Neuromuscular Dentistry objectively evaluates the complex relationship between teeth, airway, temporomandibular joints(TMJ) and the masticatory muscles in order to achieve an occlusion that is based on the optimal relationship between the mandible and the skull – Neuromuscular Occlusion or Myocentric Occlusion(MCO). It is precision dentistry because it measures occlusion and quantifies all the faculties of the stomatognathic system. This is achieved by relaxing the muscles controlling the jaw position to establish a true physiological rest position upon which treatment considerations are based. Once relaxed, do we need to add to the teeth to attain optimum jaw position or do we need to reduce tooth structure to relax the hypertonic muscles? How do we decide?
We at The Right Bite CPC®, follow an extensive regimen to help our patients. Every patient undergoes a diagnostic setup which includes the following:
1. Radiology – a. Lateral Cephalograph
c. TMJ View (Left & Right; Open & Close)
d. Airway CBCT Volumetry
2. The Right Bite Questionnaire
3. Intra-Oral & Extra-Oral examination
4. Postural examination
5. Sleep study (HST –Home Sleep test or PSG – Polysomnograph)
After this, the diagnosis is provided to the patient with a detailed explanation of the causes of the problem and the treatment methodologies.
The treatments would be as per The Right Bite NMD Protocol, in which NMD is divided into 5 categories:
1. Addition NMD
2. Reduction NMD
3. Dental Sleep Medicine
5. Allied Specialities
THE RIGHT BITE NMD PROTOCOL
Conceptualized by Dr.Raj, this protocol helps us to decide when to add and when to reduce. Several protocols were imbibed to understand the science. The Golden Proportion (Phi), Hank Shimbashi’s Golden Vertical, LVI’s GV, Myotronics - ICCMO’s TENS protocol, Tekscan – BioResearch’s DTR (Disclusion Time Reduction) protocol etc., were respectfully utilized to segregate patients to treat with the addition or reduction NMD.
Achieving the Golden Vertical (GV) with the patented J5 ULF TENS unit should be the ultimate aim of any dentist post-treatment. If the GV is more than the current Vertical Dimension (VD), we need to follow Addition NMD. If the GV is less than the VD, then Reduction NMD needs to be done on the patient.
Neuromuscular disorders like Temporomandibular Joint disorder (TMD), Obstructive Sleep Apnoea (OSA), Cervical posturology, Myofascial Pain Dysfunction Syndrome (MPDS) should also be treated the same way. Because NMD is the only holistic option available now.
Addition NMD involves applying the ULF TENS (J5 Myomintor), confirming the reduced EMGs (M-Scan), registering the new bite (K7/JT) and then providing a customized anatomic mandibular orthotic to maintain the new mandibular position for 8-10 months, which includes bi-monthly visits (if required) for orthotic adjustments. This would form the first phase.
The second phase would involve prosthodontic or orthodontic rehabilitation of the new MCO to maintain the patient in that bite permanently to avoid the relapse of the pain. The charges for this would be extra and depends on the centre. However, The Right Bite protocol has to be followed.
There are 2 types of orthotics – the usual acrylic one and the tooth coloured resin. Both function the same way but the more expensive resin orthotic is much more patient-friendly and compliant.
There are 2 ways to measure the bite.
1. The cheaper TENS Bite is only 70% precise (but 70% better than the usual CR bite) and can be registered with just the portable J5.
2. The 99% precise K7 bite would incorporate the use of the EMG and the Jaw Tracker for the most precise bite.
Since most of these patients have an anatomic variation in the presence of a deep bite, 90% undergo Addition NMD.
Reduction NMD involves applying the ULF TENS (J5 Myomonitor), confirming the EMGs (M-Scan) and then using the DTR protocol (with The T-Scan) to reduce interferences at the Micro-occlusal level to achieve the most physiological occlusal relationship.
OBSTRUCTIVE SLEEP APNOEA:
OSA is a dreaded silent killer which we dentists don’t give importance to. The night bruxism, for which we provide a night guard, is actually caused due to a difference in Oxygen desaturation during sleep; which is caused due to a mal-positioning of the mandible and hence the tongue blocking the airway. The night guard only saves the teeth from destruction during the bruxing; it doesn’t stop the cause of the bruxism which if continues would cause more muscle strain in the TMJ leading to TMD.
Almost 80% of all TMD patients have OSA and hence they all need to be screened for it by undergoing a sleep study. The Home Sleep Test (HST) is preferable. If the test shows bruxism, the TMD patient will need to wear a sleep appliance along with the day TMJ orthotic.
The bite registration for an oral sleep appliance to treat Obstructive Sleep Apnoea has to be done with the muscles in mind. A custom-made sleep appliance cannot be at the same bite registration (70% of maximum protrusion!!!) for everyone. And what about the vertical! The Right BiteTM protocol helps us to decide the right bite so that the patients don’t have any more muscle tightness in the morning after wearing the appliance in a forced advanced mandibular position.
The importance of Cervical Posturology is gaining momentum in the patho-physiology of facial pain and other neuromuscular disorders. With every change in mandibular position, there would be a compensatory change in cervical vertebral position. Hence, the possibility of TMD/Facial pain causing back pain (Descending TMD) or a rotated cervical vertebra causing TMD (Ascending TMD) should always be kept in mind during diagnosis. Hence, a physiotherapist who understands breathing and yoga, need to be incorporated.
The most important person on the team other than the NMD would be the ENT. Someone who understands the importance of the airway in occlusion; or is ready and willing to understand.
The pulmonologist would be required to intervene if the OSA shows higher value parameters.
A clinical psychologist should be involved as most of our patients are chronic sufferers due to the misdiagnosis that they suffer and hence a bit of counselling would help us resolve their issues faster.