Gnathology is a branch of dentistry that deals with different functions of the oral cavity and the relationship between the teeth, the temporal mandibular joint, the maxillary muscles and the nervous system.
The craniocervical mandibular dysfunction (CMD) is a pathology that stems from numerous factors.
It can begin with temporal mandibular joint disorder(TMJ) and extend to the cranial-cervical spinal region.
The most common symptoms are:
Joint pain whilst opening and closing the mouth
– Reduced and painful bending and turning of the head and neck
– Pain in the cervical region
– Neck pain with neck stiffness
– Shoulder pain
– Chronic muscular pain
The more extensive the symptoms of this dysfunction, the more vast are the psychological and emotional consequences on the work and family environment.
Is the problem only dental occlusion? There are mouths which are very compromised from the occlusion viewpoint which are without symptoms and there are mouths that appear to have a correct closure which present with temporal-mandibolar articulation disturbances. In fact there is a notable amount of scientific literature that illustrates the presence of a CMD also in the presence of a so called normal closure. Often there are other factors outside the mouth which induce an alteration of the tone of the cervical muscles, and have unfavorable bio-mechanical repercussions on the TMJ. A trauma to the cervical vertebrae similar to a whip-lash injury can represent a triggering factor in the TMD syndrome. Visual disturbances also need to be carefully evaluated. In fact, an alteration in the functional ability of the oculomotor muscles is often present with dyskinesia of the biting and the back of the neck muscles. In addition, also a deviation of the foots weight bearing functioning determines the functional adaptation of the spine and also the cervical spine region. This determines the necessity to investigate varying sectors: the temporal mandibular(Jaw) joint, ocular muscle orthopedics. Alterations in varying regions could thus result in a significant adaptation. In the scheme of Brodie the muscular structures that can be seen connecting the jaws maxillary muscles which leave the jaw heading towards the hyoid and going from the hyoid to the scapular nodes.
A variation in the vertical measurements of a uniform closure or worse again in a unilateral closure can cause a series of reactive contractions in the varying muscles. The purpose of these muscles is to maintain the balance between the jaw in relationship to the skull, the hyoid bone and the scapular node structures. Reduction in the vertical measurements and the loss of symmetry in the closing of the mouth is one of the first symptoms ( when one condyle is higher than the other) can be seen in the presence of a pathology in relation to the articulation of the mouth. The structure of the teeth can abrade due to incorrect use similar to that of a wheel in a car. This usage of the teeth can be on both sides of the jaw, or also only on one side causing an asymmetric mastication. Consequently, the final distance from the thick jaw bone cannot return to its original place. The reduction of this height will result in the condyle of the jaw to rise up in the articular cavity and position itself in the posterior region of the cavity which has a richer nerve supply and consequently, will more easily be the cause of pain.
These connections illustrate the necessity that the problem needs to be affronted with reference to the cranial-cervical-jaw bone the hyoid and the cervical vertebrae C1 and C2.If we also take into consideration the relationship with the rest of the spinal column, the pelvic girdle and the limbs it can be understood how an alteration in the balance of the jaw can have a significant influence on ones posture even though scientific literature hasn’t yet confirmed this. In other words, a defective dental closure can lead to a compensatory subluxation of the first two cervical vertebrae : Atlas and Axis.
The jaw and hyoid bone are similar to being suspended and can be seen as an integral part of the “system of balance and mastication of the cervical column”. They behave as a balancing mechanism through the muscle fibers (represented by the arrows) maintaining balance.
The strength of chewing through the teeth, their roots and alveolus transmit to the maxillary bone all the pressure that comes from chewing and swallowing.
Three zones of thickening of the maxillary can be noted, in correspondence to the canine draft, the position of the first molar and the pterigo- palate suture.
It is of fundamental importance that dental arches correspond and line up and that the tongue closes all the spaces during ones lifetime.
It needs to be highlighted that in the case of non corresponding dental arches, that are not correctly lined up in the correct position, the position of the jaw and the tongue are modified with every swallow.
Each time one swallows a complex mechanism takes place. During the swallowing process the position of the jaw will influence the position of the atlas (the first vertebrae of the spinal column also known as C1) and the Axis (the second, C2).
Taking into consideration as well as swallowing on average 1500-2000 times during of the day and night, the influence an occlusion has on the functioning of the first two vertebrae.
When the jaw moves downwards there is a relaxation of the muscles around the axis while closure of the mouth generates a pressure that increases the tension of the muscles around C2 (Axis)
An occlusion with reduced vertical measurements aggravates the muscular tension around C2.
It is obvious that a misalignment of the TMJ will modify the position the position of C2.
If the cause of the subluxation of the first two cervical vertebrae could be attributed to an unbalanced jaw, it would then be necessary to correct the occlusion that is the vertical measuring closure before adjusting the first two vertebrae by a physiotherapist or Kinesiologis
On check up the inspection of the face verifies muscular hypertrophy symmetrical and asymmetrical.
There can also be static asymmetric features in the facial and skeletal structures.
In other instances asymmetric functioning can be noted similar to cases of premature contacts or crossed bite and can be identified by leaving a roll of cotton wool between the teeth for a few minutes. Thereafter, it can be verified if the lateral deviation disappears after this brief unconditioning.
The line of the median superior and inferior frenuli needs to be on its axis. This line will have diverted towards the side that presents with the blockage or partial blockage of a condyle. A more precise interpretation can be achieved by also taking into consideration right and left head movements and the bending and extension of the back of the head .
On auscultation using a stethoscope “clicks” can be heard similar to the friction typical of degenerative lesions.
The fingers are placed on the skin in correspondence to the joints. The patient is then asked to open and close his mouth several times. The mobility of the two condyles or their asymmetry on the opening and closing of the mouth can be noted. Pain may also be noted in the region of the condyles.
The little finger can be delicately inserted into the ear duct and the patient can be asked to open and close the mouth to evaluate the contemporaneity of the opening and closing of the two condyles.
PALPATION OF THE MUSCLES
Delicate palpation of the Massetere, the temporal and the two ptertgoidei internal and external, the digastrics ,the trapezius and the sternomastoideo muscles and even the paravertebral and the cervical rachis are all structures that need to be identified and evaluated for possible pain.
I will list a variety of examinations that can be used and I will highlight the indispensable ones. Ortopantomography, Stratigraphy, Echography, Tomography, CAT Scan (CT), Magnetic Resonance Imaging (MRI), T scan, Electromyography (EMG), these exams are useful and helpful but are not sufficient and cannot be considered decisive for formulating a diagnosis.
This needs to be done by the Dentist by doing an objective examination whilst, also taking the clinical history. The use of Kinesiography is a different approach that allows a qualitative and quantitative evaluation of the jaws opening and closing and its lateral articulation.
Except in the case of the removal of one or more large occlusal interferences, the recovery of the central optimal closure with its relative height is moved in the final phase of therapy .
In our Surgery, the Bite has the initial purpose of bringing back the correct articulating movements in the protrusion and laterality of the temporal mandibular joint region. It does not intend to initially fix the central occlusion. This process will gradually occur and the central position will be a gradual process until the final stable position is found.
I will include at this point an article written by Doctor Reali who explains very clearly how he arrived at his techniques and conclusions. We utilize these techniques in our Dental Surgery with outstanding outcomes with our patients.
“Life is movement, movement is life”.
In the above phrase of Steel founder of Osteopathy, is enclosed the idea that brought us to the realization of the “Bite” (that is a removable medical device that can be applied to the teeth)an original device, capable of recovering and improving the symmetrical movement of the mouth.
This innovative method that can be defined as Motor Reprogramming, was originally designed for the treatment of dysfunctional problems in patients.(that is people that presented with specific dentistry problems)
In most cases it has the ability to restore the correct functioning of the mouth, that is to bring it back to correctly chew regularly and alternatively on both sides.
On the contrary, dysfunction is characterized by the loss of asymmetry of its function that is for altered movements irregular and uncoordinated (both the quality and quantity).
Amazing results were obtained by utilizing this method and they were much higher than those that initially anticipated or occlusionally sought. The entire organism responded improving posture in an amazing manner to this new therapy.
Why are these results accomplished?
The facilitation of movement is the basis of it all. In fact, an incorrect habitual functioning interferes heavily on the tone and posture of the patient. As much as the asymmetric activation of the muscles regulate the movements of the mouth, it will lead to a complex compensation of its functioning adaptation. It will force the entire organism to activate a complete series of postural compensations in the form of a functional scoliosis at the level of the spine (such as a rotation with the loss of verticalness) with the consequences of a remodeling of the general muscles.
At this point, we have carefully studied movement which is regulated by the nervous system as it programs and memorizes automatic motor reflexes on the basis of stimulus receptors leaving from the parodonto.
In fact, the stimulus receptors received leave from the spindle receptors and articular receptors from the parodonto, from the TMJ articulation, vertebrae and teeth, and from the cervical and chewing muscles.
It is not known as to why specific importance has not been placed on the correct functioning movement of the mouth and chewing on both sides. Even though an enormous contribution has been made in the field of postural dentistry through expensive and sophisticated machinery for example: EMG, TENS, Platforms utilized for finding a balanced static position for the muscles and posture, whilst in the meantime an asymmetric functioning of the mouth is capable of creating negative repercussions on a postural level.
The success and originality of the procedures we utilize consist in the possibility of its interactions on all components that determine the movement of the mouth (the teeth, TMJ, vertebrae). For these reasons the results are more widespread, regular and symmetric, with the bite in place. The startling fact is that even in the absence of the bite the movements of the mouth for example its opening, protrusion and laterality show considerable improvements in comparison to those at the outset (our appliance is in fact only utilized during the night).
This kind of improvement can be objectively measured utilizing a Kinesiography device. It is the only instrument capable of measuring movement with precision.
How are these results achieved?
From our experience such facilitation depends on motor reprogramming that can be achieved thanks to the original shape of the bite itself, and the specific recording of the occlusion functioning that is performed by testing the rotation, inflection and extension of the head.
In adjusting the bite, the patient is required to perform particular jaw movements of protrusion/retrusion and laterality to the left and right with maximum extension, hoping to promote mainly blocked movements. In the regulating of the bite, the patient is asked to move the jaw in protrusion/retrusion, from left to right, from side to side in in maximum extension hoping to mainly achieve previously blocked movements. These exercises of going and coming are controlled through occlusional maps. These are needed to modify the resin of the bite until straight symmetrical, balanced movements both anterior and posterior are achieved.
Checkups (initially weekly, then fortnightly) that monitor the habitual repetition of these movements that were originally blocked fosters the creation of new memories of movement and of joint and muscular stretching, in line with that of a correct symmetry.
The active phase is then followed by the passive phase at night, when in the absence of voluntary control the organism fights against eventual obstacles that with the presence of the bite they are intercepted.
These two phases working together lead to motor reprogramming that consists in the recuperation of movements, that previously were blocked with positive outcomes for the entire organism.
For more than 10 years, in hundreds of patients with this bite we have dealt with and resolved painful symptoms, both dentistry and postural. The responses achieved in athletes utilizing these new methods have been unexpected and efficient in the hope of preventing and resolving also in this specific sector, painful problems that arise from the practice of sport and to allow an increase in performance as our primary objective.
Our objective is to collaborate with federal structures like The National Italian Olympic Commitee (CONI) to validate and diffuse a therapeutic and preventative technique that is being confirmed already in the field of sports with results that allow unimaginable developments. The next stage will consist in collecting the information gotten from the By- te Reali to transfer it in an apparatus (device) much less awkward, by innovative orthotic device, to be able to be used also during sports (It is in a phase of advanced experimentation with promising results).
Dr. Maurizio Reali