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Neuromuscular / Reconstructive Dentistry

Dr. White is a graduate of the Las Vegas Institute for Advanced Dental Studies (LVI) where he has taken numerous courses in the areas of cosmetic, neuromuscular, and reconstructive dentistry.  Many neuromuscular cases may not require reconstruction but most if not all reconstructive cases would be approached from a neuromuscular perspective.   

What is “Neuromuscular Dentistry”?
The function of the jaw is controlled by three major components associated with dentistry and several that are not.  The three associated with dentistry are the teeth, the muscles, and the joint (TMJ).  Examples of components not associated with dentistry are the posture, airway, neural, and skeletal problems.  Neuromuscular dentist seek to establish a position for the bite so that the teeth, muscles, and joint work together in harmony.  We often utilize the assistance of others in the medical and dental fields for further evaluation and treatment.  We may include an orthodontist, oral surgeon, ent specialist, neurologist, physical therapist and chiropractor in a team approach to helping our patients.  Particular attention is paid to the airway (tonsils and adenoids), posture of the head and neck, posture of the tongue.

Understanding the Bite
If the natural teeth do not fit together properly when the muscles and joints are functioning in harmony we see problems develop.  Where we see the problem depends on where the weakest link in the system is.  If the weakest link is the teeth then we see wear of the teeth (often through the enamel), cracks in the teeth, or fractured teeth.  If the weakest link in the system is the muscles we often see facial muscle pain, head aches, or neck and shoulder pain.  If the weakest link in the system is the joint (TMJ), we often can detect clicking, popping, crepitus (a grating sound), or deviation on opening and closing.  

The nerves of the teeth are so sensitive that if the teeth are even slightly out of position (to function in harmony with the muscles and TMJ) they will have the muscles hold the jaw in a position so that as many teeth as possible will contact when you close.  This process is called proprioception and is done subconsciously without you having to think about it.  The muscles and joint are programmed to function from a certain position to accommodate the position of the teeth.  This may cause stress and/or fatigue to the muscles and joints which can become very painful or may not display any pain at all.

Understanding the role of posture may be very important, especially for patients with symptoms and pain.  A bite problem may originate with the position of the teeth or it may originate from another location such as neck, back, hip, knee, or foot.  Picture this, someone may have had a knee injury years ago in which cartilage was damaged causing one leg to be shorter.  This can cause the hips to tilt (to compensate) which can then cause the lower back to tilt (to compensate) which then affects the middle back (to compensate), then the upper back (to compensate), then the neck (to compensate), and finally the position of the jaw.

Neuromuscular dentists take a close look at the big picture and not just one tooth, one arch, or simply how the teeth fit together. 

If you have any of the signs or symptoms listed in the chart below neuromuscular dentistry may be able to help you.

Evaluation of the Neuromuscular Patient
In an ideal situation, the complete exam is done first and if a patient has signs or symptoms a neuromuscular work up would be recommended.  This would include:

1. Impressions for Diagnostic Casts
   
   
2. Pictures of current restorations, arch form, smile, and occlusion
   
   
3. Bite Registration with the muscles in a relaxed state utilizing a Tens unit
   
   
4. Evaluation of muscles, joints, and function utilizing K-7 computer software
   
   
5. X-rays of the joints

The sequence of treatment may be quite different for an emergency patient presenting with pain.  Our goal for this situation may be to get the patient comfortable first and then proceed with more in depth evaluations.

Instrumentation

Tens Unit - We often utilize a Tens Unit to help relax the muscles so an accurate bite registration can be taken.  If the muscles are in spasm it can be impossible to register the bite properly. For many patients the muscles may not have any pain or symptoms but can have a level of muscle activity that makes registering the bite very difficult if it is desired to register the bite with the muscles relaxed.   The Myomonitor (Tens Unit) operates on a 9 volt battery and provides a mild stimulation to the muscles so there is contraction and then no stimulation so there is relaxation.  This helps to deprogram the muscles so they forget where the teeth are.  Now we can register the bite where the muscles want to be.

K-7 Software - The evaluation of patients using our K-7 computer software allows our office to investigate how the muscles, joint, and teeth work together.  It also helps us determine if we suspect other issues to be involved (such as a hip/back/neck problem that may be related).  One or more of the following procedures may be used in the evaluation.
Jaw Tracking - using sensors and a magnet we can detect exactly how the jaw moves when the patient opens, closes, and functions.  We can evaluate how the jaw moves while chewing, the stability of the bite, and if there is an issue with the posture of the tongue.
SEMG - Surface electromyography allows us to measure muscle activity.  We can compare muscle activity before and after relaxation (tens unit) to see exactly how relaxed the muscles were in the first place and how much we might expect to be able to help someone with symptoms and pain.
ESG - Electrosonography uses small detectors placed over each joint (similar to headphones) to detect joint sounds such as clicking, popping, and crepitus (grating).

The advantages to this technology are many but being able to compare before and after data gives our patients something to think about, and chew on!

Treatment
After the Complete Exam we will often address routine dental concerns such as periodontal disease, caries, tooth aches.  After these concerns are addressed the neuromuscular work up is done to determine what the restorative options are for each patient.  Neuromuscular dentistry can be conservative (with appliance therapy and minimal treatment) or comprehensive (appliance therapy and bite reconstruction).   Each neuromuscular patient usually has 2 phases of treatment.

Phase 1
The first phase of treatment is the phase where we make an orthotic appliance for the patient.  This allows us to change the bite to a neuromuscular position and evaluate how much better things feel for our patient.  There are several adjustment appointments after the delivery of the appliance to refine the bite and the technology we have may be used at various steps during treatment.  The orthosis can be made as a removable or fixed appliance.  The fixed appliance is for those patients who are committed to Phase 2 from the start.  It is the more comfortable appliance, less bulky, and nothing to remove on a daily basis.  It is worn 24/7 and home care is critical.  The removable orthosis is for patients who have missing teeth or those that are not sure about their desires for Phase 2.  This appliance can be worn 22/7, only at night, or on an as needed basis in the short term but is not intended to be used long term.  If symptoms reoccur after the orthotic is removed Phase 2 will be necessary to complete the case.

Phase 2
The second phase of treatment involves one of the following options and  a combination of these options in some cases.

1. Coronoplasty- this is a procedure completed for the patient with very minor bite problems in which the enamel of the teeth is adjusted to correct the bite to a neuromuscular position.
   
   
2. Orthodontics- for patients that would benefit from moving the teeth to correct the bite to a neuromuscular position.  Dr. White utilizes the assistance of an orthodontist for this part of treatment in most cases.
   
   
3. Reconstruction- rebuilding the bite with crown and bridge restorations to correct bite problems to a neuromuscular position.
   
   
4. Oral/Maxillofacial Surgery- for the patient with more severe bite problems that involves the position of the bones of the face and not just the position of the teeth.  This level of bite correction usually involves coronoplasty and reconstruction and in some cases also orthodontics.
   

A semi-permanent orthotic- only utilized for cases where very conservative treatment is the best option.