elaimen@terra.com.br | BRIO005638. —-Ma! Pedido:070129-88 Usuario:caio selaimen Implant Dent 2002 11(3) pags. 202-214 / Osmunson B. / Vertical dimension of occlusion in implant dentistry: significance and approach Observagées:Foi incluido no pedido a discussao do artigo que segue na mesma revista.obrigado Caio Marcelo Panitz Selaimen Rua Hondrio Silveira Dias 968 '90550-150 - Porto Alegre - RS | BRASIL ee ee erVolume 11(8), September 2002, pp 202-210 POINT (CRITIQUE) (Poini-Counterpoin) Editors’ Note: The article Vertical Dimension of Occlusion in implant Dentisty: Significance and Approach by Glena L. Gittlson, DDS, appeared in Implant Dentistry, 2002;1:38~ 40. 1 A reader, Bil Osmunson DDS, MPH, took exception to aspects ofthis wring and submitted a citque to the Editors. In tum, the author was Given the opportunity to respond to this eique. What folows are the words of Osmunson (Point followed by those of Gitetson (Counterpoin). Vertical Dimension of Occlusion in Implant Dentistry: Significance and Approach by Dr. Gittelson. A Neuromuscular Approach by Dr. Osmunson ‘The neuromuscular theory (NM) places a premium on positioning the mandible in the most ergonomic. position for both optimal function and optimal rest. Simultaneous real-time measurements comparing ‘mancibular/maxilary relationship (aw tracking) combined with electromyography (EMG, or measured ‘muscle motor unit activity) of the muscles provides the most accurate clinical evaluation of muscle response to various occlusal positions. Just like an impression for a crown provides unique information when fabricating a crown, EMG with simultaneous jew tracking provides unique information when positioning the mandible, ‘The Myo-monitoris an equipment brand name for one make of low frequency TENS. TENS equipment, including the Myo-monitor, does not " monitor’ anything. However, TENS is important in dentistry for four ‘main reasons: (1) to lower the resting tension of the muscles with a massaging action; (2) to decommission the proprioceptors; (3) to determine the ergonomic trajectory of mandibular movement; and (4) to provide differential diagnostic information, The Myotronics KB or K7 measures EMG, ESG, and jaw tracking, {An illustration of a muscle-relaxed mandibular position: (WARNING: Do not attempt to diagnose or treat with this ilustration,) ‘A. Sit up straight and relax the muscles of your head and mandible. Take a deep breath and further relax (a minute or two). Relax your tongue and lips. Subjectively evaluate the tension level ofthe head, temporal, masseter and digastric muscles, and temporomandibular joint (TMW) area. This positon should be, subjectively, a very relaxed, comfortable, and rested position of your mandible without teeth touching, B. Slowly let your mandible drift up lke it is attached to a balloon and stop when any tooth frst contacts Dor't slide into centvc, just very light touch on the first tooth contact position for some time (several minutes). Ifthe contact tooth becomes sore, you are biting too hard. This is a position test forthe muscles, not the tooth. Evaluate the tension of your head, muscles, and TMV area. A neuromuscular dentist ensures the muscles are virtually as relaxed in light occlusion as they are in the mast rested position. Rest and occlusion (ight tooth contact) in a neuromuscular position will have very similar measured EMG levels. C. Now lightly close into your habitual centric occlusion, holding this position for several minutes, and again ‘evaluate your muscle tension and TMJ area. From my experience, about four people in five will feel tension start to buildin their muscles. Rest the muscles again. D. Finally, repeat light first tooth contact but this time in centric retaion “CR” (your best guess on yourself) ‘and hold for the same amount of time. Many people feel greater muscle tension in CR than habitual centric, Unless CO=CR. Again evaluate your head, muscles, and TMJ area for tension. . Repeat any or all the positions and compare levels of comfort and tension between the four positions. Webster's defines ergonomics as “the applied scence of equipment design intended to reduce operator fatigue and discomfort."2 Although our teeth usually do not remain in contact for extended periods of time, repeated posturing ina tense or strained position can lead to muscle fatigue, discomfort, and disease. With ‘simultaneous measurements of muscie activity and mandibular position, the clinician can and should locate, record, document, treat, and verify muscle activity at each chosen mandibular position for reduced fatigue ‘and discomfort.‘The NM theory and GR theory agree an the need “to fully understand the science of occlusion; the clinician who is involved with the restorative processes must also recognize the effect thet tooth contacts have on the jaw joints and the muscles that control jaw movement."1 The measured reaction of the muscle motor unit, \with simultaneous measured jaw movement must be used on each patient to evaluate the reaction of the ‘muscles to tooth contacts. Diagnostic information of muscle reaction to mandibular position should include 2 baseline of muscle activity in a relaxed position before and after Myo-monitor TENS 3 (Fig. 1), range of ‘motion (Fig. 2), chewing cycle (Fig. 3), qualitative and quantitative joint sounds (Fig. 4), trajectory of NM. closing (Fig. 5}, maximum clench ability in habitual CO compared with cotton rolls (Fig. 6), sequence of ‘muscle recruitment in CO or “first tooth contact" (Fig, 7), muscle fatigue 4 (Fig. 8), and muscle recruitment ‘needed to achieve light tooth contact in centric (Fig. 8). The clinician does not need to speculate regarding ‘muscle activity for most major muscle groups. fa np ie lo Comet har Dee Yor rr Colca vit | oe | | twsteg cog teers 5D seconds UA Peake 14.3uy, Averages 13uv a esing EMG betes sig EMG aterters Rearetio taanioe : Be 3 Baud) 8S > Steerer Sr mT mraaaiet RAO Tem Fig. 1. Myotronics scan 9 and 10 split screen taken before reconstruction, Left side in rest, right side after 1 hour TENS same day, Myotrades not removed. The wider lines, greater color, and higher numbers indicate ‘more muscle motor unit activity. Patient information used with permission.