Full Mouth Neuromuscular Reconstruction: Planning and Execution is essential for success.

This was originally a Google +  Post.  Due to an incredible response from viewers of that post I decided to repost with comments on the I Hate Headaches site.

A full mouth reconstruction is the ultimate in dentistry but it can also be a patient's worst nightmare.

The relation of the jaw to the head affects and is affected by the entire body. Ideally a full mouth reconstruction is done to physiologically healthy muscles joints breathing and function.

This video is of a patient who started with a single quadrant of crowns that morphed into a non-physiologic reconstruction. I saw him after three reconstructions of his entire mouth to treat his symptoms. The first was a Centric Relation Reconstruction and the second two were Neuromuscular Reconstruction. His final reconstruction was done well but failed to resolve many issues.
I did not do any of these reconstructions but worked to idealize his current restorations. These two videos describe a small part of the difficult journey this patient has travelled.

Correcting physiological issues should be done at the start of a case. This patient did not go looking for a full mouth reconstruction but fell into it.

It is unfortunate that a fabulous person and excellent physician fell into a trap not of his making.


https://www.youtube.com/watch?v=YxPB8eso5pg

https://www.youtube.com/watch?v=RaRqa2akLMA

Additional patient videos:  https://www.youtube.com/channel/UCk9Bfz6pklC7_UluWFHzLrg/videos

The reason there are so many issues with full mouth reconstruction is that many dentists, even etremely wel educated and proficient dentists do not understand the importance of head posture on their treatment.  Many take bites and do adjustments with the patient reclined in the dental chair.

The Quadrant Theorem of Guzay is extremely important to dentists because it explains in engineering terms how the center of jaw rotation is not in the TMJoint.  Rather, it is on the Dens process of the second vertebrae (Axis) that passes thru the first cervical vertebrae (atlas).
This is because the TMJoints acting together go thru two distinct movements rotation and translation.  These movements alwys happen simultaneously and there is no time during normal function in which pure rotation occurs.
The concepts of Centric Relation's approach to occlusion is that it is found by the dentist moving the patients jaw in a pure rotation at a border position of the joint.

The usefulness is that it is easy to transfer this information to the dental laboratory.  The problem is it is not a physiologic position and in fact the most dangerous position for all joints is in border positions.   Patients don't funtion there.

The use of TENS in  Neuromuscular Dentistry is to take the muscles to a healthy relaxed state.  This creates a three dimensional relation between the cranium (head) and mandible (lower jaw).

This relation changes when the head position changes.  It is vital to evaluate the bite in upright sitting and standing positions.  This also means that you cannot ignore the rest of the body when doing a full mouth reconstruction without risk of long term instability.


Ira L Shapira DDS, D,ABDSM, D,AAPM, FICCMO
Chair, Alliance of TMD Organizations
Diplomat, American Academy of Pain Management
Diplomat, American Board of Dental Sleep Medicine
Regent & Fellow, International College of CranioMandibular Orthopedics
Board Eligible, American Academy of CranioFacial Pain
Dental Section Editor, Sleep & Health Journal
Member, American Equilibration Society
Member, Academy of Applied Myofunctional Sciences
Member, Academy of Cosmetic Dentistry
www.ThinkBetterLife.com
www.DelanyDentalCare.com
www.IHateCPAP.com
www.iHateHeadaches.org


#fullmouthrecostruction #fullmouthneuromuscular #oralreconstruction #problemswithfullmouthreconstructions #disasterswithfullmouthreconstructions #fullmouthCRRecostruction #avoidingproblemswithfullmouthreconstructions #centricrelationfullmouthreconstruction #failedCRfullmouthrecosnstruction
#CentricRelationReconstruction #fullmouthreconstructiondisaster
#ChicagoFullMouthReconstruction #HighlandParkFullMouthReconstruction
#NewYorkFullMouthReconstruction #costfullmouthreconstruction #fullmouthreconstructionsteps #verticaldimension #verticaldimensionofocclusion

FORWARD HEAD POSTURE, MYOFASCIAL TRIGGER POINTS, TMJ, TMD, AND TENSION-TYPE HEADACHE ALL CLOSELY RELATED

A PRIMARY DIAGNOSTIC FINDING IN TMJ, TMD, TMJ DISORDERS IS MYOFASCIAL TRIGGER POINTS. THEY ARE FREQUENTLY ASSOCIATED WITH FORWARD HEAD POSTURE A COmMON FINDING IN TMJ PATIENTS. A 2006 ARTICLE "Myofascial trigger points and their relationship to headache clinical parameters in chronic tension-type headache." IN HEADACHE JOURNAL CLEARLY DESCRIBES HOW TRIGGER POINT IN "upper trapezius, sternocleidomastoid, and temporalis muscles were associated with CTTH CHRONIC TENSION-TYPE HEADACHES)"

NEUROMUSCULAR DENTISTRY UTILIZES A DIAGNOSTIC NEUROMUSCULAR ORTHOTIC AND TENS TO ELIMINATE THE FACTORS THAT CAUSE TRIGGER POINTS TO FORM AND PROPAGATE. ELIMINATION OF THESE TRIGGER POINTS CAN PREVENT TMJ DISORDERS, TREAT TMD AND CHRONIC TENSION TYPE HEADACHES. PATIENTS WITH INCREASED MYOFASCIAL TRIGGERS ALSO HAVE INCREASED INTENSITY AND DURATION OF HEADACHE ATTACKS.

A DIAGNOSTIC NEUROMUSCULAR ORTHOTIC IS A SAFE AND EFFECTIVE FIRST STEP IN THE DIAGNOSIS, TREATMENT AND ELIMINATION OF MYOFASCIAL TRIGGERS AND RELATED TMJ AND HEADACHE DISORDERS.

Headache. 2006 Sep;46(8):1264-72.
Myofascial trigger points and their relationship to headache clinical parameters in chronic tension-type headache.

Fernández-de-Las-Peñas C, Alonso-Blanco C, Cuadrado ML, Gerwin RD, Pareja JA.

Universidad Rey Juan Carlos, Physical Therapy, Alcorcon, Madrid, Spain.
Abstract

OBJECTIVE: To assess the presence of trigger points (TrPs) in several head and neck muscles in subjects with chronic tension-type headache (CTTH) and in healthy subjects; and to evaluate the relationship of these TrPs with forward head posture (FHP), headache intensity, duration, and frequency.

BACKGROUND: Tension-type headache (TTH) is a headache in which myofascial TrPs in head and neck muscles might play an important etiologic role.

DESIGN: A blinded, controlled, pilot study.

METHODS: Twenty-five CTTH subjects and 25 matched controls without headache were studied. TrPs in bilateral upper trapezius, sternocleidomastoids, and temporalis muscles were identified according to Simons et al's diagnostic criteria: tenderness in a hyperirritable spot within a palpable taut band, local twitch response elicited by snapping palpation, and elicited referred pain with palpation. A TrP was considered active if the subject recognized the evoked referred pain as familiar headache. If the evoked referred pain was not recognized as familiar headache, the TrP was considered as latent. Side-view pictures of each subject were taken in both sitting and standing positions in order to assess FHP by measuring the cranio-vertebral angle. Both measurements were made by a blinded assessor. A headache diary was kept for 4 weeks in order to assess headache intensity, frequency, and duration.

RESULTS: The mean number of TrPs on each CTTH subject was 3.9 (SD: 1.2), of which 1.9 (SD: 1.2) were active TrPs and 1.9 (SD: 0.8) were latent TrPs. Control subjects only exhibited latent TrPs (mean: 1.4; SD: 0.8). There was a significant difference between the CTTH group and the controls for active TrPs (P < .001), but not for latent TrPs (P > .05). Differences in the distribution of active and latent TrPs within each muscle were also significant for all the analyzed muscles (P < .01). CTTH subjects with active TrPs in the right upper trapezius muscle or left sternocleidomastoid muscle showed a greater headache intensity and duration, but not headache frequency, compared to those with latent TrPs (P < .05). Active TrPs in the right temporalis muscle were associated with longer headache duration (P < .01), whereas active TrPs in the left temporalis muscle were associated with greater headache intensity (P < .05). CTTH subjects with active TrPs in the analyzed muscles had a greater FHP than those with latent TrPs in both sitting and standing positions. Differences were only significant for TrPs in the left sternocleidomastoid and FHP in the sitting position (P < .01).

CONCLUSIONS: Active TrPs in upper trapezius, sternocleidomastoid, and temporalis muscles were associated with CTTH. CTTH subjects with active TrPs usually reported a greater headache intensity and longer headache duration than those with latent TrPs. CTTH subjects with active TrPs tended to have a greater FHP than CTTH subjects with latent TrPs.

intense jaw pain on left side, swollen jaw and cheek, no dental issues per dentist and endodontist...tmj or trigeminal neuralgia?

I recently received a e-mail from a patient with the following complaint:

intense jaw pain on left side, swollen jaw and cheek, no dental issues per dentist and endodontist...tmj or trigeminal neuralgia?

The question TMJ or Trigeminal Neuralgia is very limited. 95% of all pain that patients experience is muscle pain. Many patients have severe or even excruciating pain but their TM Joints are normal. These are neuromuscular problems and may have many contributing factors. Trigeminal Neuralgia is rarely the cause of pain and when it is there is usually very specific triggers. The pain usually comes and goes going from normal to intense pain after stimulating trigger.

KI have seen patients with similar symptoms that are later tracked back to cracked toooth syndrome that was not evident early on. Vacumn sinusits can also give similar symptoms.

That said, the most common cause of pain is myofascial pain acute muscle spasm, myositis or other pain of muscular orgin.

A simple test that all general dentists and/or endodontists should know is how to do trigger point deactivation with a vapocoolant and stretch that can often give instanyt pain relief. Use of a diagnostic block to the muscle can also correct these problems when used to make a differential diagnosis.

The patient did not describe whether the pain was affected by jaw movement, if there was limited opening, or many other vital facts to know if there was joint involvement.

The correct approach is to make an accurate diagnosis. This involves a thorough evaluation of the jaw musclesand (TMJ) joints but also the head and neck musculature.

The best route is to seek out a neuromuscular dentist who is trained to evaluate and correct these problems.

I frequently see patients in Chicago who have not found help locally.

Diagnosis is the key to successful treatment. Treatment should be reversible until significant pain relief is accomplished and both the patient and the doctor are comfortable with primary and secondary diagnosis.

Facial Pain, Normal Sinus CT scans, Headache, Migraine and TMD

An older study in the Laryngescope is on 104 patients with facial pain who had normal CT scans. Twenty nine of the patients had previous unsuccessful sinus surgery. The patients were approximately 80% women, TMJ disorders are usually (80%) found in female patients.

The study showed " Four percent of patients seen by a neurologist had an unsuspected serious intracranial diagnosis." It is essential that organic neurologic causes are ruled out but the 100 remaining patients had headaches of undetermined causes. Facial pain and sinus pain are a alert for MPD (myofascial pain) and TMD (temporomandibular pain). Treatment of patients with chronic headaches, migraines sinus and/or facial pain is frequently done without a neuromuscular dental evaluation even though NMD has extremely high success rates.

The Trigeminal nerve innervates the sinus cavities. It is often called the Dentist's nerve because the trigeminal nerve primarily goes to the teeth, jaw muscles, jaw joints, periodontal ligaments and is responsible in full or part for most headaches. It also controls blood flow to the anterior 2/3 of the brain thru the meninges.

Correction of underlying neuromuscular problems often allows drug free effective treatment. When CT scans are normal patients with sinus pain and facial pain should always be evaluated by a neuromuscular dentist. Neurologists should evaluate all patients with organic brain disorders but functional treatment is preferred to heavy drug therapy for the majority of patients.

Frequently Chiropracters and dentists can get miraculous results by working together especially NUCCA and A/O (Atlas Orthogonal) chiropracters. The Dentists can correct nociceptive trigeminal nerve input while the chiropracters correct cervical and head posture. Long term correction of those problems usually requires correction of descending conditions associated with improper jaw function.



Laryngoscope. 2004 Nov;114(11):1992-6.
Neurologic diagnosis and treatment in patients with computed tomography and nasal endoscopy negative facial pain.
Paulson EP, Graham SM.

Department of Otolaryngology--Head and Neck Surgery, University of Iowa, Iowa City, Iowa 52242-1093, USA.
Abstract
OBJECTIVE: To determine the helpfulness of specialist neurology referral for patients with facial pain, a normal sinus computed tomography (CT) scan, and normal nasal endoscopy findings.

STUDY DESIGN: Prospective identification of patients and analysis of data approved by the Institutional Review Board.

METHODS: The data of 104 consecutive patients presenting with facial pain, a normal sinus CT scan, and normal nasal endoscopy findings were reviewed. The patients presented to a single rhinologist in a tertiary care institution. All patients were referred for specialist neurologic evaluation and potential treatment. Further information was obtained from a patient survey.

RESULTS: Of the 104 patients, 81 were women and 23 were men. The average age was 46 years (range, 22-85). Fifty-six had clear CT scans, 48 had minimal change, and all had negative endoscopies. Twenty-nine had previous unsuccessful sinus surgery. The average follow-up period was 10.5 months. Forty of 75 patients seeing a neurologist were seen on multiple occasions. Four percent of patients seen by a neurologist had an unsuspected serious intracranial diagnosis. The most common diagnoses were migraine (37%), rebound headache (17%), chronic daily headache (17%), and obstructive sleep apnea (16%). Overall, 58% improved on medical therapy; 60% of those with a clear CT scan improved, and 53% of those with minimal change on CT scan improved (P = .749).

CONCLUSIONS: Facial pain remains a difficult symptom to diagnose and treat in rhinologic practice. Patients often undergo surgery without help. Most patients with facial pain, a normal sinus CT scan, and normal endoscopy findings benefit from neurologic consultation. Serious intracranial pathologic conditions can be excluded and diagnosis-specific pharmacogenetic therapy instituted with improvement in more than 50%.

PMID: 15510029 [PubMed - indexed for MEDLINE]