ORIGINAL ARTICLE
International Dental Journal 2014; 64: 12–19 doi: 10.1111/idj.12057
The neuromuscular approach towards interdisciplinary cooperation in medicine Maksim Yurchenko1, Hana Hub alkov a1, Ivo Klep acek2, Vladimır Macho n3 and Jirı Mazanek3 1
Institute of Clinical and Experimental Dental Medicine, First Faculty of Medicine of Charles University in Prague, Prague, Czech Republic; Department of Anatomy, First Faculty of Medicine of Charles University in Prague, Prague, Czech Republic; 3Department of Oral and Maxillofacial Surgery, First Faculty of Medicine of Charles University in Prague, Prague, Czech Republic. 2
Background: The contemporary approach of dentistry towards interdisciplinary cooperation is based on the neuromuscular concept. In recent years many authors have pointed out a correlation between orthopaedic and dental findings. Furthermore, there is an intimate biomechanical interrelationship of occlusion with cerebral fluid circulation, left and right equilibrium, gaze stabilisation and headache. The influence of a dental occlusion and temporomandibular joint (TMJ) status on general health has been widely analysed in the current scientific literature. Aim: The aim of this analytic study was to display the deep relationship between dentistry and other fields of medicine, and to show the necessity of wide cooperation between dentists and physicians. Conclusions: This study was based on a review of 41 sources, including specialised articles and books. The significance of different anatomical and physiological preconditions (occlusion, muscles and TMJ status) was considered and evaluated separately. However, as a result of modern concepts of general body health, extending cooperation between different fields of medicine is essential. The practical application of the principles of neuromuscular dentistry enables one to increase greatly the treatment efficiency of aches in muscles, headaches, postural dysfunctions as well as of many other diseases. However, the dentist’s contribution to the development of an interdisciplinary approach is underestimated. Many theoretical aspects of the interdisciplinary relationship have not been sufficiently examined, hence the practical consequences remain unclear. Further research in the field is urgently needed. Key words: Dentistry, occlusal plane, temporomandibular joint, masticatory muscles, rehabilitation
INTRODUCTION The current development of computer technologies, as well as new examination methods, enables the linking of relatively distant fields of medicine. For this reason, the term ‘integrative medicine’ is now becoming more widely used in specialised literature1. Recently, the functional connections between the structures of the maxillofacial region and other systems of the human body have been thoroughly studied and some articles published in scientific literature describe the influence of different pathological states of the maxillofacial region on orthopaedic problems. Modern research conducted in the field has proved the positive influence of a correctly performed reconstruction of occlusion on such important indices such as carriage, stable balance, aches in muscles, headaches, physical state, eyesight and some others. A dentist should not now be perceived as someone whose job is merely to treat people’s teeth, but as a physician of the maxillofacial region2. In the framework of this concept a new 12
direction of dentistry has appeared: maxillofacial dentistry or integrative dentistry. The field of maxillofacial dentistry has been widely recognised by the professional community, and this is reflected in its inclusion in the syllabuses of the world’s leading universities. In neuromuscular dentistry the following principles are applied: con• Direct connection with classical physiological cepts and application of its terms2. According to physiology, the central nervous system, muscles, joints, teeth and jaws are one functional unit. Pathological changes appearing in any part of this complex have an influence on other parts. Therefore, successful treatment has to be applied to the whole system, not only its most diseased part. This is the core assumption of modern neuromuscular dentistry, which is focused on the detection of physiological mechanisms determining the reciprocal influence of the maxillofacial region on other parts and systems of the human body © 2013 FDI World Dental Federation
The neuromuscular approach in medicine
•
From the point of view of neuromuscular dentistry, the orthogonal concept of regulating anatomical structures is a necessary condition for the natural functioning of the maxillofacial region. In the physiological head position, Camper’s plane, the HIP-plane (Hamulus–Papilla incisiva), the occlusal plane, and the ANS-Porion line should be parallel to the horizontal plane as well as perpendicular to a vertical axis1,4 (Figure 1a). Should these planes not be parallel, imbalance of the maxillofacial system could occur, which would result in a number of interconnected neuromuscular reactions (Figure 1b). The masticatory muscles play a significant role as various pathological processes in the maxillofacial region influence them. As masticatory muscles are loaded unevenly, muscle strain in its different parts is unequal, which leads to the alteration of the mechanical trajectory in the jaw joint. As a result of the uneven loading of their fascicles, the bone will adjust its attachment points to the muscles, and even its own structure. For example, the chronic spasm of m. pterygoideus lateralis could cause a deformation of the condyle. The alteration of the mandibular mechanical trajectory could be also connected with repeated premature contact between opposing maxillary and mandibular teeth. As a result of iatrogenic injury it could occur accidently. A premature contact stimulates a
During treatment a neuromuscular dentist seeks the proper balance between the work load and relaxation of the masticatory muscles. The aim of neuromuscular therapy is to create the proper conditions for muscle relaxation of the maxillofacial region as well as for the reverse movement of condyles mandibulares to the rest state, which would be optimal for a patient3 • To establish a diagnosis and to provide further treatment sophisticated equipment is used. Technical equipment and computer programs enable the analysis of the state of muscles, temporomandibular joints (TMJs) and occlusion. The received biometric data are essential for establishing an accurate diagnosis. The saying of Dr Bernard, the founding father of neuromuscular dentistry, can be applied in this instance ‘If it has been measured, it is a fact; if it has not been measured, it is an opinion’. A modern dentist is required to have not only knowledge of the maxillofacial region, but also general morphological and physiological awareness of the human body. According to the orthogonal concept applicable to both organic and inorganic units, the resistance to any loading is the strongest when the resistance axis of the structure is parallel to the axis of loading.
(a)
(b)
Figure 1. Parallelism (a) and disruption (b) of main anatomical planes in human body. Ivo Klepacek, based on an original drawing by James E. Carlsson, DDS. © 2013 FDI World Dental Federation
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Yurchenko et al. response of the nervous system (efferent impulses). With the help of head and cervical muscles, this response is intended to repeatedly return the mandibular joint to its physiological position. Furthermore, chronic and asymmetric overstrain of individual muscles and their groups could deform the bone structure and influence their growth. Muscle hypertonus could cause pathologies such as headaches, orofacial pain, different orthodontic anomalies, teeth abrasion and fractures, cervical teeth defects and TMJ disorders5. From the position of modern dentistry the determination of any mouth cavity condition is essential for diagnosing diseases, which at first sight appear not to be connected with dental pathologies. Both the loss of a tooth and the aforementioned premature contact could initiate a chain of reactions causing various disorders. In serious cases, for example loss of a molar and significant height reduction of the bite, there is a high risk of the emergence of different symptomatic complexes as a result of heightened pressure on chorda tympani and n. auriculotemporalis (tinnitus, ear congestion, non-specific facial and neck pain, glossalgia, xerostomia, herpes meatus acusticus externus)6,7. There is now clear evidence that the atypical relations between anatomical structures of the maxillofacial region could be connected with structural deformations of the cervical spine8. Accompanying mouth opening and closing, the minor displacements in cervical, thoracic and lumbar spine also contribute to this interconnection9. Occlusion dysfunctions could cause sleeping apnoea, myofascial pain syndrome, column diseases, leg-length inequality, abnormal pelvis obliquity and incorrect head posture. They affect equilibrium, craniospinal fluid circulation and physical condition, among other parameters6,10.
James E. Carlsson formulated in his book Physiologic Occlusion four basic principles of occlusion which are needed for harmony in the maxillofacial region: • All occlusal forces must occur simultaneously in each point of contact • All occlusal forces must be approximately the same • All occlusal forces must be symmetrically distributed on both sides of the jaw • Occlusal vector of each tooth must be parallel to its axis. The upper jaw is the base of occlusion and the maxillofacial region11. While the body is growing, the maxilla defines intermaxillary relations, lower jaw form and the inclination of the occlusal plane. During the viscerocranium growth, the upper jaw creates the intermaxillar relation. It does this with two simultaneous actions: connecting to the neurocranium and changing the form of the lower jaw. Later, this relation is also corrected by teeth cutting. The aforementioned correlation may be defined by measuring the angle between the occlusal plane and other reference planes of the head. Nevertheless, for optimal transfer of masticatory loading to cranial structures, occlusal forces must be directed following the orthogonal conception. The vector of each tooth loading must be perpendicular to the occlusal plane in this area. Converging axies of teeth are projecting to the imaging ‘conus dentalis’, in which axis of each tooth is directed to the ‘central point’ (Figure 2). This point is usually located in glabella (it is approximately 10 cm higher than occlusal plane, in place of the transversal and sagittal planes crossing)4. With regard to the specific layout of cranium bone structures, occlusal forces affect to the basis cranii
ANATOMICAL PRECONDITIONS Occlusion Occlusion is one of the most basic and the most important terms in dentistry. It expresses the mutual relationship between four interdependent components: teeth, jaws, masticatory muscles and TMJ. The present common definition, which defines occlusion as the position when teeth of opposite jaws are in reciprocal contact, seems somewhat insufficient. Teeth are the main component of occlusion, but the way in which they make contact is only one of its parts. Teeth contact in occlusion determines the condition of the lower jaw, cranial bones, muscles, TMJs and the cervical spine. We can recognise occlusion both statically and dynamically. The term of occlusion must be evaluated from the point of view of common medicine, physiotherapy, osteopathy, dietetics and immunology. 14
Figure 2. ’Conus dentalis’ with normal occlusal plane. Ivo Klepacek, based on an original drawing by James E. Carlsson, DDS. © 2013 FDI World Dental Federation
The neuromuscular approach in medicine and project to the area of the synchrondrosis sphenobasilaris. Changing of the occlusal plane inclination is connected to conus dentalis deformation and will cause change in the main occlusal forces1 (Figures 3 and 4). It is known that strong connection between cranial bones and vertebras with dura mater cerebri is one of the important requirements for cerebrospinal fluid (CSF) circulation. The firm attachment of the cranial bones and vertebrae with dura mater cerebri has been shown to be a necessary precondition for physiological CSF circulation1,12,13. The circulation of CSF can be also influenced at sites where the dura mater is not directly
attached to the underlying bone and the cranial bones are flexibly interconnected (synchrondroses)1,13. The so-called mobility of the skull has been targeted by many research efforts for more than 100 years14. The founder of the craniosacral theory, William Sutherland, discovered that individual bones of the skull were not interconnected as firmly as was claimed at the time, and he found that their shifting could be observed in connection with the force of the pulsating CSF1,12,15,16. Sutherland, however, interpreted this mobility as being related to respiratory phenomena (inspiration and expiration). We now know that individual skull bones also shift against each other as a result of the repeated action of cyclic forces associated with chewing, swallowing and speech1,11,17. These rather small movements in the cranial bone sutures belong to the craniosacral mechanism (a system that includes meningeal membranes, bony and connective tissue structures attached to them, the CSF and structures participating in its production and absorption)17. In modern perception, CSF is regarded as one of the components of the system of pressure and tension redistribution18. Karppinen et al.8 obtained encouraging results with their comprehensive approach to the therapy of patients suffering from chronic headaches or pain in the cervicobrachial region. In addition to traditional methods (mainly physiotherapy), they used special bite splints that shifted the mandible into a correct position with the lowest possible resting muscular activity. This resulted in improved results from treatment. Muscles
Figure 3. Deformation of occlusal plane (decrease on the right side) with consequent changes in masticatory muscles. Ivo Klepacek, based on an original drawing by James E. Carlsson, DDS.
Figure 4. Changing of occlusal forces direction in cranial structures (as result of occlusal plane deformation). Ivo Klepacek, based on an original drawing by James E. Carlsson, DDS. © 2013 FDI World Dental Federation
Muscles are extremely important components of the pathological chain that results from occlusal imbalance. Collapse of occlusal vertical dimension, deviations of the slope (angle) of the occlusal plane and the resulting compensatory changes in the tension of individual participating muscles or muscle groups are further complicated by other pathological processes: TMJ dysfunctions, pain and curvature of the cervical spine, headaches and cervical muscle pain, reduced ability to maintain balance and perform tasks requiring increased concentration and precision8,19–24. For example, clinical and experimental data show that a sudden, long-lasting change of the occlusal plane from the original position causes changes, among others, in the cervical spine, damaging the trapezius and sternocleidomastoid muscles that participate in maintaining and changing the position of the head22,25–27. Changes in the position of the head and cervical spine deformities are found in pathological occlusion defined as occlusion with a one-sided lateral dental defect22. Postural changes also accompany chronic one-sided overstraining of the sternocleidomastoid muscle 15
Yurchenko et al. contralateral to the site of a defect. Electromyographic investigations confirm a direct relationship between hypoactivity and increased sternocleidomastoid muscle tension on the side where the dentition is affected and cervical spine deviation to the side with healthy dentition22. It has also been shown that muscles influence the ability to maintain a correct lower jaw resting position28. Shimazaki et al.27 investigated the mutual relationships between muscle, occlusal plane slope and vertebral column changes. Using special software, they modelled and subsequently analysed the tension in the bony structures of the skull and spine in the setting of various arrangements of the masticatory apparatus, both for laterally sloped occlusal plane with no muscle participation and for unilateral predominance of masticatory muscles. In deviations of individual occlusal planes from a reference plane (Camper’s plane), it is possible to observe, from the frontal view, an initial hypertonus of the masticatory muscles on the side where these two planes diverge. The distribution of masticatory pressure is not homogeneous, and is predominant on the divergent side – we refer to this as compensatory redistribution of the muscle tone in the temporal muscle. It has also become apparent that chronically increased, right-sided muscle tone is capable, within a short period of time, of producing cervical spine curvature to the left and vice versa27,29. In the oral cavity, it is possible to find asymmetric wedge-shaped defects, periodontal (gingival) pockets, pathological abrasions and breaking off of enamel on the side where the planes converge1. We thus see here the consequences of imbalance and the destructive character of the developing occlusal forces. Sagittal deviations in the slope of the occlusive plane are directly related to body posture and the antero-posterior position of the head as the flexor and extensor muscles of the head participate in the compensatory reaction30,31. One example of this is a patient with mouth breathing. Chronic mouth breathing during the growth period can be regarded as the starting point of a pathogenic chain32. Insufficient pressure on the palate normally exerted by the tongue results in the formation of the so-called ‘Gothic palate’, the dental arch of the upper jaw remains narrow and the mandible is shifted backwards. Affected individuals demonstrate increased muscle tone in anterior muscles of the neck, resulting in the head bending forward. Another consequence is the increased muscle tone in the antagonists (extensors). We usually find class 2 occlusion and a specific anterior head position with extension in the atlanto-occipital joint (Figure 5). A well-informed physician may be greatly helped in his diagnostic efforts by similar findings during the entry examination as this is the most common postural dysfunction associated with occlusion33. 16
The type of force distribution in the cervical spine is undoubtedly an important factor contributing to postural dysfunctions. Computer-aided modelling of various degrees of sagittal deviations in the occlusal plane shows the influence of similar anatomical variants on the distribution of tension in the cervical spine that result from specific muscular adaptation. A comparison of three variants (normal, steep and flat occlusal plane) showed that the configuration of the tension zones in the C1–C7 vertebrae is markedly different. In the case of a physiological slope of the occlusal plane, the C1–C7 vertebrae are loaded evenly. A steeper slope results in increased stress in the upper part of the cervical spine, while a flat occlusal plane results in the forces concentrating in the C5–C7 vertebrae29. Modern investigational methods make it possible to explore the functional connection between the orofacial area and processes observed in relatively remote parts of the body. We know at present that opening one’s mouth is invariably accompanied by movements in the cervical, thoracic, and lumbar spine9. Conversely, the masticatory muscles activity and the resting position of the mandible appear to be influenced by the position of the body in space34. A similar relationship is supported by research conducted by Ueno, pointing to the direct relationship between the force with which the mouth is opened and the performance of the biceps muscle35. In neuromuscular dentistry, the pressure exerted by the tongue during swallowing plays a significant role. Although it does not produce a force comparable to that produced during occlusion, the impact of the tongue on the cranial structures is significant: it influences the development of the maxilla and the upper dental arch during the phase of growth, but it also exerts frequent and regular pressure on the palate during the swallowing act. Both these mechanisms are very important for the development and maintenance of cranial, orofacial and postural balance. The force arising during swallowing is transferred to the base of the skull, mainly via the vomer bone that is attached to the palatine and sphenoid bones. The rhythmic pressure maintains a degree of flexibility and elasticity of the spheno-basilar synchondrosis, thus helping stimulate CSF circulation. A common cause of insufficient tongue pressure is mouth breathing and positioning of the tongue between the teeth as part of the ‘infantile’ type of swallowing. Correct diagnosis in this case is helped by finding palatal deformation and ‘overjet’ in the region of lower premolars. Temporomandibular joint It is known that the condition of the dental arches and the type of occlusion are directly related to the © 2013 FDI World Dental Federation
The neuromuscular approach in medicine (a)
(b)
Figure 5. Interconnection between spine, leg and head posture. Normal (a) and disordered (b) skeleton. Ivo Klepacek, based on an original drawing by James E. Carlsson, DDS.
development of pathological changes in the TMJ. However, even perfect dentition may sustain substantial damage over a short period of time as a result of primary damage to the TMJ. This joint has a rather unique construction, position and function compared with the other joints in the human body. The fact that it is a paired joint attaching just one bone to the base of the skull has resulted in the development of two views of its anatomy. Part of the scientific community regards this joint as a single joint (art. temporocranialis) as isolated unilateral movement is ruled out in its case. However, numerous others view it as two different symmetrical joints (the traditional articulationes temporomandibulares). This dispute is rather theoretical, but it still confirms the uniqueness of the TMJ, the second most complex joint in the human body in terms of its locomotor culture. As it is located in close proximity to the orbital cavities, brain, ear and cranial © 2013 FDI World Dental Federation
nerves, it can lead to various pathological processes that affect these structures, as well as to various syndromes7. Clinicians divide the most important factors that may lead to pathology in this joint into several groups: teeth, bones, muscles, bad habits, psychoemotional stress, trauma, genetic disorders and tumours. Diagnosis is complicated by the concurrent presence of many symptoms and the difficulty of determining the primary pathology36,37. Loi and others have obtained data suggesting a relationship between osteoarthritis of TMJ, the angle of the occlusal plane and the position of the head38,39. In the case of the aforementioned disorders affecting TMJ, they succeeded in diagnosing a higher sagittal occlusal plane angle and forward shift of the head with greater extension in the atlanto-occipital joint and less marked cervical lordosis. The cephalometric study conducted by Byun et al.40 reports that diseases 17
Yurchenko et al. of TMJ are frequent in patients with dorsal rotational shift of the mandible. DISCUSSION Occlusal forces are the greatest of all forces acting on the bone structures of the head, reaching a value of up to hundreds of Newtons per one square centimetre. This is why the angle (slope) and position of the occlusal plane play a significant role in determining the vector of action of the occlusal forces transmitted onto the skull. In the case of the previously mentioned deformation of the dental cone, the occlusal forces are transmitted through the bony structures differently, resulting in imbalance and shifting of the power centre of the cranial base. Permanent asymmetry of pressure distribution can result in gradual deformation of the skull and tension and ‘contortion’ of the dura mater11. The activity of the muscles participating in restoring the cranial balance is spreading far beyond the maxillofacial region. There is little doubt about the redistribution of muscle activity caused by occlusal dysfunction. What may be disputed is the question of the character, extent and consequences of these compensatory dysfunctions. Recently, the problems of the interdependence of the orofacial pathology and functional and structural dysfunctions in other parts of the body have been discussed in the scientific literature. In addition to the considerable research proving this interconnection there is also some scepticism, with opponents pointing to a lack of scientific evidence and the imperfect methods of examination. The research conducted in this field is of great value as it enables the working out of new progressive principles of both prevention and methods of treatment. In particular, the dental component of complex rehabilitation can make a significant contribution to the treatment of pathologies of carriage, stable balance, eyesight, tinnitus, ear congestion and herpes meatus acusticus externus. Moreover, normalisation of occlusion and of the condition of the muscles should thus be regarded as an important component of therapy in all patients with pain of the cervical or maxillofacial regions. Unfortunately, this stomatological component of therapy in these patients is usually neglected as a result of the one-sided view of neurological and postural problems. This is compounded by the insufficient knowledge of dentists themselves. However, a number of important studies provide conclusive evidence about the beneficial effects of normalisation of the stomatognathic system7,41. As an example, bite-plan splints correcting the mandibular position according to neuromuscular criteria are used in various sports disciplines. 18
CONCLUSION AND SUMMARY The findings of neuromuscular dentistry can help the practising dentist solve the arguably most fundamental problem most dental professionals face, namely the unpredictability of treatment results. Reliable, aesthetic, and long-term functional fillings and prosthetic constructions should be based on balanced occlusion, joints and muscles. Moreover, interdisciplinary cooperation can help prevent a number of ‘non-stomatological’ disorders and is often helpful in achieving therapeutic success. Unfortunately, many theoretical aspects of the interdisciplinary relationship have not been sufficiently examined, and hence the practical consequences remain unclear. Further research in this field is greatly needed. Acknowledgements We express our gratitude to the PRVOUK grant from the Charles University in Prague. We thank academic painter Ivan Helekal for his support and expertise. COMPETING INTEREST None declared. REFERENCES 1. Carlson JE. Physiologic Occlusion. Alexandria, MN: Midwest Press; 2007. 2. Chan CA. Applying the neuromuscular principles in TMD and orthodontics. J Am Orthod Soc 2004 Spring 20–29. 3. Lerman MD. A revised view of the dynamics, physiology and treatment of occlusion: a new paradigm. Cranio 2004 22: 50–63. 4. Gelb H. Clinical Management of Head, Neck and TMJ Pain and Dysfunction; A Multidisciplinary Approach to Diagnosis and Treatment. St Louis, MO: Ishiyaku EuroAmerica, Inc; 1991. 5. Dawson PE. Functional Occlusion: From TMJ to Smile Design. St. Louis, MO: Mosby, Inc; 2007:18-26,46. 6. Chan CA. Architecting the occlusal plane. Aurum Ceramic Continuum 2006; Volume 19, Issue 2. 7. Gelb H, Calderone JP, Gross SM et al. The role of the dentist and the otolaryngologist in evaluating temporomandibular joint syndromes. J Prosthet Dent 1967 18: 497–503. 8. Karppinen K, Eklund S, Suoninen E et al. Adjustment of dental occlusion in treatment of chronic cervicobrachial pain and headache. J Oral Rehabil 1999 26: 715–721. 9. Yamabe Y, Yamashita R, Fujii H. Head, neck and trunk movements accompanying jaw tapping. J Oral Rehabil 1999 26: 900–905. 10. Hanke BA, Motschall E, Turp JC. Association between orthopedic and dental findings: what level of evidence is available? J Orofac Orthop 2007 68: 91–107. 11. Smith GH. Occlusal cranial balancing technique. Int J Orthod Milwaukee 2007 Spring 18: 27–33. 12. Sills F. Foundations in Craniosacral Biodynamics. Volume One. Berkeley, CA: North Atlantic Books; 2011. p. 4 13. Kern M. Wisdom of the Body. The Craniosacral Approach to Essential Health. Berkeley, CA: North Atlantic Books; 2005. p. 58–76. © 2013 FDI World Dental Federation
The neuromuscular approach in medicine 14. Magoun HI. Osteopathy in the Cranial Field. 3rd ed. Indianapolis, IN: The Cranial Academy, Inc.; 1976. 15. Nelson KE, Sergueef N, Slonek T. Recording the rate of the cranial rhythmic impulse. J Am Osteopath Assoc 2006 106: 337–341. 16. Greitz D, Franck A, Nordell B. On the pulsatile nature of intracranial and spinal CSF-circulation demonstrated by MR imaging. Acta Radiol 1993 34: 321–328. 17. Upledger JE, Vredevoogd J. Craniosacral Therapy. Seattle, WA: Eastland Press; 1983. 18. Greitz D, Wirestam R, Franck A et al. Pulsatile brain movement and associated hydrodynamics studied by magnetic resonance phase imaging. The Monro–Kellie doctrine revisited. Neuroradiology 1992 34: 370–380. 19. Ferrario VF, Sforza C, Schmitz JH et al. Occlusion and center of foot pressure variation: is there a relationship? J Prosthet Dent 1996 76: 302–308. 20. Gangloff P, Louis JP, Perrin PP. Dental occlusion modifies gaze and posture stabilization in human subjects. Neurosci Lett 2000 293: 203–206.
31. Sonnesen L, Pedersen CE, Kjaer I. Cervical column morphology related to head posture, cranial base angle, and condylar malformation. Eur J Orthod 2007 29: 398–403. 32. Chan Clayton A. A review of the clinical significance of the occlusal plane: its variation and effect on head posture. ICCMO Anthology 2007 VIII: 81–113. 33. Gelb H, Gelb M. An orthopedic approach to the diagnosis and treatment of craniocervical mandibular disorders. In: Gelb H, editor. New Concepts in Craniomandibular and Chronic Pain Management. London: Mosby-Wolfe; 1994. p. 215–259. 34. McLean LF, Brenman HS, Friedman MGF. Effects of changing body position on dental occlusion. J Dent Res 1973 52: 1041. 35. Ueno T. Study on relationship between teeth clenching in intercuspal position and isometric movement of upper limbs. Kokubyo Gakkai Zasshi 1995 62: 212–253. 36. Clark GT, Green EM, Dornan MR et al. Craniocervical dysfunction levels in a patient sample from a temporomandibular joint clinic. J Am Dent Assoc 1987 115: 251–256. 37. Clark RKF. Neurology of the temporomandibular joints: an experimental study. Ann R Coll Surg Engl 1976 58: 43–51.
22. Kibana Y, Ishijima Y, Hirai T. Occlusal support and head posture. J Oral Rehabil 2002 29: 58–63.
38. Ciancaglini R, Colombo-Bolla G, Gherlone EF et al. Orientation of craniofacial planes and temporomandibular disorder in young adults with normal occlusion. J Oral Rehabil 2003 30: 878–886.
23. Widmalm SE, Lee YS, McKay DC. Clinical use of qualitative electromyography in the evaluation of jaw muscle function: a practitioner’s guide. Cranio 2007 25: 63–73.
39. Ioi H, Matsumoto R, Nishioka M et al. Relationship of TMJ osteoarthritis/osteoarthrosis to head posture and dentofacial morphology. Orthod Craniofac Res 2008 11: 8–16.
24. Woda A, Pionchon P, Palla S. Regulation of mandibular postures: mechanisms and clinical implications. Crit Rev Oral Biol Med 2001 12: 166.
40. Byun ES, Ahn SJ, Kim TW. Relationship between internal derangement of the temporomandibular joint and dentofacial morphology in women with anterior open bite. Am J Orthod Dentofacial Orthop 2005 128: 87–95.
21. Jankelson RR. Neuromuscular Dental Diagnosis and Treatment. St. Louis, MO: Ishiyaku EuroAmerica, Inc.; 2005.
25. Ceneviz C, Mehta NR, Forgione A et al. The immediate effect of changing mandibular position on the EMG activity of the masseter, temporalis, sternocleidomastoid, and trapezius muscles. Cranio 2006 24: 237–244. 26. Davies PL. Electromyographic study of superficial neck muscles in mandibular function. J Dent Res 1979 58: 537–538. 27. Shimazaki T, Motoyoshi M, Hosoi K et al. The effect of occlusal alteration and masticatory imbalance on the cervical spine. Eur J Orthod 2003 25: 457–463. 28. Miles TS. Postural control of the human mandible. Arch Oral Biol 2007 52: 347–352. 29. Motoyoshi M, Shimazaki T, Hosoi K et al. Stresses on the cervical column associated with vertical occlusal alteration. Eur J Orthod 2003 25: 135–138. 30. Funakoshi M, Fujita N, Takehana S. Relations between occlusal interference and jaw muscle activities in response to changes in head position. J Dent Res 1976 55: 684.
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41. Moon HJ, Lee YK. The relationship between dental occlusion/ temporomandibular joint status and general body health: part 1. Dental occlusion and TMJ status exert an influence on general body health. J Altern Complement Med 2011 17: 995–1000.
Correspondence to: Dr Maksim Yurchenko, Institute of Clinical and Experimental Dental Medicine, First Faculty of Medicine of Charles University in Prague, Karlovo nam. 32, 120 00, Praha 2, Prague, Czech Republic. E-mail: [email protected]
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International Dental Journal 2014; 64: 12–19 doi: 10.1111/idj.12057
The neuromuscular approach towards interdisciplinary cooperation in medicine Maksim Yurchenko1, Hana Hub alkov a1, Ivo Klep acek2, Vladimır Macho n3 and Jirı Mazanek3 1
Institute of Clinical and Experimental Dental Medicine, First Faculty of Medicine of Charles University in Prague, Prague, Czech Republic; Department of Anatomy, First Faculty of Medicine of Charles University in Prague, Prague, Czech Republic; 3Department of Oral and Maxillofacial Surgery, First Faculty of Medicine of Charles University in Prague, Prague, Czech Republic. 2
Background: The contemporary approach of dentistry towards interdisciplinary cooperation is based on the neuromuscular concept. In recent years many authors have pointed out a correlation between orthopaedic and dental findings. Furthermore, there is an intimate biomechanical interrelationship of occlusion with cerebral fluid circulation, left and right equilibrium, gaze stabilisation and headache. The influence of a dental occlusion and temporomandibular joint (TMJ) status on general health has been widely analysed in the current scientific literature. Aim: The aim of this analytic study was to display the deep relationship between dentistry and other fields of medicine, and to show the necessity of wide cooperation between dentists and physicians. Conclusions: This study was based on a review of 41 sources, including specialised articles and books. The significance of different anatomical and physiological preconditions (occlusion, muscles and TMJ status) was considered and evaluated separately. However, as a result of modern concepts of general body health, extending cooperation between different fields of medicine is essential. The practical application of the principles of neuromuscular dentistry enables one to increase greatly the treatment efficiency of aches in muscles, headaches, postural dysfunctions as well as of many other diseases. However, the dentist’s contribution to the development of an interdisciplinary approach is underestimated. Many theoretical aspects of the interdisciplinary relationship have not been sufficiently examined, hence the practical consequences remain unclear. Further research in the field is urgently needed. Key words: Dentistry, occlusal plane, temporomandibular joint, masticatory muscles, rehabilitation
INTRODUCTION The current development of computer technologies, as well as new examination methods, enables the linking of relatively distant fields of medicine. For this reason, the term ‘integrative medicine’ is now becoming more widely used in specialised literature1. Recently, the functional connections between the structures of the maxillofacial region and other systems of the human body have been thoroughly studied and some articles published in scientific literature describe the influence of different pathological states of the maxillofacial region on orthopaedic problems. Modern research conducted in the field has proved the positive influence of a correctly performed reconstruction of occlusion on such important indices such as carriage, stable balance, aches in muscles, headaches, physical state, eyesight and some others. A dentist should not now be perceived as someone whose job is merely to treat people’s teeth, but as a physician of the maxillofacial region2. In the framework of this concept a new 12
direction of dentistry has appeared: maxillofacial dentistry or integrative dentistry. The field of maxillofacial dentistry has been widely recognised by the professional community, and this is reflected in its inclusion in the syllabuses of the world’s leading universities. In neuromuscular dentistry the following principles are applied: con• Direct connection with classical physiological cepts and application of its terms2. According to physiology, the central nervous system, muscles, joints, teeth and jaws are one functional unit. Pathological changes appearing in any part of this complex have an influence on other parts. Therefore, successful treatment has to be applied to the whole system, not only its most diseased part. This is the core assumption of modern neuromuscular dentistry, which is focused on the detection of physiological mechanisms determining the reciprocal influence of the maxillofacial region on other parts and systems of the human body © 2013 FDI World Dental Federation
The neuromuscular approach in medicine
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From the point of view of neuromuscular dentistry, the orthogonal concept of regulating anatomical structures is a necessary condition for the natural functioning of the maxillofacial region. In the physiological head position, Camper’s plane, the HIP-plane (Hamulus–Papilla incisiva), the occlusal plane, and the ANS-Porion line should be parallel to the horizontal plane as well as perpendicular to a vertical axis1,4 (Figure 1a). Should these planes not be parallel, imbalance of the maxillofacial system could occur, which would result in a number of interconnected neuromuscular reactions (Figure 1b). The masticatory muscles play a significant role as various pathological processes in the maxillofacial region influence them. As masticatory muscles are loaded unevenly, muscle strain in its different parts is unequal, which leads to the alteration of the mechanical trajectory in the jaw joint. As a result of the uneven loading of their fascicles, the bone will adjust its attachment points to the muscles, and even its own structure. For example, the chronic spasm of m. pterygoideus lateralis could cause a deformation of the condyle. The alteration of the mandibular mechanical trajectory could be also connected with repeated premature contact between opposing maxillary and mandibular teeth. As a result of iatrogenic injury it could occur accidently. A premature contact stimulates a
During treatment a neuromuscular dentist seeks the proper balance between the work load and relaxation of the masticatory muscles. The aim of neuromuscular therapy is to create the proper conditions for muscle relaxation of the maxillofacial region as well as for the reverse movement of condyles mandibulares to the rest state, which would be optimal for a patient3 • To establish a diagnosis and to provide further treatment sophisticated equipment is used. Technical equipment and computer programs enable the analysis of the state of muscles, temporomandibular joints (TMJs) and occlusion. The received biometric data are essential for establishing an accurate diagnosis. The saying of Dr Bernard, the founding father of neuromuscular dentistry, can be applied in this instance ‘If it has been measured, it is a fact; if it has not been measured, it is an opinion’. A modern dentist is required to have not only knowledge of the maxillofacial region, but also general morphological and physiological awareness of the human body. According to the orthogonal concept applicable to both organic and inorganic units, the resistance to any loading is the strongest when the resistance axis of the structure is parallel to the axis of loading.
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(b)
Figure 1. Parallelism (a) and disruption (b) of main anatomical planes in human body. Ivo Klepacek, based on an original drawing by James E. Carlsson, DDS. © 2013 FDI World Dental Federation
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Yurchenko et al. response of the nervous system (efferent impulses). With the help of head and cervical muscles, this response is intended to repeatedly return the mandibular joint to its physiological position. Furthermore, chronic and asymmetric overstrain of individual muscles and their groups could deform the bone structure and influence their growth. Muscle hypertonus could cause pathologies such as headaches, orofacial pain, different orthodontic anomalies, teeth abrasion and fractures, cervical teeth defects and TMJ disorders5. From the position of modern dentistry the determination of any mouth cavity condition is essential for diagnosing diseases, which at first sight appear not to be connected with dental pathologies. Both the loss of a tooth and the aforementioned premature contact could initiate a chain of reactions causing various disorders. In serious cases, for example loss of a molar and significant height reduction of the bite, there is a high risk of the emergence of different symptomatic complexes as a result of heightened pressure on chorda tympani and n. auriculotemporalis (tinnitus, ear congestion, non-specific facial and neck pain, glossalgia, xerostomia, herpes meatus acusticus externus)6,7. There is now clear evidence that the atypical relations between anatomical structures of the maxillofacial region could be connected with structural deformations of the cervical spine8. Accompanying mouth opening and closing, the minor displacements in cervical, thoracic and lumbar spine also contribute to this interconnection9. Occlusion dysfunctions could cause sleeping apnoea, myofascial pain syndrome, column diseases, leg-length inequality, abnormal pelvis obliquity and incorrect head posture. They affect equilibrium, craniospinal fluid circulation and physical condition, among other parameters6,10.
James E. Carlsson formulated in his book Physiologic Occlusion four basic principles of occlusion which are needed for harmony in the maxillofacial region: • All occlusal forces must occur simultaneously in each point of contact • All occlusal forces must be approximately the same • All occlusal forces must be symmetrically distributed on both sides of the jaw • Occlusal vector of each tooth must be parallel to its axis. The upper jaw is the base of occlusion and the maxillofacial region11. While the body is growing, the maxilla defines intermaxillary relations, lower jaw form and the inclination of the occlusal plane. During the viscerocranium growth, the upper jaw creates the intermaxillar relation. It does this with two simultaneous actions: connecting to the neurocranium and changing the form of the lower jaw. Later, this relation is also corrected by teeth cutting. The aforementioned correlation may be defined by measuring the angle between the occlusal plane and other reference planes of the head. Nevertheless, for optimal transfer of masticatory loading to cranial structures, occlusal forces must be directed following the orthogonal conception. The vector of each tooth loading must be perpendicular to the occlusal plane in this area. Converging axies of teeth are projecting to the imaging ‘conus dentalis’, in which axis of each tooth is directed to the ‘central point’ (Figure 2). This point is usually located in glabella (it is approximately 10 cm higher than occlusal plane, in place of the transversal and sagittal planes crossing)4. With regard to the specific layout of cranium bone structures, occlusal forces affect to the basis cranii
ANATOMICAL PRECONDITIONS Occlusion Occlusion is one of the most basic and the most important terms in dentistry. It expresses the mutual relationship between four interdependent components: teeth, jaws, masticatory muscles and TMJ. The present common definition, which defines occlusion as the position when teeth of opposite jaws are in reciprocal contact, seems somewhat insufficient. Teeth are the main component of occlusion, but the way in which they make contact is only one of its parts. Teeth contact in occlusion determines the condition of the lower jaw, cranial bones, muscles, TMJs and the cervical spine. We can recognise occlusion both statically and dynamically. The term of occlusion must be evaluated from the point of view of common medicine, physiotherapy, osteopathy, dietetics and immunology. 14
Figure 2. ’Conus dentalis’ with normal occlusal plane. Ivo Klepacek, based on an original drawing by James E. Carlsson, DDS. © 2013 FDI World Dental Federation
The neuromuscular approach in medicine and project to the area of the synchrondrosis sphenobasilaris. Changing of the occlusal plane inclination is connected to conus dentalis deformation and will cause change in the main occlusal forces1 (Figures 3 and 4). It is known that strong connection between cranial bones and vertebras with dura mater cerebri is one of the important requirements for cerebrospinal fluid (CSF) circulation. The firm attachment of the cranial bones and vertebrae with dura mater cerebri has been shown to be a necessary precondition for physiological CSF circulation1,12,13. The circulation of CSF can be also influenced at sites where the dura mater is not directly
attached to the underlying bone and the cranial bones are flexibly interconnected (synchrondroses)1,13. The so-called mobility of the skull has been targeted by many research efforts for more than 100 years14. The founder of the craniosacral theory, William Sutherland, discovered that individual bones of the skull were not interconnected as firmly as was claimed at the time, and he found that their shifting could be observed in connection with the force of the pulsating CSF1,12,15,16. Sutherland, however, interpreted this mobility as being related to respiratory phenomena (inspiration and expiration). We now know that individual skull bones also shift against each other as a result of the repeated action of cyclic forces associated with chewing, swallowing and speech1,11,17. These rather small movements in the cranial bone sutures belong to the craniosacral mechanism (a system that includes meningeal membranes, bony and connective tissue structures attached to them, the CSF and structures participating in its production and absorption)17. In modern perception, CSF is regarded as one of the components of the system of pressure and tension redistribution18. Karppinen et al.8 obtained encouraging results with their comprehensive approach to the therapy of patients suffering from chronic headaches or pain in the cervicobrachial region. In addition to traditional methods (mainly physiotherapy), they used special bite splints that shifted the mandible into a correct position with the lowest possible resting muscular activity. This resulted in improved results from treatment. Muscles
Figure 3. Deformation of occlusal plane (decrease on the right side) with consequent changes in masticatory muscles. Ivo Klepacek, based on an original drawing by James E. Carlsson, DDS.
Figure 4. Changing of occlusal forces direction in cranial structures (as result of occlusal plane deformation). Ivo Klepacek, based on an original drawing by James E. Carlsson, DDS. © 2013 FDI World Dental Federation
Muscles are extremely important components of the pathological chain that results from occlusal imbalance. Collapse of occlusal vertical dimension, deviations of the slope (angle) of the occlusal plane and the resulting compensatory changes in the tension of individual participating muscles or muscle groups are further complicated by other pathological processes: TMJ dysfunctions, pain and curvature of the cervical spine, headaches and cervical muscle pain, reduced ability to maintain balance and perform tasks requiring increased concentration and precision8,19–24. For example, clinical and experimental data show that a sudden, long-lasting change of the occlusal plane from the original position causes changes, among others, in the cervical spine, damaging the trapezius and sternocleidomastoid muscles that participate in maintaining and changing the position of the head22,25–27. Changes in the position of the head and cervical spine deformities are found in pathological occlusion defined as occlusion with a one-sided lateral dental defect22. Postural changes also accompany chronic one-sided overstraining of the sternocleidomastoid muscle 15
Yurchenko et al. contralateral to the site of a defect. Electromyographic investigations confirm a direct relationship between hypoactivity and increased sternocleidomastoid muscle tension on the side where the dentition is affected and cervical spine deviation to the side with healthy dentition22. It has also been shown that muscles influence the ability to maintain a correct lower jaw resting position28. Shimazaki et al.27 investigated the mutual relationships between muscle, occlusal plane slope and vertebral column changes. Using special software, they modelled and subsequently analysed the tension in the bony structures of the skull and spine in the setting of various arrangements of the masticatory apparatus, both for laterally sloped occlusal plane with no muscle participation and for unilateral predominance of masticatory muscles. In deviations of individual occlusal planes from a reference plane (Camper’s plane), it is possible to observe, from the frontal view, an initial hypertonus of the masticatory muscles on the side where these two planes diverge. The distribution of masticatory pressure is not homogeneous, and is predominant on the divergent side – we refer to this as compensatory redistribution of the muscle tone in the temporal muscle. It has also become apparent that chronically increased, right-sided muscle tone is capable, within a short period of time, of producing cervical spine curvature to the left and vice versa27,29. In the oral cavity, it is possible to find asymmetric wedge-shaped defects, periodontal (gingival) pockets, pathological abrasions and breaking off of enamel on the side where the planes converge1. We thus see here the consequences of imbalance and the destructive character of the developing occlusal forces. Sagittal deviations in the slope of the occlusive plane are directly related to body posture and the antero-posterior position of the head as the flexor and extensor muscles of the head participate in the compensatory reaction30,31. One example of this is a patient with mouth breathing. Chronic mouth breathing during the growth period can be regarded as the starting point of a pathogenic chain32. Insufficient pressure on the palate normally exerted by the tongue results in the formation of the so-called ‘Gothic palate’, the dental arch of the upper jaw remains narrow and the mandible is shifted backwards. Affected individuals demonstrate increased muscle tone in anterior muscles of the neck, resulting in the head bending forward. Another consequence is the increased muscle tone in the antagonists (extensors). We usually find class 2 occlusion and a specific anterior head position with extension in the atlanto-occipital joint (Figure 5). A well-informed physician may be greatly helped in his diagnostic efforts by similar findings during the entry examination as this is the most common postural dysfunction associated with occlusion33. 16
The type of force distribution in the cervical spine is undoubtedly an important factor contributing to postural dysfunctions. Computer-aided modelling of various degrees of sagittal deviations in the occlusal plane shows the influence of similar anatomical variants on the distribution of tension in the cervical spine that result from specific muscular adaptation. A comparison of three variants (normal, steep and flat occlusal plane) showed that the configuration of the tension zones in the C1–C7 vertebrae is markedly different. In the case of a physiological slope of the occlusal plane, the C1–C7 vertebrae are loaded evenly. A steeper slope results in increased stress in the upper part of the cervical spine, while a flat occlusal plane results in the forces concentrating in the C5–C7 vertebrae29. Modern investigational methods make it possible to explore the functional connection between the orofacial area and processes observed in relatively remote parts of the body. We know at present that opening one’s mouth is invariably accompanied by movements in the cervical, thoracic, and lumbar spine9. Conversely, the masticatory muscles activity and the resting position of the mandible appear to be influenced by the position of the body in space34. A similar relationship is supported by research conducted by Ueno, pointing to the direct relationship between the force with which the mouth is opened and the performance of the biceps muscle35. In neuromuscular dentistry, the pressure exerted by the tongue during swallowing plays a significant role. Although it does not produce a force comparable to that produced during occlusion, the impact of the tongue on the cranial structures is significant: it influences the development of the maxilla and the upper dental arch during the phase of growth, but it also exerts frequent and regular pressure on the palate during the swallowing act. Both these mechanisms are very important for the development and maintenance of cranial, orofacial and postural balance. The force arising during swallowing is transferred to the base of the skull, mainly via the vomer bone that is attached to the palatine and sphenoid bones. The rhythmic pressure maintains a degree of flexibility and elasticity of the spheno-basilar synchondrosis, thus helping stimulate CSF circulation. A common cause of insufficient tongue pressure is mouth breathing and positioning of the tongue between the teeth as part of the ‘infantile’ type of swallowing. Correct diagnosis in this case is helped by finding palatal deformation and ‘overjet’ in the region of lower premolars. Temporomandibular joint It is known that the condition of the dental arches and the type of occlusion are directly related to the © 2013 FDI World Dental Federation
The neuromuscular approach in medicine (a)
(b)
Figure 5. Interconnection between spine, leg and head posture. Normal (a) and disordered (b) skeleton. Ivo Klepacek, based on an original drawing by James E. Carlsson, DDS.
development of pathological changes in the TMJ. However, even perfect dentition may sustain substantial damage over a short period of time as a result of primary damage to the TMJ. This joint has a rather unique construction, position and function compared with the other joints in the human body. The fact that it is a paired joint attaching just one bone to the base of the skull has resulted in the development of two views of its anatomy. Part of the scientific community regards this joint as a single joint (art. temporocranialis) as isolated unilateral movement is ruled out in its case. However, numerous others view it as two different symmetrical joints (the traditional articulationes temporomandibulares). This dispute is rather theoretical, but it still confirms the uniqueness of the TMJ, the second most complex joint in the human body in terms of its locomotor culture. As it is located in close proximity to the orbital cavities, brain, ear and cranial © 2013 FDI World Dental Federation
nerves, it can lead to various pathological processes that affect these structures, as well as to various syndromes7. Clinicians divide the most important factors that may lead to pathology in this joint into several groups: teeth, bones, muscles, bad habits, psychoemotional stress, trauma, genetic disorders and tumours. Diagnosis is complicated by the concurrent presence of many symptoms and the difficulty of determining the primary pathology36,37. Loi and others have obtained data suggesting a relationship between osteoarthritis of TMJ, the angle of the occlusal plane and the position of the head38,39. In the case of the aforementioned disorders affecting TMJ, they succeeded in diagnosing a higher sagittal occlusal plane angle and forward shift of the head with greater extension in the atlanto-occipital joint and less marked cervical lordosis. The cephalometric study conducted by Byun et al.40 reports that diseases 17
Yurchenko et al. of TMJ are frequent in patients with dorsal rotational shift of the mandible. DISCUSSION Occlusal forces are the greatest of all forces acting on the bone structures of the head, reaching a value of up to hundreds of Newtons per one square centimetre. This is why the angle (slope) and position of the occlusal plane play a significant role in determining the vector of action of the occlusal forces transmitted onto the skull. In the case of the previously mentioned deformation of the dental cone, the occlusal forces are transmitted through the bony structures differently, resulting in imbalance and shifting of the power centre of the cranial base. Permanent asymmetry of pressure distribution can result in gradual deformation of the skull and tension and ‘contortion’ of the dura mater11. The activity of the muscles participating in restoring the cranial balance is spreading far beyond the maxillofacial region. There is little doubt about the redistribution of muscle activity caused by occlusal dysfunction. What may be disputed is the question of the character, extent and consequences of these compensatory dysfunctions. Recently, the problems of the interdependence of the orofacial pathology and functional and structural dysfunctions in other parts of the body have been discussed in the scientific literature. In addition to the considerable research proving this interconnection there is also some scepticism, with opponents pointing to a lack of scientific evidence and the imperfect methods of examination. The research conducted in this field is of great value as it enables the working out of new progressive principles of both prevention and methods of treatment. In particular, the dental component of complex rehabilitation can make a significant contribution to the treatment of pathologies of carriage, stable balance, eyesight, tinnitus, ear congestion and herpes meatus acusticus externus. Moreover, normalisation of occlusion and of the condition of the muscles should thus be regarded as an important component of therapy in all patients with pain of the cervical or maxillofacial regions. Unfortunately, this stomatological component of therapy in these patients is usually neglected as a result of the one-sided view of neurological and postural problems. This is compounded by the insufficient knowledge of dentists themselves. However, a number of important studies provide conclusive evidence about the beneficial effects of normalisation of the stomatognathic system7,41. As an example, bite-plan splints correcting the mandibular position according to neuromuscular criteria are used in various sports disciplines. 18
CONCLUSION AND SUMMARY The findings of neuromuscular dentistry can help the practising dentist solve the arguably most fundamental problem most dental professionals face, namely the unpredictability of treatment results. Reliable, aesthetic, and long-term functional fillings and prosthetic constructions should be based on balanced occlusion, joints and muscles. Moreover, interdisciplinary cooperation can help prevent a number of ‘non-stomatological’ disorders and is often helpful in achieving therapeutic success. Unfortunately, many theoretical aspects of the interdisciplinary relationship have not been sufficiently examined, and hence the practical consequences remain unclear. Further research in this field is greatly needed. Acknowledgements We express our gratitude to the PRVOUK grant from the Charles University in Prague. We thank academic painter Ivan Helekal for his support and expertise. COMPETING INTEREST None declared. REFERENCES 1. Carlson JE. Physiologic Occlusion. Alexandria, MN: Midwest Press; 2007. 2. Chan CA. Applying the neuromuscular principles in TMD and orthodontics. J Am Orthod Soc 2004 Spring 20–29. 3. Lerman MD. A revised view of the dynamics, physiology and treatment of occlusion: a new paradigm. Cranio 2004 22: 50–63. 4. Gelb H. Clinical Management of Head, Neck and TMJ Pain and Dysfunction; A Multidisciplinary Approach to Diagnosis and Treatment. St Louis, MO: Ishiyaku EuroAmerica, Inc; 1991. 5. Dawson PE. Functional Occlusion: From TMJ to Smile Design. St. Louis, MO: Mosby, Inc; 2007:18-26,46. 6. Chan CA. Architecting the occlusal plane. Aurum Ceramic Continuum 2006; Volume 19, Issue 2. 7. Gelb H, Calderone JP, Gross SM et al. The role of the dentist and the otolaryngologist in evaluating temporomandibular joint syndromes. J Prosthet Dent 1967 18: 497–503. 8. Karppinen K, Eklund S, Suoninen E et al. Adjustment of dental occlusion in treatment of chronic cervicobrachial pain and headache. J Oral Rehabil 1999 26: 715–721. 9. Yamabe Y, Yamashita R, Fujii H. Head, neck and trunk movements accompanying jaw tapping. J Oral Rehabil 1999 26: 900–905. 10. Hanke BA, Motschall E, Turp JC. Association between orthopedic and dental findings: what level of evidence is available? J Orofac Orthop 2007 68: 91–107. 11. Smith GH. Occlusal cranial balancing technique. Int J Orthod Milwaukee 2007 Spring 18: 27–33. 12. Sills F. Foundations in Craniosacral Biodynamics. Volume One. Berkeley, CA: North Atlantic Books; 2011. p. 4 13. Kern M. Wisdom of the Body. The Craniosacral Approach to Essential Health. Berkeley, CA: North Atlantic Books; 2005. p. 58–76. © 2013 FDI World Dental Federation
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31. Sonnesen L, Pedersen CE, Kjaer I. Cervical column morphology related to head posture, cranial base angle, and condylar malformation. Eur J Orthod 2007 29: 398–403. 32. Chan Clayton A. A review of the clinical significance of the occlusal plane: its variation and effect on head posture. ICCMO Anthology 2007 VIII: 81–113. 33. Gelb H, Gelb M. An orthopedic approach to the diagnosis and treatment of craniocervical mandibular disorders. In: Gelb H, editor. New Concepts in Craniomandibular and Chronic Pain Management. London: Mosby-Wolfe; 1994. p. 215–259. 34. McLean LF, Brenman HS, Friedman MGF. Effects of changing body position on dental occlusion. J Dent Res 1973 52: 1041. 35. Ueno T. Study on relationship between teeth clenching in intercuspal position and isometric movement of upper limbs. Kokubyo Gakkai Zasshi 1995 62: 212–253. 36. Clark GT, Green EM, Dornan MR et al. Craniocervical dysfunction levels in a patient sample from a temporomandibular joint clinic. J Am Dent Assoc 1987 115: 251–256. 37. Clark RKF. Neurology of the temporomandibular joints: an experimental study. Ann R Coll Surg Engl 1976 58: 43–51.
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38. Ciancaglini R, Colombo-Bolla G, Gherlone EF et al. Orientation of craniofacial planes and temporomandibular disorder in young adults with normal occlusion. J Oral Rehabil 2003 30: 878–886.
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39. Ioi H, Matsumoto R, Nishioka M et al. Relationship of TMJ osteoarthritis/osteoarthrosis to head posture and dentofacial morphology. Orthod Craniofac Res 2008 11: 8–16.
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25. Ceneviz C, Mehta NR, Forgione A et al. The immediate effect of changing mandibular position on the EMG activity of the masseter, temporalis, sternocleidomastoid, and trapezius muscles. Cranio 2006 24: 237–244. 26. Davies PL. Electromyographic study of superficial neck muscles in mandibular function. J Dent Res 1979 58: 537–538. 27. Shimazaki T, Motoyoshi M, Hosoi K et al. The effect of occlusal alteration and masticatory imbalance on the cervical spine. Eur J Orthod 2003 25: 457–463. 28. Miles TS. Postural control of the human mandible. Arch Oral Biol 2007 52: 347–352. 29. Motoyoshi M, Shimazaki T, Hosoi K et al. Stresses on the cervical column associated with vertical occlusal alteration. Eur J Orthod 2003 25: 135–138. 30. Funakoshi M, Fujita N, Takehana S. Relations between occlusal interference and jaw muscle activities in response to changes in head position. J Dent Res 1976 55: 684.
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41. Moon HJ, Lee YK. The relationship between dental occlusion/ temporomandibular joint status and general body health: part 1. Dental occlusion and TMJ status exert an influence on general body health. J Altern Complement Med 2011 17: 995–1000.
Correspondence to: Dr Maksim Yurchenko, Institute of Clinical and Experimental Dental Medicine, First Faculty of Medicine of Charles University in Prague, Karlovo nam. 32, 120 00, Praha 2, Prague, Czech Republic. E-mail: [email protected]
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