Why Neuromuscular Dentistry?
Most of you who know me know I have aligned myself with progressive restorative philosophies over the years. I was widely criticized in the mid to late 80's for following the early pioneers etching dentin with phosphoric acid. The naysayers said it would kill the pulp. It hasn't. I was widely criticized for placing aesthetic posterior restorations. The naysayers said they wouldn't last. They have. I was widely criticized for placing all porcelain restorations without metal. The naysayers said they would fracture. They didn't. I also knew I might be criticized for our occlusion philosophy as well. What I'm saying, and most of you know me well enough to understand what I'm trying to get across here, is that I would not bet my reputation on something that I think is nonsense. I've risked my life savings on LVI and I would not embrace anything that I didn't think is right. But I am as convinced about neuromuscular dentistry and its logic as I am about anything I've ever done.
It would be hard to talk about the total philosophy of LVI's occlusion in a single article. Anything I say can be taken out of context and questioned because it seems incomplete. And I think that there are more similarities than there are differences between our philosophy and others. The cusp fossa relationship, tooth contacts, etc. are not really different than other teachings, but I do believe the differences are important. In fact, I think dentists should attend other occlusion programs. It's a wonderful educational experience. But I also think there are things that we address that are not covered in other occlusion philosophies. One thing that we feel is that the occlusal plane is critical. There are six dimensions of occlusion and we address all six in the two programs as well as the full mouth reconstruction program. We believe it is very difficult to accurately create a level occlusal plane with a face bow transfer. This issue is not emphatically addressed by many other occlusal teachings. We feel the forces of occlusion need to be distributed down the long axis of the body. If the occlusal plane is canted either horizontally or anterior posteriorly, then it won't be.
Our biggest difference, and the one that seems to be the most controversial, is that we also believe that the comfortable position of the mandible is determined by the muscles, not joint anatomy. We can measure the muscles and find the most comfortable position of the mandible ("Happy Muscles"). We believe that just because you find a repeatable position, that doesn't make it comfortable! The truth is that most people in society don't close in a repeatable position. Yet they find that position every time because of the proprioceptive control over the jaw movement. What we believe is that you find the most comfortable position neuromuscularly, then restore the patient in that position, and they will occlude in that comfortable position every time because of the proprioceptive fibers. Therefore..."happy muscles"!
With the addition of Bob Jankelson and Clayton Chan, we are taking this to the precise extent. We just completed our second full mouth program and 40 dentists prepped and sat 28 units at one time. And yes, we opened the bites of most of them. They are all comfortable and we can prove it by measuring their muscle activity in their new position compared to their old position. I've done over 30 full mouth cases last year (many on dentists) and they are all occlusally comfortable. Although I only have a little more than one-year track record Bob and Clayton have years of restorative success using these principles.
We have had over 300 dentists go through our Occlusion I program with all but one being totally impressed with the content and philosophy (the one is almost there but he's a die hard gnathologist) and we are almost sold out for all 12 programs this year. Most of these people are students of other occlusal camps. Why is our Occlusion course so popular if it's nonsense and so illogical? Why have my instructors (some of the best dentists in the country) totally embraced this philosophy? Am I spiking their Kool-Aid? What Clayton Chan and Bob Jankelson do is take it to the next level with scientific documentation of our accurate results while making it obvious and understandable.
We can prove a lot of things using our principles. We can prove our cases are not so called seated in a compressed position. We can identify and find resting EMGs. Our patients' mandibles are comfortable because we can actually see the difference and see improvement in the before and after with recorded and documented EMGs. Our condyles are not in the strained position, which often shows pathologic problems via SONOGRAPHIC analysis and confirmed by TOMOGRAPHY. Our computer mandibular scanning data verifies and clearly confirms pathologies, muscles dysfunction's, jaw movement dysfunction's which can only stem from restricted Range of Motions and pathologies in the joints. We can confirm that the physiologic trajectory is anterior to habitual occlusion (CO). Thus the occlusion/ bite is less than optimal and often contributing to pathology and symptoms of occlusion. We can also prove when vertical is deficient.
Our clinical observations and findings will also confirm the same. When the CMS, EMGs, SONO, the Tomographic analysis as well as our hands-on clinical evaluation all confirm consistently these problems, I can't but be convinced by this overwhelming body of evidence that some of our patients joints are seated pathologically and need to be unseated to a physiologic position. If our patients' muscles are strained as indicated by EMGs, they can be corrected and improved with proper neuromuscular treatment protocols. On follow up tomography, we confirm joint position with even joint spacing. CMS confirms smooth movement on both frontal and sagittal views. No cross-overs on dental open and closing paths. Velocity is unhindered. EMGs are low and even. Muscle palpation and evaluation confirms no tenderness or trigger points. Sonography indicates a decrease in major measured interference's. Facial appearance and aesthetics are improved. The patient presents as a new and improved human being that is now COMFORTABLE and realizing what comfortable truly means. Our mandibles are seated where the muscles, the joints and the teeth all harmonize together physiologically and proven as well as confirmed with OBJECTIVE DATA. Not reaffirmed by some subjective feeling of arrogance and tradition. THAT IS OUR PHILOSOPHY!
It is a known fact with those in the TMJ, head, neck pain arena, and functional orthodontic arena that the neuromuscular approach is valid. The measuring technology we are using is ADA approved and FDA approved vindicating that this technology is scientific and valid as an aid in the diagnosis of TMD. We are not using hokey stuff! Are any articulators ADA approved or FDA approved as aids in the diagnosis of TMD etc?
Clayton Chan who has been at this a lot longer than me said the following, "I have never once seen a case in CR with low EMGs and the patient says they are relaxed with no pathology, etc. They are all compromised with too many clinical musculo-skeltal occlusal signs and symptoms. There are at least 58 clinical signs. Many are overlooked and even ignored! What most doctors thinks is comfortable is terrible for my patients. Sure many of those patients don't complain. They think they are "normal" They have no idea what normal / comfortable is!" Clayton heads up the Occlusion programs.
I am happy for anyone who is comfortable and content with what they are doing. Great, then you don't need any help. But I also think we need to be careful about criticizing things we know little about. For those that might not be comfortable with their occlusal expertise and also those with an open mind and a desire to learn as much about dentistry as you can, this aspect of dentistry just might be something that will change your life as much as it has mine.
Neuromuscularly yours,
Bill Dickerson
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