-up teeth are copied and replaced with hard-wearing porcelain or ceramic veneers / crowns. These are indistinguishable from natural tooth enamel. Before the permanent teeth are placed, many patients elect to whiten all their teeth. So the veneers are matched to the new lighter coloured natural teeth.
The final result is a set of teeth that look better, make the face younger and protect against further tooth-grinding damage.
Restoring the teeth's natural looks and protection will reverse the effects of tooth grinding or 'bruxing'. It will also have a strong rejuvenating effect on the smile.
Clinically, a better solution is to restore the teeth to the correct biting positions that offer self-protection when the jaw slides side-to-side.
Finding this position is key to NeuroMuscular dentistry and offers a starting point for relief of chronic problems of the Temporomandibular joint, TMJ/TMD, and restoring a beautiful and natural Long-lasting smile. We continue to undergoe specialised training at renowned Las Vegas Institute where the focus is on advanced diagnosis and treatment www.lvilive.com.
NeuroMuscular Dentistry for Professionals
How Neuromuscular Dentistry Can Help You
Neuromuscular dentistry is the art and science of using the relaxed position of the head and neck to place the jaw in an optimal physiological position. Twenty five years of research and clinical experience have shown this technique to be effective in treating patients with various levels of head and neck pain. It is also used in finding the optimal jaw position before restorative dentistry and greatly increases the longevity of restorations and natural dentition.
The process involves various modalities such as ultra low frequency trans-cutaneous electrical stimulation (TENS), sometimes using a sophisticated computer programme to record and interpret tempromandibular joint (TMJ) sounds, masticatory (chewing) muscle activity (EMGS) and the path of movement the jaw follows in function (CMS). This information allows us to find the most relaxed physiologic position for the jaw which may be combined with tomography (specialised jaw joint x-ray) helping to determine the best bite for comfort and aesthetics.
Tempromandibular joint dysfunction (TMD) also referred to as Myofascial Pain Dysfunction (MPD) or tempromandibular joint syndrome (TMJ). This is a chronic illness that affects 75% + for the UK population. There are many people who have no pain but still have Occlusal disease (misaligned bite). Worn, chipped or broken teeth, broken fillings, changing position or shape of the smile are all indications that and individual can benefit from treatment.
As a chronic degenerative disease, it often takes years to develop. We have new techniques and computerized technology that can help many that have been able to find relief.
People who suffer TMD have a structural imbalance in their jaw-to-skull relationship.
This is caused by a bad bite (malocclusion), which causes the following:
- Alteration of the position of the TMJ placing excessive pressure on the joint and tissues around them.
- Twisting the jaw into a strained position. This affects the muscles in the face, back, neck and shoulders.
To correct this, the jaw is brought back into a muscularly balanced position and in most cases, we can do this without surgery or braces.
If you suffer from:
| Headaches | Neck, shoulder or back pain (descending problems) |
| Unexplained loose teeth | Facial pain |
| Worn, chipping or breaking dental restorations | Clicking or grating sounds in jaw joints |
| Pain or soreness around the jaw joints | Limited movement or locking jaw |
| Pain in teeth that seems to move around | Numbness in their fingers and arms |
| Excessive wear so restoration seems impossible | Congestion or stuffiness of ears |
| Patient needs bite taken, but seems different each time! | Patient seems overclosed but the patients physiologic parameters are unknown to you |
NMD
The stomatognathic system is composed of three distinct entities:
A. TEETH - will DOMINATE the other components because mandibular bracing during swallow requires the teeth to meet in habitual (centric) occlusion.
B. TEMPOROMANDIBULAR JOINTS - ACCOMMODATE to allow the teeth to intercuspate regardless of the physiologic desirability of habitual (centric) occlusion.
C. NEUROMUSCULAR SYSTEM - ACCOMMODATES to bring the teeth into intercuspation regardless of the abnormal demands often placed upon the muscles to bring the teeth into intercuspation.
Frequently Asked Questions About Neuromuscular Dentistry
Muscles + Joints + Teeth = Neuromuscular Dentistry
WHAT is Neuromuscular Dentistry?
Occlusion is the foundation of dentistry. It is of key importance in the success of every major dental procedure. Occlusion is affected by a triad of factors - the teeth, the muscles and the temporomandibular joints. Traditional dentistry has focused on the teeth - what might be called 'one-dimensional' dentistry. Neuromuscular Dentistry (NMD) is a term that has been applied to the additional consideration of the 'second & third dimensions' - muscles and TM joints.
Neuromuscular Dentistry is the science of dentistry that embodies accepted scientific principles of patho-physiology, anatomy, form and function. NMD objectively evaluates the complex relationship between teeth, temporomandibular joints and the masticatory muscles in order to achieve an occlusion that is based on the optimal relationship between the mandible and the skull. It is the science of occlusion that is based on a premise of relaxing the muscles to establish an optimal occlusal position. In summary, NMD is the science of occlusion that objectively measures the physiologic functions affected by occlusion to achieve the desired treatment goal.
WHY is Neuromuscular Dentistry Important?
The limited time in the dental curriculum makes if difficult enough for schools to prepare dentists to deal with the teeth. Muscles and joints typically get a cursory once-over. As dentists go into practice, it is not uncommon to hear them say that they have done procedures 'by the book' and yet have less than satisfactory results. Or, that a case is so complex they refer the case out rather than treat it themselves. Neuromuscular dentists commonly report that taking muscle and joint status into consideration aids them in optimizing treatment, minimizing the times that they are 'surprised' by less than ideal outcomes, and gives them the added insight needed to treat complex cases.
WHAT is TENS (Transcutaneous Electrical Neural Stimulation)?
Neuromuscular Dentistry begins with the true relaxation of the muscles through the use of TENS. TENS is a widely used term, but as used in Neuromuscular Dentistry it is more properly called ultra-low frequency electrical muscle stimulation. This safe, battery operated device delivers a mild electrical stimulus to the muscles via neural pathways. The stimulus induces involuntary contraction of the muscles controlled by the facial (7th) and masticatory (5th) cranial nerves.
WHAT Use TENS?
Muscles of the face and neck are often 'programmed' (propriocepted) to control head and mandibular posture in a way that accommodates occlusion, even though that particular occlusion may be less than ideal. The Neuromuscular Dentist wants to relax these often tense muscles to find their true resting state and establish the occlusion at that position. It is extremely difficult to voluntarily overcome this proprioception, so 'TENS' is used. A secondary use of low frequency stimulation is to achieve drug-free pain relief of pain of muscular origin.
WHY Use Myotronics TENS?
Myotronics TENS products, the Clinical Myomonitor and the Home Treatment unit BNS-40, are backed by a history of safe, effective use since 1966. The only fixed-rate device of its kind that provides true bilateral, simultaneous stimulation, the Myotronics products provide stimulus at a fixed rate of once every one and one-half seconds (or 40 times per minute).
The Myomonitor's '3d electrode' ensures safe and simultaneous stimulation of masticatory muscles. In addition, the stimulation of the Myomonitor propels the mandible upward from rest position and registers a physiologic occlusal position with ease and accuracy. Fail-safe circuitry and the fixed low frequency rate provides the ultimate in safety.
WHY is Evaluation of Physiologic Function Important?
The state of the teeth and the joints very often cause the muscles to accommodate. Evaluation of the hard tissue alone does not provide insight to the true status of the occlusal system. This is why the Neuromuscular Dentist uses objective, scientific documentation methods in the comprehensive evaluation of occlusion. Through the use of jaw tracking, electromyography and joint sound recording, a complete analysis of the function (or dysfunction) of the masticatory system is accomplished.
WHAT is Electrosonography (ESG)?
ESG is most commonly called 'sonography' and sometimes 'joint vibration analysis'. It utilizes computer based vibration sensitive transducer technology that quickly and non-invasively records joint sounds and vibrations originating in the temporomandibular (TM) joints. The patient wears a lightweight headset that positions two sensors over the joints. The technician instructs the patient to open and close, and in just a few minutes valuable information about joint function is captured for analysis.
WHY Use Sonography?
Bone transmission of sound is so rapid that unilateral study of joint sound with a stethoscope may not even discern which side the sound is coming from. Further, sounds studied in this manner are subjective and not documented. Data captured by means of sonography not only record joint sounds from both TM joints simultaneously, the information can be played back at will. The dentist can analyze this recorded information in a number of ways that may yield additional insight regarding joint status and joint function. The test can be used as a very quick assessment of joint status and to document patient response to treatment.
WHY Use Myotronics Sonography?
Introduced in 1989, the Myotronics ESG is the only system to incorporate transducers calibrated to a vibration measurement standard. These high quality devices are capable of picking up even small sound vibrations from the tissue overlying the TM joints - diagnostic sounds that less sensitive systems fail to detect.
THE THREE PHASES OF DENTISTRY
There has been a three-phase progression occurring in dentistry. The first phase was Tooth Carpenter Phase, which started with G.V. Black and continued until the late 1980s. In this phase, dentists primarily worked on one tooth at a time, paid or no very little regard to aesthetics, and ignored occlusion other than on the tooth they repaired. It's amazing, but some dentists are stuck in the Tooth Carpenter Phase to this day. Insurance companies reinforce the Tooth Carpenters by paying for this type of dentistry. Tooth Carpenters love the one-tooth-at-a-time approach.
The second phase was the Aesthetic Phase. Here, dentists treated multiple teeth, paid significant attention to aesthetics and minimal attention to occlusion. Much of the 1990s encompassed this phase of dentistry's evolution. The majority of dentists remain in this phase.
The third phase is the Mouth Doctor Phase. Here, dentists do more arch and full-mouth dentistry, pay significant attention to aesthetics and to the entire stomatognathic system - teeth, bones, muscles, nerves and joints. The Mouth Doctor Phase is the union of aesthetic dentistry and Neuromuscular Dentistry. This union is radically transforming the way dentistry is practiced. You are free to choose when you want to start harnessing that power.
Neuromuscular dentists focus on four factors:
1. Function - maximum efficiency of the stomatognathic system
2. Health - teeth, muscles, nerves, bones and joint vitality
3. Comfort - a stomatognathic system that is pain-free and causes no pain in other areas of the body
4. Aesthetics - a beautiful smile
TREATMENT PROTOCOLS FOR NMD
TREATMENT PROTOCOL for MUSCULOSKELETAL DYSFUNCTION
CONSULT -
- Meeting the Doctor and discuss the problem.
- Brief screening muscle palpation.
- Doctor to present a treatment method and options.
COMPREHENSIVE EXAMINATION -
- Review the complete history of the problem.
- Medical/dental history.
- Review previous doctors and health care providers' recommendations and treatments.
- Head and neck examination - including muscle palpation.
- Occlusal evaluation.
- TMJ evaluation with Optional sonography (joint sound recordings) - Scan 16.
- Periodontal examination.
- Review of radiographs Full mouth, panoramic. (Optional tomograms, cephlometric, submental vertex, lateral C-spin, AP coronal trauma series).
- Recording of pre-existing dental conditions.
ADAVNCED NEUROMUSCULAR ANALYSIS -
- Diagnostic Casts.
- Optional Computerized Mandibular Scan (CMS) - Scan 2,3,13.
- Optional Electromygraphic (EMG) Analysis with low frequency TENS - Scan 6,9,10,11.
- Optional Sonographic Analysis / Range of Motion Analysis - Scan 15,16.
PHASE I THERAPY -
- Orthosis Therapy with TENS
- Computerized Neuromuscular (Myo-Bite) registration to determine neuromuscular jaw rest position .
Follow up orthotic adjustment visits:
Some advanced x-rays and tomography and accompanying view are taken at an outside dental x-ray laboratory.
