Neuromuscular or Physiologic Based Dentistry

The way your upper and lower teeth come together (your bite or occlusion) is part of a system of teeth, muscles and joints. IF your teeth do not fit together properly (misaligned bite) the muscles and the joints accommodate by working harder to bring the teeth together. Whether you think about it or not your teeth come together thousands of times a day when you swallow. A misaligned bite often leads to muscles that are overworked when they should be relaxed. Tired overworked muscles become easily fatiqued. Fatiqued muscles leads to muscle spasm which leads to muscle PAIN. Muscles which are in spasm and pain contract or shorten and since it is the muscles which control the position of your jaw, contracted muscles tend to ‘torque” or twist the jaw which affects the position and function of the TM Joint itself.

If your bite is misaligned this torqueing action occurs every time you bring your teeth together to chew and swallow your food!

When the jaw joints are out of alignment, a wide variety of chronic painful signs and symptoms can occur from these repetitive actions. TMJ patients often live with one or more of the below listed symptoms for years, because many people who suffer from TemporoMandibular Joint Dysfunction (“TMJD”) simply do not realize it.

Signs and Symptoms of TMJD include:

  • chronic tension headaches
  • migraines
  • pain in their jaw muscles
  • difficulty opening and difficulty swallowing.
  • deviation of the jaw (to the right or left) on opening or closing
  • difficulty sleeping
  • clicking, popping and or grinding in the jaw joints,
  • itchy plugged ears or reduced hearing.
  • a sore neck and shoulders and even tingling in the fingers.
  • vertigo (dizziness)
  • ringing in their ears (tinnitus)

if you place a fingertip in each ear and open your mouth you can feel your jaw joints moving. That tells you how close to the ears these joints are, which in turn explains why TMD might cause ear symptoms.

A good bite is indicative of good posture and good muscle health. Alternatively, a bad bite, or one that is mis-aligned, can result in additional health problems. If you suffer from TMJD problems, Dr. Willoughby may be able to help.

There can be several leading causes for TMJD including:

  • A bad bite or malocclusion.
  • Clenching and Grinding of your teeth
  • Constricted airway
  • Traumatic injury to your teeth, mouth, head or neck

Dentists like Dr. Andrew Willoughby who treat TMJD consider the entire head and neck as part of one “Stomatognthic” system which controls the positioning and function of your jaw.

Dr Willoughby’s primary goal is to relax the muscles controlling jaw position in order to establish a true physiological rest position upon which further treatment considerations can be based. The resulting jaw position is called the Neuromuscular bite.

Dr. Willoughby spends a significant amount of his time helping to diagnose and treat patients with TMJ Disorders. Dr. Willoughby is a Premier Preferred Provider of Invisalign and can utilize Invisalign therapy to help permanently correct the alignment of his TMJ patients’ teeth.

How and why is NMD Performed?

Dr. Willoughby and you may be considering various types of dental treatments to improve your smile or to correct your misaligned bite or correct a painful condition. To provide you with an optimal bite that gives you beautiful smile as well as healthy muscles and joints, Dr. Willoughby will evaluate and study the complex relationship between your teeth, jaw joints and muscles. Dr. Willoughby will then apply his knowledge and expertise to diagnose, then treat, your bite. The first step starts with an appropriate diagnosis.

TMJD Diagnosis

Step One

The first step in determining if you suffer from TMJD is to have Dr Willloughby a comprehensive zero based dental examination of your head and neck which includes;

  1. intra oral and extra oral palpation and assessment of the muscles associated with jaw opening and closing.
  2. extra-oral palpation and assessment of the muscles associated with head and neck posture and movement;
  3. a complete workup of the signs and symptoms associated with your Craniomandibular and Musculoskeletal Dysfunction including the frequency, duration, onset and triggers for your symptoms.
  4. CT scans of your TM Joints and discs may be used to assess any potential signs of internal derangement, bone remodeling and or osteoarthritic degeneration of the disco-condylar complex.
  5. Digital xrays may be used to assess the health and integrity of your dentition and supporting periodontal tissues.
  6. Diagnostic models of your teeth which will later be mounted using your Habitual and Neuromuscular bite.

Step Two

Step two in diagnosing your TMJ condition is to undergo a real time analytical, electronic evaluation of the jaw joints and jaw muscles. This allows us to capture very detailed (analytical not subjective) information about the status of your muscles and joints which allows us to more accurately diagnose your condition. For this, Dr. Willoughby uses specialized “K7” computerized equipment to perform a detailed Diagnostic evaluation system. The K7 equipment accurately records the following:

Jaw Tracking

Movements of your jaw muscles, mandible and teeth – referred to as “jaw tracking” so that Dr. Willoughby can measure and study the pattern of jaw opening and closing thru its full range of motion.

The above picture reveals a jaw tracking Scan in which the patient has limited opening and a pathologic cross over bite

The above picture reveals a jaw tracking Scan in which the patient has limited opening and a pathologic cross over bite

Electromyography

Electrical activity of various Jaw muscles –referred to as Electromyography or “EMG scans. These scans provide detailed information of key muscles that control the jaw during various functions as well as at rest.

The above picture reveals an EMG Scan of a patient with a bad bite causing muscle spasm and pain (before muscle relaxation with TENS) in which the patient has severely elevated levels of muscles activity when she brings her teeth lightly together –indicating a “pathological bite”

 

The above picture reveals an EMG Scan of a patient with a bad bite causing muscle spasm and pain (before muscle relaxation with TENS) in which the patient has severely elevated levels of muscles activity when she brings her teeth lightly together –indicating a “pathological bite”

Sonography

Jaw joint sounds – Sonography…..this allows us to listen to the jaw joint vibrations and assess the status and overall health and function of the TM joint and disc complex.

The following pictures show a patient that Dr. Willoughby is performing a K7 Diagnostic workup on. While the head-gear that is placed on the patients heads may look “strange,” it is an important part of the TMJD diagnosis process. The K7 Diagnostic system is only one of a few digital computer systems of its kind capable of providing real time, comprehensive analytical, objective data in the diagnosis and treatment of TMJD.

Step Three

Once a diagnosis of CMD has been ascertained and Dr. Willoughby has used the K7 EMG scans to identify exactly which jaw muscles are in spasm, the patient is then hooked up to a The Transcutaneous Electrical Neural Stimulation “TENS” device (brand name Myomonitor)

By applying a small continuous but intermittent electrical stimulation to the muscles in the jaw and neck the Myomonitor can relax sore stiff muscles by pumping out metabolites such as lactic acid (which cause muscle pain) and re-oxygenating the muscles. The Myomonitor is a small battery-powered unit with several electrodes which Dr. Willoughby and his staff attach to strategic places on the patients head, neck, and shoulders while they relax and watch television. Some patients even fall asleep during their TENS sessions. Patients which undergo a TENS session find that it significantly reduces their muscle spasm and makes their jaw muscles feels much more relaxed. It helps eliminates headaches and removes tension in the shoulders and neck.

The photos above illustrate one of our patients looks like hooked up to our TENS unit and a K7b unit.

After 20-30 minutes, most of the metabolites and lactic acid will have been pumped out of your jaw muscles leaving them in a completely relaxed state – often for the first time in years. Eliminating the chronic muscle fatique, stress and tightness in the muscles which control lower jaw movement allows it to open, close and rest in a slightly different orientation.

The above picture reveals relaxed muscles after TENS. The purple and green EMG’s are intentionally hi to confirm biting while the red and black EMG’s are show muscle relaxation both at rest and with the teeth together.

after TENS

The following picture reveals a jaw tracking scan after the patients jaw muscles have been relaxed with a TENS machine and a new neuromuscular relaxed bite trajectory has been established.

ideal neuromuscular trajectory

We refer to this new jaw position as the ideal or “Neuromuscular trajectory” and it is the position where your jaws, jaw joints and muscles are in a state of physiologic harmony and are ideally aligned. This “neuromuscular position” is confirmed using EMG data and is a position where the patients facial esthetics are also ideal. Dr. Willoughby then uses his K7 equipment to identify, capture and record a very accurate 3-dimensional bite record of this correctly aligned jaw joint position. This is called a myo-centric bite.

Step Four

To hold this new bite or jaw relationship in a stable position where the joints and the muscles have an opportunity to “heal’ over time typically requires the placement of a Neuromuscular orthotic. Unless you have been previously treated by another Neuromuscular Dentist this orthotic will be unlike any mouthguard or splint you may have previously had fabricated as it can only be adjusted after a TENS session once the jaw muscles have been relaxed. The NM orthotic can be designed to be removable or it can be fixed (bonded) onto the natural teeth and is worn 24/7. These special orthotics help to eliminate many of the chronic signs and symptoms of TMJD by holding the jaws and the jaw joints in a position where the muscles are relaxed and at or near physiological rest.

Here is a picture of a patient’s Neuromuscular orthotic in place. Notice before and after how it has changed the bite relationship.

In our Dental Studio the ultimate goal of your TMD treatment is to make this new relaxed jaw position permanent. Each TMD case is individual and Dr. Willoughby will discuss the methods that could be used in helping address your specific needs.

It can take 3 to 6 months or longer and multiple TENS adjustment sessions, before some patients will begin to see a complete cessation in their signs and symptoms. It all depends on the severity of your symptoms –you cannot expect to undo a decade of chronic muscle spasm in day-that is not realistic. Once the patient’s discomfort has been stabilized for a period of time, the patient has several choices;

  1. they can reduce the wear time of their orthotic to night time only which should prevent the symptoms from getting any worse but will not eliminate them or
  2. they can elect to permanently correct their bad bite or malocclusion by either;
    1. orthodontically moving their teeth using brackets or invisalign trays or
    2. they can elect to have crowns and veneers placed on some or all of their teeth to hold their teeth in this new bite position. The esthetic look of these new crowns and veneers is often times a startling, dramatic life changing procedure.

Below is a Patient still in a lower orthotic who has had All their upper teeth restored into a new neuromuscular bite. This patient is 82 years old – beautiful result don’t u think?

If you think you may be suffering from TMJD, please either refer to our TMJ Questionnaire section for further information or call us at 604.541.1800.

When the principles of neuromuscular dentistry are applied to cosmetic or general dentistry, your results should be long lasting, comfortable, and aesthetically pleasing.

Please contact an office near you to schedule a TMJD consultation appointment.