FROM the ARCHIVES

MICRONSMATTER:
When to Grind, When NOT to Grind
n my clinical practice I have found that stabilizing the bite is key to optimal treatment results, especially for those cases involving muscle pain related TMD, comprehensive restorative and orthodontic malocclusion problems. If the clinician desires to minimize the repeated follow up occlusal adjustment visits, it is imperative for the dentist to recognize that microns matter. Figure 1. Many patients are keenly aware of the sensitivity of their bites. Not all treating dentists know that their patients have fine proprioceptive differences in their occlusion. Riis and Giddon (1990) reported interdental incisor discrimination of 14 micron thickness between the teeth in some cases. Other investigators suggested discrimination below 10 microns.1 It has been reported that a human hair can be as thin as 17 microns. We know individuals can feel a human strand of hair between their teeth. Humans can feel the differences in their bites after a new restoration or

FROM the FRONTLINE

The masticatory system is a highly detailed and innervated posturing system.

By Clayton A. Chan, D.D.S. Director and Founder of Occlusion Connections

Figure 1

Figure 2

Figure 3

Occlusal Adjustments Should Support:

 Stabilization of the periodontium and dental occlusion Reduction in TMJ clicks and  pops (joint degeneration)  Elimination of masticatory muscle pain and dysfunction Removal of abnormal jaw clo sure patterns  Improved maxillary to mandibular posture and stability Improved head, cervical spine,  occiput and pelvis balance.

prosthetic treatments (e.g., crowns, fillings, dentures) are placed intra orally. Fine occlusal prematurities if left unadjusted, can set off a chain reaction of problems including tooth sensitivity, mobility, bone loss, gingival recession, root canals, fractured cusps, excessive grinding and clenching, mandibular torque, head and neck aches, TMD problems and possible clicking and popping of the jaw joints. If the bite is not properly adjusted, symptoms may occur, affecting the periodontium, musculature and even the central nervous system. A bite that is not properly balanced, regardless of whether it is before or after restorative/ prosthetic, or orthodontic treatments, as well as any routine operative restorative visit, can awaken an underlying musculoskeletal occlusal problem. This could turn into an annoying or troublesome challenge for the patient and clinician if not detected and treated. Microns Matter! Figures 2, 3&4 During jaw opening, the mandible is acted on by four combined forces: 1) Visco-elastic resistance to stretching jaw closing muscles, 2) lateral pterygoid muscles, 3) digastric/suprahyoid muscles, and 4) gravity. Bio-physiologic mechanics indicates that without these constraints the mandible would cause an isolated door hinge movement of rotation

Figure 4

(about the center of the condyle) and translation (down and forward in the direction of a hypothetical articular eminence).

Objectives for Occlusal Adjustments:

1. T  o establish synchronous balanced occlusal contacts on both left and right sides so that the involuntary movement of the mandible and voluntary closure of the mandible are equal. Low frequency Myomonitor TENS (Myotronic-Noromed, Inc., Kent, WA) is used to produce an involuntary mandibular six dimensional movement. 2.  To obtain equal intensity of occlusal marks in order to establish optimal function during resting and functioning modes of mandibular movements. 3.  To relieve any anterior contacts that may entrap the freedom of movement of the mandible and jaw joints during involuntary and voluntary closure.
Continued

1. R  iis D and Giddon DB. Interdental discrimination of small thickness differences. J. Prosthet Dent 24:324-334, 1990.

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4. T  o establish cuspid rise and anterior disclusion.

This is What I Do:

Physiologic maxillary to mandibular jaw positioning is critical for my cases. Without knowing how these two entities are properly aligned physiologically, all bite adjustments will be off no matter how accurate the occlusal adjustment technique. Adjusting the bite to a proper physiologic opening and closing pattern is important, especially to those discerning patients with high occlusal sensitivity. Removing all premature incline interferences without obliterating and flattening the occlusal anatomy (keeping and preserving anatomical form) is also important. I use both technology as well as Accufilm II marking paper to visualize the premature occlusal marks. An occlusal prematurity is any occlusal contact that occurs on any incline plane before any other incline mark. These can best be identified with involuntary muscle closing responses to remove micro mandibular torque.

me in achieving comfortable craniomandibular occlusal balance for my patients without manual manipulation of the lower jaw. I want both voluntary tapping occlusal marks to synchronize with involuntary TENS occlusal mark closure patterns. If these occlusal marks are not one and the same, one will have occlusal slides and micro interfering skids that will contribute to underlying musculoskeletal malocclusion, mandibular torque and TMD problems. I often use the red marks to establish centric contacts and the black marks to help me identify the lateral skidding prematurities. When adjusting and balancing the retrusive contacts, I use the black marks to identify the retrusive contacts and the red marks to help me see what surface of the occlusion I should not adjust. Involuntary pulse stimulus with low frequency TENS produces a mandibular jaw closure pattern that helps remove micro jaw torques not seen with the naked eye. I believe it is crucial to recognize the true pitch, yaw, roll, vertical, lateral and AP positioning of the mandible and temporomandibular joints that affect how the occlusal marks are visualized in the mouth. Clinicians will either adjust voluntary habitual accommodated occlusal marks that they commonly see or will adjust involuntary occlusal marks that represent mandibular closing occlusal marks free of mandibular muscle strain and torque. Figures 9-14

Figure 9

Figure 10

Figure 11

What I Use (Figures 5-8):

1. 2 articulating paper forceps 2.  Parkells AccuFilm II Double sided (Red/Black) 3.  Fine tapered diamonds/burs (high speed ) and or acrylic tapered lab burs (straight HP) 4.  Low frequency TENS (J5 Myomonitor, Myotronics) 5.  Jaw Tracker to visualize mandibular positioning (sagittal, vertical, frontal) within 0.1 millimeters (K7 Kineseograph, Myotronics-Noromed, Inc., Kent, WA).

Figure 12

Industry Standard in Marking Occlusal Accuracy

Figure 13

I use a low frequency TENS (Transcutaneous electro neural stimulation) unit that produces involuntary, bilateral pulse stimulation to the muscle along with my AccuFilm II to identify occlusal prematurities. Adjustments are carefully made to preserve cusp fossa form as well as the marginal ridges. Establishing synchronized black or red occlusal marks bilaterally upon involuntary closure aids
2

For decades AccuFilm has been the industry standard for marking occlusal accuracy. Its super fine 21 micron (0.0008) thickness allows the clinician to visualize precise occlusal markings during the bite adjustment process. AccuFilm II (red and black) is the marking film Ive used in my practice for the past 23 years. It has allowed me to contrast centric occlusal marks from lateral skid marks. This colored film combination has enhanced my ability to identify abnormal proprioceptive occlusal prematurities, (with great accuracy), that skew the bite and strain the musculature. Establishing balanced occlusal marks, free of
Continued

Figure 14

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maxillo-mandibular torque, is key to establishing physiologic muscle harmony and occlusal comfort.

8.  When there exists airway obstruction and breathing problems.

My Occlusal Adjusting Techniques:

1.  I adjust my patients in an upright sitting position for all cases involving complex restorative or TMD problems.

When it is ACCEPTABLE to GRIND

2.  I use two articulating paper forceps to help position my AccuFilm II over the posterior quadrants. 3.  I use low frequency TENS to produce a voluntary mandibular tapping response into the AccuFilm when identifying occlusal prematurities.

1.  When the patient is not experiencing any masticatory pain or discomfort. (This means, no tender muscles of the temples, facial muscles, lower jaw muscles and shoulder muscles, prior to any dental procedure). 2.  When a solid, stable habitual bite exists. Also when routine single tooth dentistry is performed and the dentist needs to only adjust the new filling or crown. 3.  When there is no clicking or popping of the jaw joints prior to any dental procedures. (patient and dentist should be aware of this)! 4.  When there is sufficient vertical height and dimension of tooth structure available. 5.  When there is sufficient enamel to adjust. 6.  When a single tooth is hitting or contacting prematurely and is sensitive. 7.  When it has been recognized that jaw joint degeneration does not exist. (no clicking or grating-crepitus sounds).

5.  First establishing centric marks on an optimal neuromuscular trajectory is key to removing mandibular torque and skews in the bite. 6.  Lateral excursive adjustments are made to remove any incline skids, preserving canine rise. 7.  Protrusive incisal balance is then established.

4.  I adjust all occlusal prematurities until involuntary closing responses are synchronized with voluntary tapping closing marks.

8.  Retrusive contacts are established by laying the patient in a reclined position and adjusted so there are even posterior contacts. Getting the correct bite is crucial for all of my cases, especially when I need to address complex TMD pain with lower anatomical orthotics and or resolve restorative arch - type muscle related crown and bridge occlusal problems.

For more information on how Dr. Clayton A. Chan manages and teaches occlusion see: http://occlusionconnections.com

When NOT to GRIND or EQUILIBRATE the TEETH

1.  When the patient reports or experiences tender or painful masticatory muscles. 2.  When there is jaw joint pain (Intra capsular or extra capsular) 3.  When there is existing jaw joint degeneration (Tomographic, MRI or cone beam imaging can confirm). 4.  When there are clicking and popping sounds (crepitus) during opening and closing of the jaw (this indicates that the jaw/occlusion is not stable). 5.  If there is previous history of jaw locking opened or closed. (This usually is an indication that there is a condylar disc problem). 6.  If the person has had an extensive amount of restorative dentistry performed, adjusting or equilibrating the bite will often lead to further occlusal problems (unless the dentist is extremely skilled and understand the consequences and treatment outcome). 7.  When there is lack of posterior vertical dimension of occlusion.

ABOUT the AUTHOR

Clayton A. Chan, DDS Director/Founder of Occlusion Connections
Occlusion Connections is a teaching and post graduate instructional center committed to advancing dentists understanding and skills in dental occlusion. It is an information and training center committed to convey the art, science and values of both gneuromuscular (gnatho-neuro-muscular) and neuromuscular technology. It is a group of clinicians who have common goals, positively interact and share their experiences relating to clinical dentistry in order to advance the dental profession and serve patients at the highest level. For more information on Occlusion Connections: Email: jane@drclaytonchan.com Phone: (702) 271-2950

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