Ultra Low Frequency Transcutaneous Electric Nervous Stimulation (ULF-TENS) is extensively used for pain relief and for the diagnosis and treatment of temporomandibular disorders (TMD). In addition to its local effects, ULF-TENS acts on the autonomic nervous system (ANS), with particular reference to the periaqueductal gray (PAG), promoting the release of endogenous opioids and modulating descending pain systems. It has been suggested that the PAG participates in the coupling between the emotional stimulus and the appropriate behavioral autonomic response. This function is successfully investigated by HRV. Therefore, our goal is to investigate the effects of trigeminal ULF-TENS stimulation on autonomic behavior in terms of HRV and respiratory parameters during an experimentally-induced arithmetic stress test in healthy subjects. Thirty healthy women between 25 and 35 years of age were enrolled and randomly assigned to either the control (TENS stimulation off) or test group (TENS stimulation on). Heart (HR, LF, HF, LF/HF ratio, DET, RMSSD, PNN50, RR) and respiratory (BR) rate were evaluated under basal, T1 (TENS off/on), and stress (mathematical task) conditions. Results showed that HRV parameters and BR significantly changed during the arithmetic stress paradigm (p<0.01). Independently of stress conditions, TENS and control group could be discriminated only by non-linear HRV data, namely RR and DET (p=0.038 and p=0.027, respectively). During the arithmetic task, LF/HF ratio was the most sensitive parameter to discriminate between groups (p=0.019). Our data suggest that trigeminal sensory ULF-TENS reduces the autonomic response in terms of HRV and BR during acute mental stress in healthy subjects. Future directions of our work aim at applying the HRV and BR analysis, with and without TENS stimulation, to individuals with dysfunctional ANS among those with TMD.
KEYWORDS: Experimental stress; Heart rate variability; Randomized clinical trial; Transcutaneous electric nervous stimulation; Trigeminus

Protocols in the Craniomandibular Dysfunction Patient: Two Cases Study from a Neuromuscular Perspective Approach
Carlos A. Capmourteres, DDS, MICCMO; Myriam L. Carballo, DDS, MCCMO; Virginia Testa, DDS

At the present the patient we named as a craniomandibular dysfunction patient (CMDP) is a very complex patient that can be the result of one or multiples concomitant entities that requires from the professional a deep knowledge of neuromuscular function and dysfunction and of psychosomatic and postural influences and a proper training in the management of dental occlusion in order to treat this complexity syndrome of the craniomandibular complex successfully. The term CMDP (craniomandibular dysfunction patient) , includes the Temporomandibular Disorders (TMD) that is a group of musculoskeletal disorders, affecting alterations in the structure and/or function of the temporomandibular joints, masticatory muscles, dentition and supporting structures, although its significance is more extensive and considers the influence of another systems distant from the head and neck, that are finally recognize as etiologic factors suggested as contributing to the development of TMD. Under the umbrella of CMDP we include not only the functional disturbances of the masticatory system, if not the masticatory muscles disorders, the TMJ disk displacements, and the craniocervical-mandibular disorders, also known as craniomandibular disorders (CMD).

Treatment Based on the Neuromuscular Concept: A Case Report
Tsuguyasu Sasaki, DDS, FICCMO

This report presents a case in which evaluation of the mandibular position and occlusal reconstruction were performed based on the neuromuscular concept, and good outcome was obtained with use of Golden Vertical as a parameter of occlusal vertical dimension in addition to use of K7 for evaluation of jaw movements and EMG.

The Application of the HIP-Analyzer for the Evaluation of the Maxillary Occlusal Plane Topography
Sergey Shestopalov, PhD, DO; Konstantin Ronkin, DMD, MICCMO

The orientation of the upper occlusal plane is an important component in many clinical situations. Over the course of one hundred years, the main reference planes were the Francfort and Camper’s planes. In 1955, Cooperman and Willard found that HIP plane (hamular-incisive-papilla) anatomically related to the cranium. The application of the HIP-plane in prosthodontics and orthodontics is actively discussed today. Many studies have shown that the HIP plane has been observed to be a more stable reference point in determining the orientation of maxillary occlusal plane position. Other studies have shown that the HIP plane has the smallest angle with an occlusal plane (2.61°±0.81°).

Craniomandibular-Dental Imbalances Effect on Mandibular Closure Pattern, Condylar Position and Neuromuscular Stability: Case Evaluation
Martin Fraschetti, DDS, MICCMO

Craniomandibular disorders have long been the nemesis of obtaining a predictable neuromuscular bite. Instrumentation, while discerning a stable neuromuscular trajectory, does not lend itself to reveal the underlying skeletal imbalances that will produce neuromuscular relapse. This evaluation is the compilation of archial skeletal analysis, cause and effect on closure pattern and their relation to neuromuscular instrumentation. The use of neuromuscular instrumentation as a method of diagnosis and treatment without the aid of skeletal analysis, both pre and post treatment can be misleading when establishing phase III stability.

Perspectives about TMD: The Role of Neuromuscular Orthodontic Treatment Case Study
Prof. Dra Myriam L. Carballo, DDS, MICCMO; Dra Maria Celina Gil, DDS, FICCMO

It has long been known that if we want to preserve a friend it is necessary to avoid a discussion about religion and politics. The same principle applies to the dental community regarding dental occlusion and mandibular position, especially if they relate to the etiology of craniomandibular and temporomandibular disorders (TMD).   The literature presents two extremely diverse paradigms regarding the etiology, diagnosis and treatment of TMD. Majority of clinicians believe that dental occlusion and mandibular position play a primary etiologic role in the development of this pathology. Others dismiss this concept as strongly and attribute TMD to emotional tension and chronic pain, which they feel are responsible for the development of the signs and symptoms that characterize this type of syndrome. Another controversial point that has been strongly debated among clinicians who seek answers to the mysteries of the treatment of TMD patient is how neuromuscular orthodontic treatment influences the resolution of this syndrome.

Neuromuscular Orthodontic Treatment in a Patient with Lateral Occlusal Discrepancy and its Influence on the Alignment of the Spinal Column
Graciela Bruzzone, DDS, MS, FICCMO; Graciela Maffía, DDS, MS, FICCMO

At the present time in Medicine and Dentistry biomedical instrumentation plays a vital role in the diagnosis and treatment of diseases. Bioelectronic instrumentation also became fundamental in orthodontics as part of that technology. In this case report, the authors demonstrate the application of the Myomonitor, computerized mandibular scanning and surface electromyography in the diagnosis and treatment of patients with temporomandibular disorders (TMD) and lateral discrepancy in occlusion and the effect of Neuromuscular Orthodontics on the posture.  It will be demonstrated that a change in the temporomandibular joint in an overbite causes changes in posture and shows you how to restore muscle and postural balance. During the diagnosis and treatment the EMG spectral analysis and TENS therapy were applied.

TMD Dental Reconstruction Patient: A Case Study
Konstantin Ronkin, DMD, MICCMO

Ruth was seen as a new patient looking for cosmetic work to improve her smile and overall oral health. She had no idea that her current dental occlusion was the cause of many symptoms. She had severe dental anxiety and was upset with herself for avoiding the dentist for several years. After trying to seek dental help a few times during this time period away, she could not find a doctor that she was happy with or felt comfortable with. Ruth had gotten to the point where she wanted to improve herself aesthetically and was ready to do what she needed to do to get healthy. Ruth was given options for restoring her smile and overall oral health. Ultimately, Ruth declined the option of restoring the posterior teeth and undergoing Invisalign treatment to align her front teeth, and decided to proceed with full mouth reconstruction.  The dental treatment rendered utilizing neuromuscular dental concepts and procedures affected a resolution of her TMD symptoms and achieved the cosmetic results for which she sought treatment.

Effect of Three Different Mandibular Advancement Devices and Two Different Bite Techniques on the Resultant Sleep Metrics
Shamshudin (Sam) Kherani, DDS, FAGD, MICCMO

It has been documented in the literature that nearly 20% of the American Population suffers from Sleep Apnea (Obstructive, Central and Mixed). Majority of the cases comprise of the Obstructive type of Sleep Apnea. As such, it is considered to be a major health hazard. Furthermore, it is documented that 85-90% of these patients have not been diagnosed yet. Therefore, this is an area that needs further research and study as to how to better serve our populations.

The Craniomandibular Dysfunction (CMD) – a frequently overlooked disorder in the treatment of unspecific back pain
Brigitte Losert-Bruggner, Dr. med. dent. MICCMO
Rainer Schöttl, DDS, MICCMO

Neuromuscular reflexes create direct links between the cranio-mandibular and the cranio-cervical region. As a result, a malposition of the jaw (CMD) invariably causes a malposition in the upper cervical spine (CCD = cranio-cervical dysfunction) and vice versa. Unless CCD and CMD are treated simultaneously by manual therapists and the dentist, patients often suffer from therapy resistant, causally unexplainable unspecific complaints such as headaches, neck, shoulder and back pain. This study looked at unspecific back pain of 555 patients with cranio-mandibular (CMD) and cranio-cervical (CCD) dysfunction. 404 (73%) of the 555 CMD/CCD patients complained of therapy-resistant unspecific back pain.

Consideration of the Mandibular Position in Implant Prosthetics
Tsunehiko Matsushima, DDS, PhD, FICCMO

Objective evaluation of the mandibular position is essential for planning implant prosthetics. Implant prosthetic treatment has a risk of post-operative mandibular dysfunction such as the mandibular displacement and associated TMD due to intrinsic implant features, unless the pre-operative mandibular position that is not in harmony with the functional occlusal system is corrected. Therefore pre-operative evaluation of the mandibular displacement is the most important step for occlusal reconstruction.

An Assessment of the Usefulness of Kinesiograph as an Aid in the Diagnosis of TMD: A Review of Manfredini et al’s studies
Barry C. Cooper, DDS, MICCMO; Fray Adib, BSEE, MBA
Reprinted with permission: J Craniomandibular and Sleep Practice 2015 Jan;33(1):46-64

Performing a literature review of publications by Dr. Manfredini et al related to their TMJ injection therapy outcome with conclusions on the clinical utility of computerized measurement devices used in the management of TMD. In addition, reviewing their published opinion on an occlusion: MD vs a biopsychosocial paradigm for TMD. Manfredini et al authored an article published in JADA 2013, the most recent of 12 articles. In all studies, subjects received TMJ injections with an objective measurement outcome criterion; increased maximum mouth opening (MMO) and subjective symptom improvement of pain and chewing function.

Physiologic Neuromuscular Dental Paradigm for the Diagnosis and Treatment of Temporomandibular Disorders
Prabu Raman, DDS, MICCMO
Reprinted with permission: Journal of the California Dental Association, Aug 2014

Shifting from traditional anatomical/mechanistic models, the physiologic neuromuscular dentistry (PNMD) paradigm acknowledges the primacy of physiology in shaping and controlling anatomy in a functioning human body. Occlusal disharmony from mandibular discrepancy to cranium leads to temporomandibular disorders (TMD), which is a disease of musculoskeletal imbalance in the postural chain exceeding the individual’s physiologic adaptive capacity. To diagnose optimal craniomandibular alignment, PNMD is guided by real-time objective physiologic data such as electromyography (EMG).

A Position Paper of the International College of Cranio-Mandibular Orthopedics (ICCMO)
Barry C. Cooper, DDS
Published J Craniomandib Pract, 2011; 29 (3): 237-244
“Measure what is measurable and what is not measurable, make measurable.” Galileo Galilei
This position paper is endorsed by the Board of Regents of the International College of Cranio-Mandibular Orthopedics, 2011.

Purpose: Two principal schools of thought regarding the etiology and optimal treatment of temporomandibular disorders exist; one physical/functional, the other biopsychosocial. This position paper establishes the scientific basis for the physical/functional. The ICCMO Position: Temporomandibular disorders (TMD) comprise a group of musculoskeletal disorders, affecting alterations in the structure and/or function of the temporomandibular joints (TMJ), masticatory muscles, dentition and supporting structures. The initial TMD diagnosis is based on history, clinical examination and imaging, if indicated. Diagnosis is greatly enhanced with physiologic measurement devices, providing objective measurements of the functional status of the masticatory system: TMJs, muscles and dental occlusion. The American Alliance of TMD organizations represent thousands of clinicians involved in the treatment of TMD. The ten basic principles of the Alliance include the following statement: Dental occlusion may have a significant role in TMD; as a cause, precipitant and /or perpetuating factor. Therefore, it can be stated that the overwhelming majority of dentists treating TMD believe dental occlusion plays a major role in predisposition, precipitation and perpetuation. While our membership believes that occlusal treatments most frequently resolve TMD, it is recognized that TMD can be multi faceted and may exist with co-morbid physical or emotional factors that may require therapy by appropriate providers. The International College of Cranio-Mandibular Orthopedics (ICCMO), composed of academic and clinical dentists, believes that TMD has a primary physical/functional basis. Initial conservative and reversible TMD treatment employing a therapeutic neuromuscular orthosis that incorporates relaxed, healthy masticatory muscle function and a stable occlusion is most often successful. This is accomplished using objective measurement technologies and ultra low frequency transcutaneous electrical neural stimulation (TENS).
Conclusion: Extensive literature substantiates the scientific validity of the physical/functional basis of TMD, efficacy of measurement devices and TENS and their use as aids in diagnosis and in establishing a therapeutic neuromuscular dental occlusion.
Clinical Implications: A scientifically valid basis for TMD diagnosis and treatment is presented aiding in therapy.

Establishment of a Temporomandibular Physiological State with Neuromuscular Orthosis Treatment Affects Reduction of TMD Symptoms in 313 Patients
Barry C. Cooper, D.D.S.; Israel Kleinberg, Ph.D., D.D.S., D.Sc.
Published J Craniomandib Pract, April 2008; 26 (2): 104-117

The objective of this investigation was to test the hypothesis that alteration of the occlusions of patients suffering from temporomandibular disorders (TMD) to one that is neuromuscularly, rather than anatomically based, would result in reduction or resolution of symptoms that characterize the TMD condition. This hypothesis was proven correct in the present study, where 313 patients with TMD symptoms were examined for neuromuscular dysfunction, using several electronic instruments before and after treatment intervention. Such instrumentation enabled electromyographic (EMG) measurement of the activities of the masticatory muscles during rest and in function, tracking and assessment of various movements of the mandible, and listening for noises made by the TMJ during movement of the mandible. Ultra low frequency and low amplitude, transcutaneous electrical neural stimulation (TENS) of the mandibular division of the trigeminal nerve (V) was used to relax the masticatory muscles and to facilitate location of a physiological rest position for the mandible. TENS also made it possible to select positions of the mandible that were most relaxed above and anterior to the rest position when the mandible was moved in an arc that began at rest position. Once identified, the neuromuscular occlusal position was recorded in the form of a bite registration, which was subsequently used to fabricate a removable mandibular orthotic appliance that could be worn continuously by the patient. Such a device facilitated retention and stabilization of the mandible in its new-found physiological position, which was confirmed by follow up testing. Three months of full-time appliance usage showed that the new therapeutic positions achieved remained intact and were associated with improved resting and functioning activities of the masticatory muscles. Patients reported overwhelming symptom relief, including reduction of headaches and other pain symptoms. Experts consider relief of symptoms as the gold standard for assessment of effectiveness of TMD treatment. It is evident that this outcome has been achieved in this study and that taking patients from a less to a more physiological state is an effective means for reducing or eliminating TMD symptoms, especially those related to pain, most notably, headaches.

Examination of a Large Patient Population for the Presence of Symptoms and Signs of Temporomandibular Disorders
Barry C. Cooper, D.D.S.; Israel Kleinberg, Ph.D., D.D.S., D.Sc.
Published J Craniomandib Pract, April 2007; 25 (2): 114-126

Temporomandibular Disorder (TMD) is a term generally applied to a condition or conditions characterized by pain and/or dysfunction of the masticatory apparatus. Its characterization has been difficult because of the large number of symptoms and signs attributed to this disorder and to variation in the number and types manifested in any particular patient. For this study, data on 4,528 patients, presenting over a period of 25 years to a single examiner for TMD treatment, was made available for retrospective analysis and determination of whether the TMD care-seeking patient can be profiled, particularly pain difficulties. All patients in this database filled out a questionnaire and were examined for the prevalence of a range of symptoms and clinical examination findings (signs) commonly attributed to TMD. There was no attempt in this study to assign patients to TMD diagnostic subcategories. The data collected were analyzed to determine which of these symptoms and signs were sufficiently “characteristic of the TMD condition” that they might be used in diagnosis, research and treatment, especially in patients needing relief from pain and discomfort. All 4,528 patients reported symptoms and all but 190 of them also showed signs upon examination. Symptoms most commonly reported on the questionnaire included (i) pain (96.1%), (ii) headache (79.3%), (iii) temporomandibular joint discomfort or dysfunction (75.0%) and (iv) ear discomfort or dysfunction (82.4%). In the 4,338 patients who showed signs, the most prevalent was tenderness to palpation of the pterygoid muscles (85.1%), followed by tenderness to palpation of the temporomandibular joints (62.4%). Pain symptoms and signs were often accompanied by compromised mandibular movements, TMJ sounds and dental changes, such as incisal edge wear and excessive overbite. Clearly prevalence of pain disclosed by the symptoms and signs examinations was high. Patients showed variable prevalence and nonprevalence of eight categories of painful symptoms and seven categories of painful signs. Despite the variability, these might be developed in the future into TMD scores or indices for studying and unraveling the TMD conundrum.

The neuromuscular occlusion concept. III. Myofunctional impressions in completely edentulous denture arches.
Lucian Ene, DDS, PhD; Marian-Vladimir Constantinescu, DDS; Teodor Trăistaru, DDS.
Rev Chir Oncol Radiol ORL Oftalmol Stomatol Ser Stomatol. 1985 Jan-Mar;32(1):35-48.
[Article in Romanian].

In a continued presentation of the neuromuscular occlusal concept the authors describe the methodology used for impressions of the completely edentulous arches according to this concept and make some considerations on the basis of clinical experimentation extending over a period of 5 years.
KEYWORDS: Edentation; Dental prosthesis; Dental occlusion.
PMID: 3161152

Kinesiographic analysis of the mandible in occlusal dysfunction.
Teodor Trăistaru, DDS; Marian-Vladimir Constantinescu, DDS; Lucian Ene, DDS, PhD.
Rev Chir Oncol Radiol O R L Oftalmol Stomatol Ser Stomatol. 1984 Oct-Dec;31(4):301-306.
[Article in Romanian]

The aim of all restoration therapy is to achieve optimal relationship between occlusal surfaces, both in the centric relationship and in maximal intercuspidation, and in excentric mandibular movements. The occlusal relationship become the final expression of the entire activity of the components of the dento-maxillary apparatus. Mandibular kinesiology is a possibility for research and diagnosis, by analyzing the physiology and the pathology of the locomotive in the dento-maxillary apparatus. In this paper the authors present their results in the opening and closing movements, the limit of the mandibulary movements in the sagittal plane and the duration of the opening and closing movement. The study disclosed some elements which are characteristic for mandibulary movements, as compared with the functional movements.
KEYWORDS: Dental occlusion; Mandible.
PMID: 6242201

The concept of neuromuscular occlusion. II. The apparatus and its function.
Marian-Vladimir Constantinescu, DDS; Teodor Trăistaru, DDS.
Rev Chir Oncol Radiol ORL Oftalmol Stomatol Ser Stomatol. 1984 Jul-Sep;31(3):193-198.
[Article in Romanian].

The authors continue their presentation of the neuromuscular occlusal concept. In the present note they describe the apparatus and the working technique which are necessary for the determination, recording and the transfer of the occluding position which is directed neuromuscularly.
KEYWORDS: Dental occlusion; Musculus masseter; Diagnosis.
PMID: 6240734

The neuromuscular occlusion concept. I. Considerations on the mandibular neuromuscular position.
Lucian Ene, DDS, PhD; Marian-Vladimir Constantinescu, DDS; Teodor Trăistaru, DDS.
Rev Chir Oncol Radiol ORL Oftalmol Stomatol Ser Stomatol. 1984 Apr-Jun;31(2):89-96.
[Article in Romanian]

Mandibular-cranial functional relationships continue to be a focus of interest for both clinicians and investigators in this field of oral physiology, especially the since the negative effects of the alterations of these relationships are well known. The authors present one the actual concepts in the field of the occlusal physiology: the neuromuscular theory advanced by B. Jankelson. A review is presented of the data published in the literature in connection with the transcutaneous electrical neural stimulation in the specific conditions of the dento-maxillary apparatus. The specialized literature provides a sufficient amount of clinical informations which support the idea that the various occlusal concepts are at the limits of tolerance of normal functional capabilities of the dento-maxillary apparatus. The value of the therapeutical solutions depends on the precision of the determinations, on the understanding of the occlusal phenomena and the clinical experience of the stomatologist.
KEYWORDS: Dental occlusion; Articulatio temporomandibularis.
PMID: 6242192