ADDENDUM II

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A SELECTION OF PUBLISHED ARTICLES OF CLINICAL INTEREST IN NEUROMUSCULAR DENTISTRY
1987 – 2009

Boyd, C.S., Slagle, W.F., Boyd, C.M., Bryant, R.W., and Wiygul, J.P. The Effect of head position on electromyographic evaluations of representative mandibular positioning muscle Groups. Cranio. Vol. 5, No. 1, January 1987.

The results of this investigation indicate that the electromyographic responses of the masticatory muscles are modified by head position. Dorsal extension increased activity of the temporalis muscles, and ventral flexion increased activity of the masseter and digastric muscles. Of practical significance, it would appear that voluntary alteration of head posture affects the activity of the musculature. The importance of head position becomes relative to many areas of dentistry such as bite registration for full denture, fixed reconstruction, orthodontic diagnosis, and treatment of temporomandibular joint dysfunction and myofascial pain and dysfunction when this important finding is considered.

Gay, T., Bertolami, C.N., Donoff, R.B., Keith, D.A, and Kelly, J.P. The acoustical characteristics of the normal and abnormal temporomandibular joint. J. Oral Maxillofac Surg. Vol. 45. 1987.

This paper describes the results of a clinical study that recorded and analyzed sounds emitted from the temporomandibular joint (TMJ) during simple function as a means for differentially diagnosing disorders of the joint. The technique is based on the principle that each different disorder of the TMJ produces a different effect on the mechanical relationship between the articulating surfaces of the joint, and that these mechanical effects can be determined by analyzing joint sounds in relation to joint movement. A total of 79 patients (101 joints) were studied; 32 (46 joints) were diagnosed as having extracapsular disorders, (primarily MPD), 27 (32 joints) were diagnosed as having a displaced disc with reduction, nine (10 joints) were diagnosed as having a displaced disc without reduction, and 11 (13 joints) were diagnosed as degenerative disease (osteoarthritis/arthrosis). In addition, 25 adults (50 joints) with normal TMJs were included as controls. The results of this study demonstrated that each specific disease of the TMJ is characterized by a unique relationship between the sounds propagated by the joint and the movement of the joint. Essentially, an extracapsular disease was characterized by acoustic quiescence during natural (as opposed to maximal) jaw movement, an internal derangement by a usually symmetrical short duration click/reciprocal click, or random click complex, depending on the subcategory of the disorder, and a degenerative disease by a long duration noise during either or both jaw opening and closing. The data further suggest that the technique serves to reflect the mechanical events (and abnormalities) that are involved in function of the diseased joint and has potential for use as a clinical diagnostic tool.

Konchak, P.A., Thomas, N.R., Lanigan, D.T., and Devon, R. Vertical dimension and freeway space: A kinesiographic study. The Angle Orthodontist, April 1987.

A statistical correlation is found between the S-N/mandibular plane angle and clinical freeway space, but there was no correlation after TENS stimulation. The S-N/MP angle did not prove to be a reliable predictor of freeway space.

Cooper, B.C. Myofacial pain dysfunction: A case report. Cranio. Vol. 6, No. 4, October 1988.

This article follows the case of a 16-year-old female in whom myofacial pain dysfunction was precipitated by the physical trauma of a bicycle accident, ultimately resulting in a maximum interincisal opening of 8mm. The practitioner‟s therapeutic goal was to fully relax the musculature and reposition the mandible with an anatomically accurate orthotic to maintain optimal muscle function without accommodative function.

Fagan, M.J. The need for integrating TMJ therapy with implant prosthodontic cases. NY State Dent. Journ. Vol 55, No. 4, pp. 29-32, April 1989.

In this paper, guidelines for TMJ diagnosis and treatment were reviewed, and a case history was presented demonstrating the need for the integration of TMJ therapy. The case history presented is just one of many cases in the author’s practice where the implant candidate also presented with a CM-TMJ disorder. The author emphasizes the incorporation of a CM-TMJ disorder screening exam and history to complement the initial consultation by all practitioners. This should include: 1) check for pops, clicks, in front of ears, (opening, closing, protruding); 2) range of motion (three fingers opening); 3) headaches; 4) grind or brux (night or day); 5) palpate key masticatory muscles of the head and neck; 6) tooth interferences; and 7) bite feels off. The author understands that not all practitioners have access to various diagnostic instrumentation, but emphasizes that this should not prevent the practitioner from diagnosing and treating CM-TMJ disorders or referring for such treatment. The literature has not indicated the overall benefits of implant prosthodontics other than allowing mastication of food and a feeling of self-esteem; but the benefits also allow the treatment and relief of CM-TMJ disorders via a stable occlusion.

Fagan, M.J., III. Neuromuscular concepts in prosthodontics. Implant Prosth: Surgical and prosthetic techniques for dental implants. Yearbook Publishers, MA 1990, Chapter 12, pp 173-196.

In this book chapter, the author makes the case for routinely incorporating TMD screening and history to complement the initial implant consultation. He also discusses how the neuromuscular approach can aid in pre-surgical planning and may open additional options for treatment.

Thomas, N.R. Pathophysiology of head and neck musculoskeletal disorders: The effect of fatigue and TENS on the EMG mean power frequency. Frontiers of Oral Physiology. Vol. 7, pp. 162-170, 1990.

This study using 21 randomly selected subjects was done to demonstrate how spectral analysis of the surface EMG signal can sometimes produce valuable objective data for the diagnostic process when EMG amplitude alone would not. Simply stated, amplitude alone may indicate a resting muscle status, whereas mean power frequency analysis of that same muscle may indicate that the low amplitude reading is due to fatigue.

Langberg, G.J. Computerized Mandibular Scanner: A valid adjunct to magnetic resonance imaging for the diagnosis of internal derangement of the temporomandibular joint. Bergamini M (ed): Pathophysiology of head and neck musculoskeletal disorders. Front Oral Physiol. Basel, Karger, 1990, Vol 7, pp 5 2—66

In a study of 21 patients, 17 females and 4 males with an average age of 29.95 years, the computer mandibular scanner aided in efficacy of diagnosis in 20 of 21 patients.
These preliminary results would tend to indicate that the computer mandibular scanner may be valid as a diagnostic modality for diagnosis of internal derangement of the TMJ.

It would be worthwhile to evaluate whether the computer mandibular scanner can document medial displacement of the disk. The true worth of the MRI is that it performs an elegant function in this facet of imaging where other modalities seem to fall short.

Yamashita, A and Yatani, H. Occlusal bonding for long-term neuromuscular occlusion. NY State Dent. Journ. Vol. 56, No. 4, April 1990.

Langberg, G.J. Ultra-low-frequency TENS: A well-kept secret. Pain Management. Clinical Tips. Sept-Oct. 1990.

Lynn, J. and Mazzocco, M. Computerized mandibular motion analysis: A physiologic perspective. Computers in Clinical Dentistry. September 1991.

In this well-referenced book chapter, the authors review the literature related to the anatomy and biochemistry of occlusion and its role in relation to headache. They also review the apparatus and procedures used for computerized mandibular motion analysis, surface EMG of the masticatory muscles, and computerized study of TM joint sounds as an aid in occlusal evaluation and in achieving a true physiological rest position of the mandible.

Coy, R.E, Flocken, J.E, and Adib, F. Musculoskeletal etiology and therapy of craniomandibular pain and dysfunction. Cranio Clinics Intl, Williams and Wilkens, Baltimore, 1991. pp 163-173.

The investigators sent questionnaires and guidelines for submission of case histories to Fellows of the International College of Craniomandibular Orthopedics, who are geographically dispersed over the United States. The practitioners were requested to supply data and case histories on patients who were treated specifically for Craniomandibular pain or dysfunction. Sixty-eight case histories received from 20 practitioners that met the study guidelines were included. The data reported in these case histories indicate that a common measurable etiology is responsible for the many ostensibly diverse manifestations of craniomandibular pain and dysfunction. The diagnostic validity and usefulness of the electronically derived quantitative data are supported by the correlative subjective perception by the patient of alleviation of symptoms in response to the correction of skeletal malrelation and the consequent reduction of muscle tension . The course of treatment provides rapid initial palliation followed by long-term resolution as a result of orthopedic correction of skeletal malrelation. The continuing positive responses to this noninvasive treatment based on quantitative as well as subjective diagnosis indicate the need in every case of craniomandibular pain or dysfunction to rule in or rule out musculoskeletal dysfunction as the most common underlying etiologic factor in most aspects of craniomandibular pain and dysfunction.

Jankelson, R.R. Validity of SEMG as the ―gold standard‖ for measuring muscle postural tonicity in TMD patients. Anthology of ICCMO. Vol. II, 103-25. 1992.

Whenever possible, any disease or dysfunctional state must be reduced to a cellular/histochemical model. The literature is definitive that muscle hypertonicity is characteristic of TMD. The histochemical state of hypertonic craniomandibular skeletal muscle follows that of hypertonic skeletal muscles in other anatomic, areas of the body. All biologic models suggest the cellular electrical phenomena being measured is a summation of terminal efferent transmembrane potentials resulting from both somatic and psychogenic factors contributing to postural tonicity. Starting from a ceded premise that monitoring postural tonicity with EMG biofeedback is a rational and recognized clinical procedure, the scientific evidence affirms that intra-subject EMG monitoring of postural states is a rational and recognized procedure. Investigators and clinicians recognize that manual palpation is not a reliable indicator of the histochemical electrical status of hypertonic muscle. However, EMG is well established as the “gold standard” for measuring hypertonic states in the medical profession. It is also universally understood that lowering postural hypertonicity is a desired therapeutic objective for management of musculoskeletal dysfunction at any level of the human postural chain.

Jankelson, R.R. Temporomandibular Joint Sounds: A Scientific Review. Myotronics, Inc. 1992.

Combadazou, J.C., and Combelles, P.R. The efficacy of sonography in the diagnosis of joint disorders. Anthology of ICCMO, Vol II, 207-14, 1992.

Bergamini, M.F., and Prayer-Galletti, S.U. Systematic manifestations of musculoskeletal disorders related to masticatory dysfunctions: The effect of fatigue and TENS on the EMG mean power frequency. Anthology of ICCMO, Vol II, 89-102, 1992.

Butterworth, J.C., and Deardorff, W.W. Passive eruption in the treatment of craniomandibular dysfunction: A post treatment study of 151 patients. J. Prosth. Dent. Vol. 67, No. 1, April 1992.

There is a sparse post treatment evaluation of craniomandibular dysfunction (CMD). This study describes the use of an orthopedic interocclusal appliance with passive eruption for the treatment of CMD. The clinical results of 151 patients treated using the passive eruption procedures were assessed at a follow-up time averaging 1.75 years after treatment with a highly structured telephone interview questionnaire. The treated patient population was chronic, averaging 2.58 years in pain and 2.25 previously ineffective treatments for their CMD. Although this was a subjective inquiry, the treated patients confirmed significant reductions in symptoms, a decrease in pain and interference ratings, and reduced health care utilization. A subgroup of 38 patients who previously had no relief with flat-plane therapy exhibited similar positive results. Treatment failures were also assessed but were low. The results are discussed in terms of the patients‟ support of the efficacy of the passive eruption procedure, including the need for future research.

Morgan, D.H. Tinnitus of TMJ origin: A preliminary report. Cranio. 1992 Apr; 10 (2):124-9.

Twenty patients whose chief complaint was tinnitus were examined. They were not known to have temporomandibular disorders. They did not have pain or dysfunction. They were examined by physicians for ear disorders and the results were considered negative. Each of these patients had a complete history and clinical temporomandibular joint examination. The clinical examination included muscle and joint palpation and stethoscopic examination of the joint. This examination also included selected computerized mandibular scans and electromyographic studies of selected facial muscles. Each subject had eight views of transcranial lateral oblique x-rays taken. It was determined that 19 of these individuals had one or more clinical, electromyographic, and radiographic indications of a temporomandibular disorder. From this study, it appears that individuals who have tinnitus with no apparent otologic basis for this symptom should have a careful evaluation of the temporomandibular apparatus. A temporomandibular disorder may be one of the primary causes of this symptom.

Garry, J.F. Craniomandibular pain and dysfunction of elusive occlusal origin. Am. J. Pain Management. Vol. 3, no. 4, October 1993.

The case described is that of a 57 year old white female who, in her nine-year search for relief from craniofacial pain, was seen by 103 different health professionals. The patient had documented expenses in excess of $300,000 for previous diagnostic, therapeutic, and pharmacologic procedures. Through previous treatment, she gained no more than brief, temporary periods of relief. A successful diagnosis and subsequent management of her case with the aid of electronic diagnostic modalities is described. The approach described has resulted in her now having been symptom-free for over eight years.

Lynn, J.M., and Mazzocco, M.W. Neuromuscular differentiation of craniocervical pain: Is it headache or TMD? Am. J. Pain Management. Vol. 3, No. 4, October 1993.
Clinicians confronted with patients suffering with chronic headache and/or craniocervical pain often must face diverse possibilities in their development of a differential diagnosis.

Because of the extensive anatomic, physiologic and biochemical interactions, many disease processes will manifest with similar and overlapping symptoms. Successful treatment of these individuals relies on accurate diagnoses; incorrect diagnoses will most likely lead to disappointing therapeutic outcomes. This review of the literature examines previous conceptual philosophies for the evaluation of patients with craniocervical pain and clearly leads the clinician to conclude that a multidisciplinary approach is indicated for these patients. This article also includes relevant material to allow clinicians to begin to assess their patients in a more effective manner.
Jarmek, G. Lactic acid: Psychological versus physiological ramifications with a case history. Anthology of ICCMO, Vol III, 301-23, 1994.

Bergamini, M.F., Pantaleo, T., and Prayer-Galletti, S.U. Neurophysiological mechanisms involved in the mediation and control of musculoskeletal pain as a basis for the therapeutic approach. Anthology of ICCMO, Vol III, 7-32, 1994.

Cooper, B.C. and Cooper, D.L. Recognizing otolaryngologic symptoms in patients with temporomandibular disorders. Anthology of ICCMO, Vol III, 105-22, 1994.

Temporomandibular disorders (TMD) afflict millions of men, women and children. Although the management of these disorders has traditionally been the pervue of dentistry, the most common symptoms are otolaryngologic. The involvement of an otolaryngologist was important and necessary in the role of primary diagnostician and as a secondary diagnostician to rule out primary otolaryngologic disease in many of the 2,760 patients evaluated over the past 13 years. In 996 patients referred to the Center for Myofacial Pain/TMJ Therapy from the Otolaryngology Clinic of the New York Eye and Ear Infirmary, 85% complained of ear symptoms, including otalgia (64%), dizziness (42%), and muffling (30%). Sixty percent complained of throat symptoms, while headaches were reported by 81%. In 1,764 private patients evaluated for TMD, 53% were seen and/or referred by an otolaryngologist. The dentist and otolaryngologist must act as a team in recognizing and diagnosing TMD. As many of the symptoms of TMD fall within the pervue of the otolaryngologist, he or she must be cognizant of the clinical presentation of TMD. Likewise, dental practitioners must utilize the services of their medical colleagues to rule out primary otolaryngologic disorders in all patients with suspected TMD.

Moses, A.J. Scientific methodology in temporomandibular disorders. Part II: Ethology. Cranio. Vol 12, No. 3, July 1994.

The historical background of ethology and the paradigm of clinical treatment as scientific experiment, rather than practice of the art of dentistry are discussed. Ethology is defined and explained relative to the study of temporomandibular disorders (TMDs) using instrumentation, measurement and retrospective clinical studies of successfully treated cases as meaningful research for improvement of future treatment.

Cooper, B.C. The role of bioelectronic instruments in the management of TMD. NY State Dent. J. November 1995.

Temporomandibular disorders (TMD) comprise a group of conditions that can affect the form and function of the temporomandibular joint (TMJ), masticatory muscles and dental apparatus. Proper management of TMD by the dentist requires accurate appraisal of the status of the patient‟s dentition, TMJ and associated neuromuscular apparatus. Certain predefined standards or parameters of function/dysfunction are accepted by the profession. Electronic instrumentation provides objective measurement of many of these biological phenomena, and thus can be used throughout treatment for critical analyses that monitor and enhance treatment efficacy. A treatment protocol for TMD is presented that uses electronic instrumentation to establish a neuromuscular occlusion.

Cooper, B.C. The role of bioelectronic instruments in documenting and managing temporomandibular disorders. J. Amer. Dental Assn. Vol. 127, Nov. 1996.

This reduces the reliance on subjective clinical observations, which, although it is the historical norm, is known to be inaccurate and can lead to errors in diagnosis. TMDs most often manifest themselves with a muscular functional abnormality.

Ferrario, V.F., Sforza, C., Miani, A. Jr., Serrao, G., and Tartaglia, G. Open-close movements in the human temporomandibular joint: Does a pure rotation around the intercondylar hinge axis exist? J. Oral Rehabil, Vol. 23. No.6. June 1996.

Mandibular movement near the maximum intercuspal position was analyzed for the location of the mean instantaneous centre of curvature of the interincisal point path. Measurements were performed using a kinesiograph in 28 healthy young adults with sound dentitions and free from temporomandibular joint disorders. The subjects performed habitual open-close cycles at different speeds; opening movements started from the centric relation occlusion were also analyzed. In none of the 28 subjects was the interincisal point path derived from pure rotation movements performed around the intercondylar axis, not even in the first millimeters of motion. Translation and rotation were always combined, and the position of the centre of curvature changed during the motion, showing different characteristics in the open and closed movements; these patterns were also dependant upon motion speed. The results show that the hinge axis theory cannot explain the mandibular movements because a pure rotation did not occur around the intercondylar axis.

Sakagami, R., and Kato, H. The relationship between the severity of periodontitis and occlusal conditions monitored by the K6 Diagnostic System. J. Oral Rehabil. 1996 Sep; 23(9):615-21.

The occlusal conditions of periodontitis patients were investigated by using a computerized monitoring device. Thirty-three mild to severe periodontitis patients were enrolled in the study and they were categorized into three groups by their periodontitis severity. Each subject answered a preliminary questionnaire, received routine dental examinations, and underwent MKG/EMG tests using the K6 Diagnostic System. Clinical manifestations of periodontitis were confirmed by the questionnaire and the routine clinical examinations. According to the MKG tests, the traces of maximum opening distance and vertical freeway space showed no significant statistical difference among the groups. However, the velocity of terminal tooth contact was significantly delayed in the severe periodontitis group. According to the EMG tests, there was no significant difference in the rest mode EMG activities, but the function mode EMG activities significantly weakened in the severe periodontitis group. These results showed that severe periodontitis patients had poor occlusal conditions that might have been triggered by the instability of centric occlusion due to attachment loss.

Sato, S., Goto, S,. Takanezawa, H., Kawamura, H., and Motegi, K. Electromyographic and kinesiographic study in patients with non reducing disk displacement of the temporomandibular joint. Oral Surg. Oral Med. Oral Path. Vol. 81, No.5, May 1996.

OBJECTIVE. The purpose of this study was to clarify electromyographic and mandibular kinesiographic properties of the chewing movements in patients with unilaterally painful nonreducing disk displacement of the temporomandibular joint. STUDY DESIGN. Chewing movement in 50 female patients was evaluated by electromyograph and mandibular kinesiograph, and the results were compared with those in 31 normal controls. RESULTS. In the analysis by electromyograph, some differences between patients and controls were found. In the analysis by mandibular kinesiograph, chewing movement showed deviation to the chewing side in the TMJ-affected-side chewing but did not show deviation in the TMJ-unaffected-side chewing in the horizontal plane. The maximal anteroposterior width between opening and closing paths in the sagittal plane was smaller in the experimental subjects. CONCLUSION. These differences between patients and controls may be helpful to diagnosis for painful nonreducing disk displacement of the temporomandibular joint.

Moses, A.J. Scientific Methodology in Temporomandibular Disorders: Part IV: Evaluation of the TMD Literature Relative to Neuromuscular Instrumentation. Anthology of ICCMO, Vol. IV, 195-206. 1997.

Konoo, Y., and Konoo, T. Chronological change of frequency in sonographic analysis of patients with musculoskeletal disorders. Anthology of ICCMO, Vol. IV, 9-16, 1997.
Kramer, A.J. Headache resolution in a 14-year-old female: A case study of patient with a bilateral tongue thrust, anterior open bite and bilateral open bite, bilateral cross bite, and occlusion on only two teeth. Anth of ICCMO, Vol. IV, 121-28, 1997.

Jankelson, R.R. Effect of vertical and horizontal variants on the resting activity of masticatory muscles. Anthology of ICCMO, Vol. IV, 69-76, 1997.

Combadazou, J.C. Orthopedic treatment of the internal derangements: diagnosis, treatment, and results. Anthology of ICCMO, Vol. IV, 139-47, 1997.

Schottl, R. Craniomandibular Orthopedics: A therapeutic approach to chronic musculoskeletal pain. Anthology of ICCMO, Vol. IV, 99-112, 1997.
Chronic musculoskeletal dysfunction is a frequently overlooked factor in the diagnosis triggerpoints in the sternocleidomastoids of chronic pain, especially in dentistry. It is not sufficient to describe a patient suffering from chronic pain solely in terms of the location of some rotational axis of his mandible in the temporal fossae. Equally, there is no need to give up and view chronic pain as solely psychogenic or as an affliction without cure. Rather, the role of chronic musculoskeletal accommodation as one of the major contributors to chronic pain must be appreciated in order to be able to identify its true etiology and design meaningful therapy. Once the patient is considered as a whole and the necessary interdisciplinary cooperation is established, a functional basis can frequently be reestablished, shaking off the yoke of chronic muscle hyperactivity placing the patient in a more stable and vital position.

Bazzotti, L. Neuromuscular and psychological effects of TENS U.L.F. Electromyographic, kinesiographic, S.T.A.I. and salivary cortisol measures. Anthology of ICCMO, Vol. IV, 129-37, 1997.

On 52 subjects studied by electromyography and mandibular kinesiography, it has been confirmed that TENS U.L.F. produces the effect of neuromuscular relaxation and also the unmasking of the adaptation of the mandibular rest position. The use of S.T.A.I. and salivary cortisol measuring demonstrated no negative influence of this procedure on the emotional status. It is confirmed that TENS U.L.F. is a non-irritant procedure whose effects are well directed towards the neurophysiological system.
Bracco, P., Deregibus, A., Piscetta, R., and Giaretta, G.A. TMJ clicking: A comparison of clinical examination, sonography, & axiography. Cranio. Vol. 15, No. 2, April 1997.
A sample of 30 subjects, 15 with and 15 without subjective temporomandibular joint (TMJ) complaints (noises, sounds), underwent a clinical examination, a sonography and an axiography, to detect TMJ clicking. The clinical examination found 22 noisy joints in a total of 60 TMJs considered. Axiography found 19 noisy joints and sonography 32. While 90% of the examined joints showed agreement between axiography and clinical examination (with a little higher sensitivity demonstrated by clinical examination with respect to axiography), 20% of the joints were positive for clicking in sonography only. Sonography showed a high sensitivity in detection of joint noises which suggests its utility as a screening test for early detection of craniomandibular disorders.

Vargo, C.P., and Hickman, D.M. Cluster-like signs and symptoms respond to myofascial/craniomandibular treatment: A report of two cases. Cranio. 1997 Jan; 15(1):89-93.
Two cases with pain profiles characteristic of cluster-like headache, both within and outside the trigeminal system, are reported. One male patient would typically awaken from sleep with severe unilateral temporal head pain and autonomic signs of ipsilateral lacrimation and nasal congestion. A female patient exhibited severe unilateral boring temporal and suboccipital head pain with associated ipsilateral lacrimation and rhinorrhea. In addition, both patients presented with signs and symptoms of masticatory and/or cervical disorders. These two cases illustrate possible treatment alternatives, as well as possible influences from cervical and masticatory structures in the development of cluster or cluster-like headache.

Cooper, B.C. The role of bioelectronic instrumentation in the documentation and management of temporomandibular disorders. Oral Surg Oral Med Oral Pathol Oral Radiol Endod. 1997 Jan; 83(1):91-100.

Temporomandibular disorders (TMDs) can affect the form and function of the temporomandibular joint, masticatory muscles, and dental apparatus. Electronic measurement of mandibular movement and masticatory muscle function provides objective data that are defined by commonly accepted parameters in patients with TMDs; these data can then be used to design and monitor therapy and enhance treatment therapy. In this study, data on 3681 patients with TMD are presented, including electronic test data on 1182 treated patients with TMDs. Electronic jaw tracking was used to record mandibular movement and to compare the presenting and therapeutic dental occlusal positions. Electromyography was used to analyze the resting status of masticatory muscles and occlusal function at presentation and after therapeutic intervention. Transcutaneous electrical nerve stimulation therapy relaxed masticatory muscles and aided in the determination of a therapeutic occlusal position. The data show a positive correlation between the clinical symptoms of TMD and the presenting occlusion, accompanied by muscle activity. A strong positive correlation also appears to exist between a therapeutic change in the dental occlusion to a neuromuscularly healthy position with use of a precision orthotic appliance and the significant relief of symptoms within 1 month and at 3 months.

Kasman, G.S, Cram, J.R, and Wolf, S.L. Clinical Applications of Surface Electromyography. Aspen Publications, 1998.

Clinical Applications in Surface Electromyography: Chronic Musculoskeletal Pain offers extensive reference material on the use of surface electromyography (SEMG) in the clinical setting. This book is best suited as a clinical reference, but it could also serve as a supplemental text for an advanced course on the evaluation of orthopaedic conditions.

Bixby, G.K. A clinical technique for the management of a class II skeletal relationship with an anterior open bite as a result of long face syndrome in the adult patient. Functional Ortho. Jan./Feb. 1998

Bazzotti, L. Mandible position and head posture: Electromyography of sternocleidomastoids. Cranio. 1998 Apr; 16(2):100-8.

A study was performed to evaluate relationships between mandible position, dynamics, muscle activity and head posture while swallowing by use of surface EMG and mandible kinesiograph on two population groups (118 pathologics and 31 controls). The study produced the following: 1. specific mandible dynamics with a very fast rising phase (0.3 sec) and longer phase of stabilization (1.5 sec); 2. more than 60% of the subjects presented deglutition at occlusion level, the others swallowing at a distance of 0.1-4.6 mm; 3. the whole muscle activity (temporals, masseters, digastrics, sternocleidomastoids) lasted 1.5 sec with no correlation of duration to age; 4. sternocleidomastoids fired at swallowing with an effort of one-half of temporals or masseters; 6. firing order presented a particular pattern: digastrics more often first, sternocleidomastoids more often last. No differences were found between the pathologics and controls. Findings suggest that the oral phase or mandible dynamic, and the stabilization phase or oropharyngeal phase of swallowing, has an individual role that is important in head postural equilibrium.

Minagi, S., Matsunaga, T., Shibata, T., and Sato, T. An appliance for management of TMJ pain as a complication of Parkinson’s Disease. J. of Craniomandibular Practice, January 1998, Vol 16. No.1

This is a case report of a 71 year-old female with pain in the right TMJ, who was also suffering from Parkinson‟s Disease and was treated using a new intraoral occlusal appliance. The new appliance was designed to limit excessive mandibular excursion to the right side by restricting the mediotrusive movement of the left coronoid process. The appliance significantly suppressed involuntary mandibular excursion

Hickman, D.M., and Cramer, R. The effect of different condylar positions on masticatory muscle electromyographic activity in humans. Oral Surg Oral Med Oral Pathol Oral Radiol Endod. 1998 Jan; 85(1):18-23.

OBJECTIVES: The purpose of this study was to determine a condylar position that permitted the greatest total temporalis and masseter muscle activity in maximum static clench. STUDY DESIGN: Twenty normal adults, 9 women and 11 men, were evaluated to determine masseter and temporalis activity in maximum static clench with mandibular condyles in different therapeutic positions. Bimanually manipulated, leaf gauge, centric occlusion, and neuromuscular condylar positions were studied. RESULTS: When mandibular condyles were placed anteroinferiorly in a neuromuscular position, total masticatory muscle recruitment was the greatest. In a bimanually manipulated or a leaf gauge position, mandibular condyles were positioned superoposteriorly, producing the least amount of muscle recruitment. CONCLUSIONS: The result of any therapeutic position should be an improvement in muscle function. With respect to balance and activation, a neuromuscular condylar position proved to be the position capable of recruiting the greatest motor unit activity when compared with a bimanually manipulated position, a leaf gauge position, and a neuromuscular position.
Deregibus, A., and Bracco, P. Chewing cycle analysis. Anthology of ICCMO. Vol. V, 119-38. 1999.

Diagnostic opportunities of chewing cycle analysis have also been presented. Attention was focused on the possibility of discriminating which joint is primarily involved in the pathology. Interpretation of data considered in this paper came either from a review of the scientific literature or from many years of experience in this field. The authors suggest that daily use of this new diagnostic facility could be useful in both diagnosis and monitoring of therapy. In fact, it must be remembered that the aim of therapy for the dysfunctional patients is not only the resolution of pain, but also the improvement of the functional capabilities.

Peet, E.K., and Clister, K. Changes in craniomandibular neuromuscular function and biomechanics following applied kinesiology diagnostic procedures and manual manipulative therapy. International College of Applied Kinesiology, 1999-2000; 1:125-131

This case report using the Myotronics K6-I bioelectronic measuring device shows improved electromyographic activity and range of movement within the craniomandibular muscles in a patient with jaw pain who had co-management between functional dentistry and Applied Kinesiology (AK). An 11-year-old male had been experiencing symptoms of jaw pain and headaches for 6 weeks following an automobile accident. After AK treatment, a staff technician of the dental office performed the Myotronic K6-I computer assessments on the boy after treatment in a separate room and was blinded from the AK testing and treatment procedures. Graphs presented from the Myotronics instrument showed, post-manipulation, that the boy demonstrated improvement in virtually every measured variable. Subsequent office visits revealed both subjective and objective improvement in his condition. This study demonstrates that AK procedures produced remarkable improvements in TMJ function as documented with the K6-I device. Further research using this kind of instrumentation on larger patient cohorts is warranted.

Thomas, N. Utilization of electromyographic spectral analysis in the diagnosis and treatment of craniomandibular dysfunction. Anth of ICCMO. Vol. V, 159-70. 1999.
Ambroz, C., Scott, A., Ambroz, A., and Talbott, E.O. Chronic low back pain assessment using surface electromyography. Journal of Occupational and Environmental Medicine: June 2000 – Volume 42 – Issue 6 – pp 660-669.

This investigation examined surface electromyography as an additional tool in the comprehensive clinical evaluation of patients with chronic low back pain (CLBP). Electromyographic signals from electrodes placed in the lumbar area of 30 CLBP patients and 30 non-pain control subjects were compared. Patients and controls were matched for age, gender, and body mass index. Paired t test showed a statistically significant difference between the two groups. The muscle activity mean values were threefold higher in CLBP patients than in controls (P < 0.00001) in the static testing, and twofold higher in CLBP patients than in controls (P < 0.00001) in the dynamic testing. Our findings indicate that surface electromyography assessment of the paraspinal muscle activity may be a useful objective diagnostic tool in the comprehensive evaluation of CLBP.

Dickerson, W., Chan, C., and Mazzocco, M. Concepts of occlusion, the scientific approach: Neuromuscular occlusion. Signature, 2000, Vol. 7, No. 2; pp 14-17.

The neuromuscular occlusal approach is based on the precepts of science. We now have scientific instrumentation that can record and verify the observations and symptoms presented by our patients. Neuromuscular dentistry is the science-based philosophy that has brought further understanding of muscle physiology into clinical dentistry. Many of the questions have now been clearly answered, allowing the neuromuscular dentist to investigate further, opening doors that were previously closed in the realm of dental diagnosis and treatment. The authors believe that everyone is trying to accomplish the same thing – that which is best for our patients. They are happy for everyone who is comfortable with what he or she is doing. For those clinicians uncomfortable with their occlusal expertise, however, and also for those with open minds and the desire to learn as much about the stomatognathic system as possible, this aspect of dentistry may be as transforming as it has been for the authors.

Gerber, J.W. TMD Stabilization: Orthodontic Finishing Success. Functional Orthodontist. Spring 2001.

Ferrario, V.F., Marciandi, P.V., Tartaglia, G.M., Dellavia, C., and Sforza, C. Neuromuscular evaluation of post-orthodontic stability: An experimental protocol. Int J. Adult Orthodon Orthognath Surg. 2002. 17(4):307-13.

To prevent relapse after orthodontic treatment, retention is often considered indispensable. Soft tissues are thought to have a significant influence on dental movements. To quantify the influence of masticatory muscles on post-treatment relapse, and in an attempt to avoid unnecessary procedures, 2 male orthodontic patients (13 and 30 years old at debonding) were followed up. The patients completed 2 years of fixed orthodontic treatment and received no post-orthodontic retention. After 1 week and again after 6 months, alginate impressions of dental arches and a surface electromyographic (EMG) assessment of the masseter and temporalis muscles during maximum voluntary clenching were performed. The younger patient received surface EMG monitoring once a month for the first 6 months and at the 1-year follow-up appointment. Arch dimensions and the 3-dimensional inclination of the facial axis of the clinical crown (FACC) were measured using a computerized digitizer. Symmetry in muscular contraction was measured by the percentage overlapping coefficient (POC), and potential lateral displacing components were assessed by the torque coefficient (TC). At the 6-month follow-up, no clinical modifications were observed. Quantitative evaluation assessed

that arch dimensions had changed slightly (up to 1 mm). While the adolescent patient had no modifications in FACC inclinations, the 30-year-old patient showed significant alterations (up to 18 degrees). In all examinations of the adolescent patient, POC was higher than 86% and TC was lower than 10%. In the adult, POC was inside the normal range, while all TCs were higher than 10.5%. The larger TC measured in the adult may explain the larger modifications in the 3-dimensional position of his dental crowns. In conclusion, a surface EMG assessment may help in the detection of patients who might need post-orthodontic retention.

Barciela Castro, N., Fernandez Varela, J.M., Martin Biedma, B., Rilo Pousa, B., Suarez Quintanilla, J., Gonzalez Bahillo, J., and Varela Patino, P. Analysis of the area and length of masticatory cycles in male and female subjects. J Oral Rehabil. 2002. Dec; 29(12):1160-4.

It is difficult to determine the existence of a normal or physiological masticatory cycle, because there exists great individual diversity. This study presents some data about two parameters of masticatory cycles according to the frontal plane, i.e. the area and length of right-sided and left-sided cycles in a group of 30 young people, 18 women and 12 men. For our study the Myotronics K6-1 kinesiograph was used. It registers the magnetic field and allows us to obtain graphic recordings of the jaw movement in the three space planes. Other authors have analyzed these parameters, but none of those reviewed provides information about the distribution to each side or according to the gender of sampling subjects selected for the analysis. We have tried to describe the normal morphology of the masticatory cycles and, also, establish a reference so as to provide help in the diagnosis of the functional pathology of the masticatory system.

Mazzocco, M.W., and Hickman, D.M. ―Space‖ – the Final Frontier: Use of neuromuscular measurements in clinical treatment. Anthology of ICCMO. Vol. VI, 3-14. 2003.
Losert-Bruggner, B. Comparison of various methods for determination of the therapeutic positioning of the mandible. Anthology of ICCMO. Vol. VI, 36-41. 2003.
Gerber, J. TMD stabilization: Orthodontic finishing success. Anthology of ICCMO. Vol. VI, 113-20. 2003.
Chan, C.A. Treating craniomandibular dysfunctional patients implementing gnathological or neuromuscular concepts. Anthology of ICCMO. Vol. VI, 15-33. 2003.

Treating craniomandibular disorders (CMD or TIVID), is an area of dentistry that has often times frustrated the clinician due to its multi-faceted musculoskeletal occlusal signs and symptoms. An aspect that should be considered in this arena of treatment is the study of occlusion that relates the maxillary and mandibular teeth as well as the temporomandibular joints and the mandible to the cranium. Investigating even further into this arena of occlusion, one discovers that it also involves physiologic dynamics of muscle activity and muscle rest that drives the masticatory element of occlusion. It is the supporting element that is often overlooked in the health care field that allows the human body to posture and optimally function as a complete healthy system. It is apparent after a more thorough understanding, diagnosis and evaluation by the dentist that musculoskeletal, postural, emotional, biochemical and/or functional issues may be part of the suffering patients complaints. Many of the symptoms that accompany this disorder continue to challenge the great minds of the dental profession who may not be aware that the signs and symptoms which are presented go beyond the occlusal perspective of how teeth articulate and where the centricity of condyle to glenoid fossa relationship exists. Traditionally it was believed that these disorders can be treated through gnathological occlusal principles. However, there are fundamental differences between gnathological and neuromuscular approaches in therapy when addressing the needs of patients who present with the numerous signs and symptoms that compromise the craniomandibular dysfunctional patient. These differences are presented in this paper. A clinical case report is presented and reviewed which has been treated gnathologically and later treated neuromuscularly implementing computerized electro-diagnostic and treatment instrumentation validating the often unrecognized differences.

Moschu-Vurtsi, A., and Haralabakis, N.B. Mandibular kinesiology in children with enlarged tonsils before and after tonsillectomy. European Orthodontics Society, 79th Congress Prague, Czech Republic 10 -14, June 2003.

To examine mandibular kinesiology in a group of children before and after tonsillectomy and to evaluate the relationship between enlarged tonsils and jaw movement.
Jones, D.G. Classification: 21st century’s version. J. Amer. Orthodontic Society. Fall 2004.

Bracco, P. Correlation between posture and occlusion. International Congress 2004.

There was a strong relation between mandibular position and body posture: 91 out of 95 (96%) subjects showed variations in load distribution closing mouth either in centric occlusion or in centric relation or in myocentric position. Furthermore, 92 out of 95 (98%) subjects showed changes also in the distance between theoretical and real barycenter on x axis, and 95 cases out of 95 (100%) showed changes on y axis. Similar results were observed by the authors in previous experiences (2). The results seem to support the observation that different jaws relations imply differences in body posture.

Berzin, F. Surface electromiography in the diagnosis of syndromes of the cranio-cervical pain. Brazilian J. Oral Science. July/Sept 2004. Vol. 3. No. 10.

This paper first provides a review of the anatomy and physiology of striated muscles, focusing on the muscle fiber, motor unit and μ neuron. We also commented on the factors that affect the depolarization of this neuron, resulting in its excitation or inhibition, and thereby altering the contractions of the motor unit, which in turn alters the equilibrium of the muscle dynamics. The changes caused by these factors, such as muscular hyperactivity, found mainly in the temporal muscles, with the jaw the resting position and chewing are also discussed. However, muscular hyperactivity is most frequently observed in the masseter muscles. The suprahyoid muscles, responsible for the positioning of the tongue, also show a large number of alterations. We also commented on the changes observed in the contractions of the posterior cranio-cervical musculature, sternocleidomastoid muscles and the upper fibers the trapezius, which are sources of referred pain.

Cooper, B.C. Parameters of an optimal physiological state of the masticatory system: the results of a survey of practitioners using computerized measurement devices. Cranio. 2004 Jul;22(3):220-33.

While bioelectronic instruments have been available for nearly 30 years to assist dentists in day-to-day evaluations of patients‟ masticatory systems, little guidance has been published to support physiological norms or ideals. An electronic questionnaire was developed and administered to an international group of dentists familiar with the use of bioelectronic instrumentation. Respondents were asked to provide feedback on the norms or ideal parameters of jaw movement, masticatory muscle function with electromyography, and joint sounds through electrosonography that they use in guiding evaluation and treatment of patients with temporomandibular disorders, neuromuscular occlusion, and orthodontics. Surveys were collated to determine areas of consensus. Out of 150 surveys, 55 responses were received from dentists representing nine different countries. Sixty percent of the respondents reported treating more than 150 cases in the past five years using bioelectronic testing. While experience ranged from 2-30 years with different types of devices, average experience was longer with mandibular/jaw tracking (mean 15.3 years) and electromyography (mean 14.1 years) than with electrosonography (mean 7.0 years). Parameters proposed as norms or ideals for electromyographic rest and clench values, and mandibular tracking (velocity, freeway space, and trajectory to closure) were very consistent. Although a smaller number of respondents reported utilization of electrosonography, their criteria for data significance and tissue-type genesis of joint sounds were consistent. While the intra-patient variability may limit the diagnostic use of bioelectronic instruments, the current study demonstrates that through decades of experience, dentists have independently arrived at very consistent definitions of an ideal physiology that can be used to guide treatment.

Chan, C.A. Applying the neuromuscular principles in TMD and orthodontics. J. Am. Orthodontic Soc., pp 20-29, Spring, 2004.

Neuromuscular dentistry goes beyond traditional dentistry in that it includes consideration of the “physiologic posture” of the mandible. Determining habitual posture vs. physiologic posture requires evaluation of the muscles, joints and nerves involved in mandibular posture and function in addition to the teeth. Today‟s computerized measuring and recording instrumentation, together with an understanding of neuromuscular principles, give dentists the ability to be true “physicians of the mouth.” Muscles cannot be evaluated by radiographic analysis alone. With bioinstrumentation it is possible to determine a proper resting jaw position that positively affects the facial, head, and neck muscles and the teeth as well as the joints. A case study is presented in great detail describing how a severe TMD case had failed to respond to long and frustrating traditional dental therapy, but was then resolved through the application of neuromuscular principles and evaluation. Following provisional treatment that proved a symptom-free mandibular position, the case was permanently finished to that position with orthodontic treatment.

Takamatsu, H. Determination of vertical dimension to achieve a functional and esthetic occlusion. Anthology of ICCMO. Vol. VII, 111-22. 2005.

Gleichauf, C. The effect of a neuromuscular physiologic orthosis on masticatory muscle fatigue. Anthology of ICCMO. Vol. VII, 47-56. 2005.

Capmourteres, C. A neuromuscular approach to implant dentistry: A case study. Anthology of ICCMO. Vol. VII, 99-104. 2005.

The use of bioelectronic measurement instrumentation is the only way to create or restore this occlusion, giving the implant dentistry the most predictable result, and avoiding potential complications often associated with implant failures.

As technology advances, the new approach to treatment planning a dental implant rehabilitation should include a thorough clinical examination, complete radiographic evaluation, and a diagnostic wax-up on mounted study models in the neuromuscular occlusal position as determined by TENS. In this author‟s opinion, this neuromuscular diagnostic protocol, as it was detailed in this case study, will benefit both the patient and the clinician in the quest for achieving predictable results in the future.

Piancino, M.G., Farina, D., Talpone, F., Castroflorio, T., Gassino, G., Margarino, V., and Bracco, P. Surface EMG of jaw-elevator muscles and chewing pattern in complete denture wearers. J Oral Rehabil. 2005 Dec; 32(12):863-70.

The aim of this study was to investigate the adaptation process of masticatory patterns to a new complete denture in edentulous subjects. For this purpose, muscle activity and kinematic parameters of the chewing pattern were simultaneously assessed in seven patients with complete maxillary and mandibular denture. The patients were analyzed (I) with the old denture, (II) with the new denture at the delivery, (III) after 1 month, and (IV) after 3 months from the delivery of the new denture. Surface electromyographic (EMG) signals were recorded from the masseter and temporalis anterior muscles of both sides and jaw movements were tracked measuring the motion of a tiny magnet attached at the lower inter-incisor point. The subjects were asked to chew a bolus on the right and left side. At the delivery of the new denture, peak EMG amplitude of the masseter of the side of the bolus was lower than with the old denture and the masseters of the two sides showed the same intensity of EMG activity, contrary to the case with the old denture. EMG amplitude and asymmetry of the two masseter activities returned as with the old denture in 3 months. The EMG activity in the temporalis anterior was larger with the old denture than in the other conditions. The chewing cycle width and lateral excursion decreased at the delivery of the new denture and recovered after 3 months.

Castroflorio, T., Icardi, K., Torsello, F., Deregibus, A. Debernardi, C., and Bracco, P. Reproducibility of surface electromyography in human masseter and anterior temporalis muscle areas. Cranio. April 2005.

The aim of this study was to test the hypothesis that surface electromyography (sEMG) recordings, made at mandibular rest position from the masseter and temporalis anterior areas, are intra- and inter-session reproducible. A template was designed and built to permit the correct electrode placement from one session to the next session. A sample of 18 subjects was examined. Two groups, homogeneous for age, sex, and craniofacial morphology were selected. The first group included asymptomatic subjects with no signs or symptoms of temporomandibular joint dysfunction (TMD) and the second group included patients suffering from muscle-related TMD. Data were obtained from different sEMG recordings made at mandibular rest position in the same session and in different sessions, repositioning the electrodes using a template designed for that purpose. The electromyograph used in this, study is part of the EMG K6-I Win Diagnostic System. Results showed that reproducibility of sEMG signals from the masseter and anterior temporalis areas at mandibular rest position is possible.

Castroflorio, T., Farina, D., Bottin, A., Piancino, M.G., Bracco, P., and Merletti, R. Surface EMG of jaw elevator muscles: Effect of electrode location and inter-electrode distance. J Oral Rehabil. 2005 Jun 32(6):411-7.

This study addresses methodological issues on surface electromyographic (EMG) signal recording from jaw elevator muscles. The aims were (I) to investigate the sensitivity to electrode displacements of amplitude and spectral surface EMG variables, (II) to analyze if this sensitivity is affected by the inter-electrode distance of the bipolar recording, and (III) to investigate the effect of inter-electrode distance on the estimated amplitude and spectral EMG variables. The superficial masseter and anterior temporalis muscles of 13 subjects were investigated by means of a linear electrode array. The percentage difference in EMG variable estimates from signals detected at different locations over the muscle was larger than 100% of the estimated value. Increasing the inter-electrode distance resulted in a significant reduction of the estimation variability because of electrode displacement. A criterion for electrode placement selection is suggested, with which the sensitivity of EMG variables to small electrode displacements was of the order of 2% for spectral and 6% for amplitude variables. Finally, spectral and, in particular, amplitude EMG variables were very sensitive to inter-electrode distance, which thus should be fixed when subjects or muscles are compared in the same or different experimental conditions.

Chan, C., and Thomas, N.R. Clinical and scientific validation for optimizing the neuromuscular trajectory using the Chan protocol. Anthology of ICCMO. Vol. VII, 3-16. 2005.
Observable effects of anteriorizing the mandible in the frontal/lateral domain has been considered using computerized mandibular scanning confirmed with simultaneous EMGs with ultra low frequency Myomonitor TENS. Tomographic evidence is used to confirm an optimized condylar disc relationship along the optimized neuromuscular trajectory. A clinical comparative study of the classic Scan 4/5 versus the optimized (Chan Scan) was done comprising 73 candidates (43 males, 31 females). Results indicated that 78.5% of all optimized (Chan Scan) trajectories taken were anterior to the classic scan 4/5 trajectory. 21.5% of the optimized (Chan Scan) trajectories were equal to the classic scan 4/5 trajectory. Patient‟s response to the modified scan was greatly improved over a shorter treatment period than the controls.
Cooper, B.C. Parameters of an optimal physiological state of the masticatory system: The results of a survey of practitioners using computerized measurement devices. Anthology of ICCMO. Vol. VII, 17-33. 2005.

While bioelectronic instruments have been available for nearly 30 years to assist dentists in day-to-day evaluations for patients‟ masticatory systems, little guidance has been published to support physiological norms or ideals. An electronic questionnaire was developed and administered to an international group of dentists familiar with the use of bioelectronic instrumentation. Respondents were asked to provide feedback on the norms or ideal parameters of jaw movement, masticatory muscle function with electromyography, and joint sounds through electrosonography that they use in guiding evaluation and treatment of patients with temporomandibular disorders, neuromuscular occlusion, and orthodontics. Surveys were collated to determine areas of consensus. Out of 150 surveys, 55 respondents were received from dentists representing 9 different countries. Sixty percent of the respondents reported treating more than 150 cases in the past five years using bioelectronic testing. While experience ranged from 2-30 years with different types of devices, average experience was longer with mandibular/jaw tracking (mean 15.3 years) and electromyography (mean 14.1 years) than with electrosonography (mean 7.0 years). Parameters proposed as norms or ideals for electromyographic rest and clench values, and mandibular tracking (velocity, freeway space, and trajectory to closure) were very consistent. Although a smaller number of respondents reported utilization of electrosonography, their criteria for data significance and tissue-type genesis of joint sounds was consistent. While the intra-patient variability may limit the diagnostic use of bioelectronic instruments, the current study demonstrates that through decades of experience, dentists have independently arrived at very consistent definitions of an ideal physiology that can be used to guide treatment.

Eatmon, R. Changes in mandibular posture after muscle relaxation, using transcutaneous electrical nerve stimulation. Anthology of ICCMO. Vol. VII, 35-46. 2005.
The posture of the body and its related pattern of function with the mechanics of muscles moving bones at the pivot of the joints is the premier focus for physical rehabilitation of neuromuscular pathology. The temporomandibular dysfunction patient likewise must be evaluated and treated with this premise in mind. Postural analysis must be made to try to restore the physiologic alignment of the mandible to the cranial base so that a foundation is established from which to evaluate and plan the management of the case. Successful, non-surgical management has been accomplished by using data obtained from electromyographically testing the muscles of mastication and by using computerized mandibular jaw tracking to help establish the pathology of muscle and skeletal alignments. The posture of the mandible after application of transcutaneous electrical nerve stimulation is measured in its new neuromuscular position to determine what, if any, positional changes do occur.

Bruzzone, G.L. Orthodontic finishing for two TMD patients. Anthology of ICCMO. Vol. VII, 67-90. 2005.

Today, state of the art treatment in orthodontics involves the recognition, diagnosis and stabilization of TMD symptoms prior to orthodontic treatment. The purpose of this paper is to show two severe, yet opposite cases – the short face and the long face – both presenting with TMD problems, and both treated using neuromuscular principles.
Simmons, W.C. Neuromuscular orthotics in the treatment of bruxing and clenching in subjects with and without cervical pathology. Anthology of ICCMO. Vol. VII, 141-48. 2005.
A clinical evaluation of neuromuscularly derived mandibular orthosis in 40 patients diagnosed with bruxism and clenching parafuntion is reported. Neuromuscular occlusal orthodics are carefully adjusted utilizing neuromuscular instrumentation and Tek-scan occlusal balancing. Orthotics are monitored for the occurrence of wear facets for a period of six months. Neuromuscularly derived mandibular occlusal orthotics are shown to be effective in the treatment of eccentric bruxism indicating this condition has a direct relationship to occlusal disharmonies. In sharp contrast, clenching parafuntion, predominating in patients with cervical dysfunction, was resistant to orthotic therapy. Bruxing and clenching are redefined to reflect a hypothesis of different underlying causes and treatment outcome expectations. Possible physiologic pathways for bruxing and clenching are discussed.

Kares, H. Treatment outcome of myocentric splint therapy aided by a standardized symptom list. Anthology of ICCMO. Vol. VII, 57-64. 2005.

The goal of this study was to prove the effectiveness of myocentric splints on a range of symptoms suffered by CMD patients. The experiment involved the attempt to optimize the indication positioning and prognosis at the start of the dental functional therapy. 62 women and 21 men between 20 and 65 years old were questioned from a list of symptoms at the time a myocentric splint was incorporated and 4 weeks thereafter. We were able to document significant improvements in headaches, joint cracking, facial pain, neck pain and shoulder pain. Symptoms such as ringing in the ears, dizziness and insomnia were improved in approximately 50% of the cases but snoring showed hardly any change.

Ito, M., Okubo, M., Kobayashi, H., Iijima, M., Narita, N., and Matsumoto, T. Trigeminal input modulates acoustic stapedius reflex and inner ear function. IADR Conference
Proceedings, Brisbane, Australia, June 28-July 1, 2006.

The aim of this study was to demonstrate the neural connection between trigeminal system and auditory system by means of neurotology devices. Methods: Fourteen healthy volunteer with the mean age of 30 years were participated in this study. Middle and inner ear function were measured with middle ear analyzer (Tympanogram; TG and acoustic stapedius reflex; SR) and distortion product otoacoustic emission (DPOAE) system before and after electrical stimulation of bilateral masseter muscles. The repetitive stimulus, 25 mA for 500 msec at 1.5-second intervals, was applied with TENS unit (Myotronics, Inc.) for 40 min, Each data obtained by middle ear analyzer and DPOAE system before and after stimulation was compared statistically with Wilcoxon signed-ranks test. Results: There was no significant difference in the middle ear function including static compliance showing mobility of tympanic membrane (before: 0.62(0.28)ml after:0.61 (0.3 1)ml), and middle ear pressure (-12.6(11.0)ml -10.3(12.0) daPa). On the other hand, the significant difference was shown in the reflex latency of SR (90.5(24.6)1 96.9(29.2) msec, P<0.05). Also, the significant difference was found in DPOAE showing activities of the cochlear hair cells at the level of 1250 Hz (c9.6(5.3)ml 9.2(5.0) dBSPL, P<0.05). Conclusions: This study provides the evidence that electrical stimulation of bilateral masseter muscles can modulate acoustic stapedius reflex and inner ear function. Neurotology devices may become diagnostic tool to evaluate ear symptoms in patients with TMJDs. Further study is needed to clarify the arising mechanism of ear symptoms in patients with TM.TDs.

Deng, M.H., Long, X., Li, X.D., Cheng, V., and Yang, X.W. Clinical application of electrosonography in diagnosis of anterior disc displacement with reduction. L Zhonghua Kou Oiang Yi Xue Za Zhi. 2006 Feb; 41(2):108-10.

The objective of this study was to investigate the electrosonography character of sounds emanating from anterior disc displacement with reduction of TMJ and the value of it in clinical diagnosis. The sounds from healthy TMJ, anterior disc displacement with or without reduction of TMJ, and osteoarthritis of TMJ were recorded and analyzed by K6-I system, then the data was used for diagnosis of anterior disc displacement with reduction in clinic. A special kind of waveform was found in the electrosonography of sounds from anterior disc displacement with reduction repeatedly, and seldom or not in sounds from healthy joints, anterior disc displacement without reduction or osteoarthritis of TMJ. The diagnostic sensitivity of anterior disc displacement with reduction by using electrosonography analysis was 77 2% and specificity was 93 3% when compared with the clinical diagnosis based on clinical appearance and radiography evidence CONCLUSION: The special kind of waveform may be characteristic wave of sounds from anterior disc displacement with reduction of TMJ, which is useful as an aid in diagnosis of anterior disc displacement with reduction in clinic.

Kato, M, Kogawa, E, Santos, C, and Rodrigues, P. TENS and low-level laser therapy in the management of temporomandibular disorders. J Appl Oral Sci. 2006; 14(2):130-5.

Pain relief and reestablishment of normal jaw function are the main goals of conservative management of Temporomandibular Disorders (TMD). Transcutaneous electrical nerve stimulation (TENS) and laser therapy are part of these modalities, although little is known about their real efficacy in controlled studies. This research compared these two treatments in a sample of 18 patients with chronic TMD of muscular origin, divided into two groups (LASER and TENS). Treatment consisted of ten sessions, in a period of 30 days. Active range of motion (AROM), visual analogue scale (VAS) of pain and muscle (masseter and anterior temporalis) palpation were used for follow-up analysis. Data were analyzed by Friedman test and ANOVA for repeated measurements. Results showed decrease in pain and increase in AROM for both groups (p<0.05), and improvement in muscle tenderness for the LASER group. Authors concluded that both therapies are effective as part of TMD management and a cumulative effect may be responsible for the improvement. Caution is suggested when analyzing these results because of the self-limiting feature of musculoskeletal conditions like TMD.

Deng, M., Long, X., Dong, H., Chen, Y., and Li, X. Electrosonographic characteristics of sounds from temporomandibular joint disc replacement. 1 Int J. Oral Maxillofac Surg. 2006 May; 35(5):456-60.

The purpose of this study was to investigate the waveform and electrosonographic characteristics of sounds emanating from internal derangement of the temporomandibular joint (TMJ). TMJ sounds were recorded from 10 joints of normal people (NP), 10 joints from patients with anterior disc displacement with reduction (DDR) and 20 joints from patients with anterior disc displacement without reduction (DDNR). The sounds were analyzed through fast Fourier transfer methods to observe their waveforms and electrosonographic characteristics. The observations were then used in differentially diagnosing internal derangement. Wave pattern and electrosonography (ESG) differed among the NP, DDR and DDNR groups. There was very little difference in frequency between the sounds from DDR and DDNR, but the amplitude of the DDR sounds was higher than those of DDNR and NP. The sensitivity and specificity of ESG diagnosis for DDR were 77.2% and 93.3%, respectively, while for DDNR they were 8l.6% and 64.7%, respectively.

Chan, C.A. Multi-dimensional diagnosis and treatment to avoid orthodontic and surgical pitfalls. J. Amer. Orthodontic Society. Fall 2006.

Clinicians are now realizing that vertical orthopedic eruption of teeth is active throughout life, and with the development of clinical techniques to help in vertical erupting of teeth and increasing the vertical dimension, there is a growing demand to learn how to effectively verticalize and control proprioceptive occlusal inputs from the teeth orthopedically within the neuromuscular parameters of occlusion.7 As long as mal-occlusion dominates the musculoskeletal system, mandibular jaw open and closing patterns will be posterior to an isotonic path of physiologic closure. Muscles lengths will foreshorten, resulting in muscular pains and pathologic dysfunction. Optimizing muscular health and identifying muscular disease objectively will increase case stability and improve long term retention. Addressing these orthopedic/functional orthodontic musculoskeletal problems through the eyes of neuromuscular principles will prevent misdiagnosing and mistreatment of the abnormal posterior Class II and abnormal anterior Class Ill jaw relationships. The significance of the increase in occlusal vertical dimension and its accompanying horizontal change in mandibular position confirms the need to quantitatively measure existing muscle tension and relaxation modes of the masticatory system. These diagnostic tests are clinically useful to assess skeletal mal-relations in evaluating the indications for surgical correction of prognathism or retrognathism. In cases in which the cuspal anatomy has not yet been unduly defaced by wear or extensive restorative treatment, orthodontic vertical eruption alone is the treatment of choice, especially for musculoskeletal dysfunction and temporomandibular joint derangement problems.

Ferrario, V.F, Piancino, M.G., Dellavia, C., Castroflorio, T., Sforza, C., and Bracco, P. Quantitative analysis of the variability of unilateral chewing movements in young adults.
Cranio. 2006 Oct; 24(4):274-82. In the current study, a kinesiograph was used to detect and record the three-dimensional motion of the mandibular mid-incisor point during unilateral chewing as a function of time. The aim of the study was to quantify the within-subject short-term reproducibility of the kinesiographic recordings in normal, healthy subjects. Ten seconds of unilateral (right and left) gum chewing were recorded in 20 control subjects using computerized kinesiography. Each subject performed 18 chewing sequences (three repetitions x three sessions x two sides). Chewing cycle duration, volume, standardized depth and width, and the number of reversed cycles were calculated. Intraclass correlation coefficients (two-way random effects analysis of variance with interactions) and paired t-tests were used to compare sessions. For each subject and side, chewing variability was expressed as the coefficient of variation (percentage ratio of standard deviation to mean) of each variable. Mean left and right side mastications were computed over all sessions and subjects. For all the analyzed variables, larger variations between subjects (analysis of variance, p < 0.001) than between sessions were found, with intraclass correlation coefficients ranging between 0.432 (left side cycle duration) and 0.989 (right side standardized width). No systematic errors between the three measurement sessions were found for cycle volume and shape (paired t, p > 0.05). The highest between subjects/ between sessions variance ratios (up to 223.28) were found for cycle duration and shape. In all subjects, chewing cycle volume was very variable, with mean coefficients of variation up to 47% (left side in females). Cycle duration and standardized depth and width were more reproducible, with mean coefficients of variation up to 10% (duration), 14% (standardized width), and 18% (standardized depth). The spatial characteristics of gum chewing cycles had a large within-subject variability. The temporal and size-standardized (shape) characteristics were more consistent within subject. The results should allow selection of a set of relatively more consistent variables for the definition of normality and the comparison of patients.

Cooper, B.C and Kleinberg, I. Examination of a large patient population for the presence of symptoms and signs of temporomandibular disorders. Cranio 2007 Apr: 25(2):l 14-26.

Temporomandibular Disorder (TMD) is a term generally applied to a condition or conditions characterized by pain and/or dysfunction of the masticatory apparatus Its characterization has been difficult because of the large number of symptoms and signs attributed to this disorder and to variation in the number and types manifested in any particular patient For this study, data on 4,528 patients, presenting over a period of 25 years to a single examiner for TMD treatment, was made available for retrospective analysis and determination of whether the TMD care-seeking patient can be profiled, particularly pain difficulties All patients in this database filled out a questionnaire and were examined for the prevalence of a range of symptoms and clinical examination findings (signs) commonly attributed to TMD. There was no attempt in this study to assign patients to TMD diagnostic subcategories The data collected were analyzed to determine which of these symptoms and signs were sufficiently “characteristic of the TMD condition” that they might be used in diagnosis, research and treatment, especially in patients needing relief from pain and discomfort All 4,528 patients reported symptoms and all but 190 of them also showed signs upon examination. Symptoms most commonly reported on the questionnaire included (i) pain (96.1%), (ii) headache (79.3%), (iii) temporomandibular joint discomfort or dysfunction (75.0%) and (iv) ear discomfort or dysfunction (82.4%) In the 4,338 patients who showed signs, the most prevalent was tenderness to palpation of the pterygoid muscles (85.1%), followed by tenderness to palpation of the temporomandibular joints (62.4%) Pain symptoms and signs were often accompanied by compromised mandibular movements, TMJ sounds and dental changes, such as incisal edge wear and excessive overbite. Clearly prevalence of pain disclosed by the symptoms and signs examinations was high Patients showed variable prevalence and nonprevalence of eight categories of painful symptoms and seven categories of painful signs Despite the variability, these might be developed in the future into TMD scores or indices for studying and unraveling the TMD conundrum.
Grazia Piancino, M., Farina, D., Merlo, A., Greco, M., Aprato, M., and Bracco, P. Early treatment with “function generating bite” of a left unilateral posterior cross-bite: Chewing pattern before and after therapy with FGB. IJO, 2007 Summer, Vol. 18, NO. 2.

A case of a 5.2 years-old child, with a left unilateral posterior cross-bite, from the canine to the second deciduous molar, corrected with the functional appliance “Functional Generating Bite” (FGB) is reported. The chewing cycles were recorded before and 6 months after correction. The number of reverse chewing cycles on the cross-bite/corrected side decreased significantly six months after therapy (2% with the soft bolus and 4% with the hard bolus) with respect to the initial condition (70% with the soft Bolus and 79% with the hard bolus). In conclusion, the FGB achieved the orthodontic correction and also the corrected the masticatory function.

Hickman, D.M., and Stauber, W. Mapping mandibular rest in humans utilizing electromyographic patterns from masticatory muscles. Cranio. 2007 Oct; 25(4):264-72.

As the mandible assumes its resting position in space, antagonistic muscles should assume their resting lengths as is demonstrated by resting and isometric electromyography. This zone of mandibular rest can be mapped using these physiologic parameters of muscle activity. Three positions were evaluated: a maximum physiologic open position, a maximum physiologic closed position, and a physiologic rest position. Additionally, each subject’s maximum intercuspation position was evaluated. Within the physiologic zone of rest, formed by the maximum physiologic open position and maximum physiologic closed position, muscle recruitment was the greatest in a physiologic group. Results indicated that muscle function was significantly greater within the zone of mandibular rest than at the intercuspal position.

Bergamini, M., Pierleoni, F., Gizdulich, A., and Bergamini, C. Dental occlusion and body posture: a surface EMG study. Cranio. Jan 2008; 26(1):25-32.

The objective of this study was to access, using surface electromyography (EMG), the rest activity of paired sternocleidomastoids, erectors spinae at L4 level, and soleus muscles in a group of 24 volunteer subjects (12 males, 12 females, aged 23-25 yrs) affected by sub-clinical dental malocclusions in different situations of dental occlusion. The subjects’ occlusion was balanced (neuromuscularly) (registered on an acrylic wafer). Rest activity was assessed using the sEMG. The measurements were achieved on subjects while standing barefooted, before (Test 1), and 15 minutes after they wore the acrylic wafer (Test 2). The result was a significant reduction of the mean voltage for each muscle. Paired muscles were registered and the balancing rate between right and left muscles showed improvement for all the paired muscles (Wilcoxon test p < 0.05). No significant difference was noted in the relaxation and balancing rates between the muscles tested. The data confirmed a beneficial effect of balancing the occlusion with an acrylic wafer on the following paired postural muscles: sternocleidomostoid, erector spinae, and soleus.

Dong, Y., Wang, X.M., Wang, M.Q., and Widmalm, S.E. Asymmetric muscle function in patients with developmental mandibular asymmetry. J. Oral Rehabil. 2008 Jan; 35(1):27-36.

The aim was to test the hypothesis that developmental mandibular asymmetry is associated with increased asymmetry in muscle activity. Patients with mandibular condylar and/or ramus hyperplasia having unilateral cross-bite were compared with healthy subjects with normal occlusion. Muscle activity was recorded with surface electrodes in the masseter, suprahyoid, sternocleidomastoid muscle (SCM) and upper trapezius areas during jaw opening-closing-clenching, head-neck flexion-extension, and elevation-lowering of shoulders. Root mean square (RMS) and mean power frequency (MPF) values were calculated and analyzed using anova and t-tests with P < 0.05 chosen as significance level. The SCM and masseter muscles showed co-activation during jaw and head movements, significantly more asymmetric in the patients than in the healthy subjects. The RMS and MPF values were higher in the patients than in the controls in the SCM and suprahyoid areas on both sides during jaw opening-closing movement. The results indicate that the ability to perform symmetric jaw and neck muscle activities is disturbed in patients with developmental mandibular asymmetry. The results support that co-activation occurs between jaw and neck muscles during voluntary jaw opening and indicate that postural antigravity reflex activity occurs in the masseter area during head extension. Further studies, where EMG recordings are made from the DMA patients at early stages are required to verify activity sources and test if the asymmetric activity is associated with muscle and joint pain in the jaw and cervical areas.

Cooper, B.C., and Kleinberg, I. Establishment of a temporomandibular physiological state with neuromuscular orthosis treatment affects reduction of TMD symptoms in 313 patients. J. of Craniomandibular Practice, 2008 Apr, Vol. 26, No. 2

The objective of this investigation was to test the hypothesis that alteration of the occlusions of patients suffering from temporomandibular disorders (TMD) to one that is neuromuscularly, rather than anatomically based, would result in reduction or resolution of symptoms that characterize the TMD condition. 313 patients with TMD symptoms were examined for neuromuscular dysfunction, using several electronic instruments before and after treatment intervention. Such instrumentation enabled electromyographic (EMG) measurement of the activities of the masticatory muscles during rest and in function, tracking and assessment of various movements of the mandible, and listening for noises made by the TMJ during movement of the mandible. Ultra low frequency and low amplitude, transcutaneous electrical neural stimulation (TENS) of the mandibular division of the trigeminal nerve (V) was used to relax the masticatory muscles and to facilitate location of a physiological rest position for the mandible. The neuromuscular occlusal position was recorded in the form of a bite registration, which was subsequently used to fabricate a removable mandibular orthotic appliance that could be worn continuously by the patient. Three months of full-time appliance usage showed that the new therapeutic positions remained intact and were associated with improved resting and functioning activities of the masticatory muscles. Patients reported overwhelming symptom relief, including reduction of headaches and other pain symptoms.

Makarita, H.R. Full mouth rehabilitation and bite management of severely worn dentition. J. Cosmetic Dent 24 (2) 85-96, Summer 2008.

This patient initially exhibited severe occlusal disharmony and craniomandibular dysfunction. A series of diagnostic tests using computerized instrumentation was conducted, which provided objective data that was used in treatment planning. Not until the patient‟s new vertical dimension position was tested for several months was any treatment attempted.

It is well accepted that there is more than one philosophy or method that can be utilized to arrive at a physiologic bite position. As responsible clinicians, we should study the different treatment modalities available to our profession before making a decision as to which one to implement. Whichever method applied it must be in the patients‟ best interest. Before proceeding to final restorations, it is imperative to establish a comfortable, stable bite derived from verifiable, objective clinical data.

Cooper, B.C. Relationship of temporomandibular disorders to muscle tension-type headaches and a neuromuscular orthosis approach to treatment. J. of Craniomandibular Practice. Vol 27, No. 2, April 2009.

A prominent etiological theory proposed for TMD related headache is that it results from a dysfunctional masticatory muscle system, wherein muscle hyperactivity is frequently caused by dental temporomandibular disharmony. The central goal of this article was to determine from a literature review of the subject whether there is significant evidence to support a relationship between headaches and TMD prevalence. A second purpose was to determine from such a review whether any relationship was one of cause and effect and whether treatment of the TMD condition can result in meaningful reduction or resolution of headaches, In the literature, there was a substantial amount of evidence for a positive relationship between TMD and the prevalence of headaches, and most importantly, that these were the muscle tension-type. Evidence for a cause and effect relationship was strong. It generally showed in numerous patients that TMD treatment of a large number of patients resulted in significant improvement in the physiological state of the masticatory system (muscles, joints and dental occlusion). Reduction or resolution of muscle tension-type headaches that were present was clinically significant. The authors concluded that TMD should be considered and explored as a possible causative factor when attempts are made to determine and resolve the cause of headaches In patients with this affliction. A benefit of resolving headaches at an early stage in their development is that it might result in the reduction of its potential for progression to a chronic and possibly migraine headache condition.

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