|Year : 2015 | Volume
| Issue : 1 | Page : 12-16
Clinical outcome of subjective symptoms in myofascial pain patients treated by immediate complete anterior guidance development technique using digital analysis of occlusion (Tek-scan) and electromyography
Department of Prosthodontics, Dayananda Sagar Dental College and Research Centre, Rajiv Gandhi University of Health Sciences, Bengaluru, Karnataka, India
|Date of Web Publication||12-Aug-2015|
Department of Prosthodontics, Dayananda Sagar Dental College and Research Centre, Rajiv Gandhi University of Health Sciences, Bengaluru, Karnataka
Source of Support: None, Conflict of Interest: None
| Abstract|| |
Objectives: The purpose of this study is to evaluate the effect of occlusal equilibration using immediate complete anterior guidance development (ICAGD) technique by Kerstein. This technique is the most advanced verifiable and measurable way of digitally analysing the occlusion using T-scan technology and muscle activity using electromyography. Materials and Methods: This study is to assess the subjective symptoms of 75 patients diagnosed as myofascial pain patients and who were treated by ICAGD technique as described by Kerstein. The common complaints of the patients were pain in the masseter and temporal muscles, jaw tiredness in the mornings, night bruxing and difficulty in chewing. This technique involves occlusal equilibration to remove all posterior interferences and establish anterior guidance. The patients were treated over three visits 1-week apart and followed for 3 years. The symptoms reduction occurred for all the patients after the first correction in about 5-10 days. In about a period of 3 years review, no recurrence was seen of the chronic myofascial symptoms. Results: Regardless of the chronic nature of the patient's symptoms, symptom reduction occurred in a week's time. This agrees with the studies of Kerstein and others. Discussion: If free excursive mandibular movements are not established, may lead to muscle dysfunction at later years. Thus, equilibration should be done to establish good and free functional movements without any interference.
Clinical relevance to interdisciplinary dentistry
Using biometric tools like T scan helps dentists to 100% accurate diagnosis of TMD/ occlusion problems and to treat the case objectively. In the area of interdisciplinary practices, these gadgets help us to identify the issues precisely. Thus, a clinician will be at an advantage to locate the causative factor immediately with accuracy and treat the patient.
Keywords: Digital analysis of occlusion, electromyography, enameloplasty, immediate complete anterior guidance development, joint vibratography, myofascial pain, occlusal discrepancy, T-scan
|How to cite this article:|
Thumati P. Clinical outcome of subjective symptoms in myofascial pain patients treated by immediate complete anterior guidance development technique using digital analysis of occlusion (Tek-scan) and electromyography. J Interdiscip Dentistry 2015;5:12-6
|How to cite this URL:|
Thumati P. Clinical outcome of subjective symptoms in myofascial pain patients treated by immediate complete anterior guidance development technique using digital analysis of occlusion (Tek-scan) and electromyography. J Interdiscip Dentistry [serial online] 2015 [cited 2019 Dec 14];5:12-6. Available from: http://www.jidonline.com/text.asp?2015/5/1/12/162738
| Introduction|| |
Occlusion is one of the fields of dentistry in which much over treatment and in some cases faulty treatment has been performed. When we speak about need for treatment, all kinds of treatment should be considered, from counselling, behavioural therapy, physiotherapy and various other kinds of occlusal therapy. The question is always if anything of benefit can be offered to the patient that will provide relief to his/her signs and symptoms. Thus any patient with soreness of jaw muscles, limitation of jaw movement or impairment of temporomandibular joint (TMJ) function could be considered as candidates for occlusal therapy.
The chronic myofascial pain signs and symptoms are; pain in the face, limited mouth opening, muscle tenderness, deviation of the jaw on opening, noises in the TMJ and pain in and around TMJ area. ,,
Occlusal therapy constitutes a deliberate intervention for the purpose of changing the occlusal status. It should be based on an objective diagnosis and evaluation in each case. It has been reported that the reduced dysfunctional activity with the use of bite planes would return if the bite planes were left out of the mouth at night; but it didn't return for patients who had occlusal adjustment by immediate complete anterior guidance development (ICAGD) technique, even if they stopped using the bite planes. ,,
Occlusal equilibration as a treatment modality for relieving the symptoms of myofascial pain has been successful for some people and not so for some people. 
The present study reports the result of 75 patients with chronic myofascial pain symptoms treated by "occlusal equilibration using ICAGD technique" given by Kerstein as the treatment option with computer-guided ICAGD enameloplasty and simultaneously recorded T-scan and electromyography (EMG) data.
| Aims and objectives|| |
To assess the therapeutic efficacy of T-scan III guided and measured ICAGD occlusal adjustment procedure in creation of the occlusal scheme in which disclusion time is < 0.4 s/excursion and to resolve the muscle hyperactivity in myofascial pain patients confirmed using EMG tracings; then assess their effect in bringing down the subjective symptoms of myofascial pain.
Patients complaining of symptoms of myofascial pain in the face, limited mouth opening, muscle tenderness, deviation of the jaw on opening, noises in the TMJ and pain in and around TMJ area.
None, since patients coming with these symptoms are taken up for treatment.
| Materials and methods|| |
This study included 75 patients diagnosed as chronic myofascial pain cases. Out of these 75 cases: 22 men and 53 women having an age range of 18-60 years were present. Of this, 11 men were between 18 and 35 years and 11 of them between 36 and 60 years. 41 women were in the age group of 18-35 years and 12 of them between 36 and 60 years. The areas of pain reported are in the region of masseter, temporalis, and lower border of the mandible near molar area and in the ear or TMJ region [Table 1].
All the patients were screened with the biometric diagnostic investigations like T-scan (digital analysis of occlusion), EMG and joint vibratography (JVA) to study existing dentition. JVA analysis will tell us whether the case is intra capsular or extra capsular disorder. Extra capsular cases were studied by using T-scan and EMG, for the tooth contact sequence, changing occlusal forces and fluctuating muscle activity levels of the temporalis and masseter muscle. The recorded details are from an intercuspation position followed by excursive movements till the muscle shutdown occurred.
About the location and nature of pain, a total of 147 sites of chronic discomfort with some patients showing more than one area were recorded. In this, temporalis area showed the maximum at 67 times and then the masseter area 57 times. The onset of the pain or discomfort was described by 67 people as tension and pain in the temporal area and the next pattern was pain in the masseter area while chewing and stiffness in the face in the mornings. Thirty one patients had unilateral or bilateral joint disturbances in the form of clicks or pops. The symptom distribution subjectively has been shown in [Table 2].
About the intensity of symptoms, an ordinal scale of Visual Analogue Scale having ratings from 0 to 10 were used to categorise the symptoms in to mild/moderate/severe as shown in [Table 3].
Technique of immediate complete anterior guidance development treatment protocol
The protocol for ICAGD is to start by recording the traces of all mandibular movements using T-scan and EMG after JVA being recorded. Once the traces are studied for occluding time and discluding time details, the occlusal interferences in excursive mandibular movements are eliminated like all Class I to III interferences described by Glickman [Figure 1] and [Figure 2]. Once this is achieved, either by reduction-enameloplasty or by addition to teeth, immediate posterior disclusion in <0.5 s should be achieved. The intentions are to establish ICAGD with <0.5 s disclusion time in excursive mandibular movements.
When we equilibrate occlusion by ICAGD technique, keep asking the patient-where is the highest pressure point in the bite, do you have any rocking points, is it equal on left and right side, is it very light at the back end when you bite, is it hurting in temples, face, neck or ears when you bite, do you feel blocked when you want to glide from side to side, is there raised tension in your face when you bite and do you have anything that you do not like about your bite.
Immediate complete anterior guidance development is done in 2 phases. In first phase after analyzing the digital data of T-scan, enameloplasty (reduction) or addition to teeth with composites is done in such a way, immediate posterior disclusion in <0.4 s is achieved. This reduces muscular contraction in masticatory muscles by suppressing the mechanoreceptor activity due to shortened disclusion time. There by lessened lactic acid produced with increased availability of oxygen for the muscular tissues. This reduced muscle hyper activity will be immediately shown as muscle relaxation, decreased pain, stress released from the face etc., for the patient's.
The arch relation between maxillary and mandibular teeth is as follows; 59 of them angles Class 1, 7 of them Class 2 inclusive of both the divisions and 9 of them Class 3. All of them were subjected to complete occlusal examination which revealed centric relation to centric occlusal (CR-CO) discrepancy of 0.25-3 mm in both the horizontal and vertical direction. In this, 49 patients had gone through orthodontic corrections. Even though they had good vertical relationship; 11 people had posterior cross bites and 4 of them anterior open bite.
All these patients were having inability or limited ability to right and/or left excursive movements when anterior teeth are in contact. This was primarily due to both working and nonworking interferences in the posterior teeth
[Figure 3] and [Figure 4]. Some of these patients could move a bit from their habitual maximum contact and others move laterally if they first separated their teeth vertically. Twenty-one of them had protrusive interferences too, even though all of them could protrude mandible. Most of them had anterior worn out (wear out facets) incisal edges especially canines, there by anterior guidance being lost [Figure 5]. The 23 patients who were using acrylic resin splints (night guards) were subjected to occlusal evaluation without the splints. All these patients were unable to do lateral movements from intercuspal position due to working and nonworking interferences. The major factor in all these patients was missing freedom for the mandibular excursive movements in all directions in contact with the opposing teeth due to lack of anterior guidance. Since this is a subjective description of the findings, no control group is used.
In the second phase, on 8 th day (after 1-week) pre- and post-treatment records are recorded [Figure 6]. Occlusal interferences are looked for and cleared till the new habitual bite is eventless by having <0.4 s disclusion time and the entire craniofacial physiology is at its best health. This is confirmed with the bio-metric reports of T-scan, EMG and JVA and disappearance of myofacial pain dysfunction syndrome symptoms over a period of 4-6 weeks completely. Patient is reviewed periodically to avoid changes in disclusion timings at regular interval of 1, 3, 6 months and every 6 months afterwards for 3 years. Follow-up visits showed that after reduction, the pretreatment levels of excursive muscular hyperactivity were lessened. 
| Treatment and results|| |
Treatment objective was to free the contact mandibular movements in all eccentric directions by occlusal equilibration as described by Glickman  and Kerstin's  ICAGD technique. But no attempt is being made to modify the closure position to CR and neither an attempt was made to correct the CR-CO discrepancy.  The sole treatment purpose was to remove all nonworking and working interferences and develop an anterior guidance. For patients with anterior open bite and Class II angles relation, guidance was established on canines and first premolars, Class III angles relation it was provided on incisors and canines and Class I relation it was on canines and incisors.
After the first visit for occlusal equilibration, all patients in the second visit after 1-week reported of easy jaw movements and fresh feeling in the face, lack of stiffness in the face indicating stress free facial tissues and no muscle pain. Sixty seven patients were very happy, five of them still complained of 10-20% of symptoms who had few more interference. After the second visit corrections, even these five patients were very much comfortable. The other three patients were having flat occlusal surfaces and needed couple of visits to gain anterior guidance after which even they were comfortable.
Regardless of the chronic nature of the patient's symptoms, symptom reduction occurred in a week's time. This agrees with the studies of Kerstein and Farrell  and others. All the 75 patients reported no facial tension or fatigue on eating. The bruxing patients reported of relaxed muscles and no pain. The episodes of bruxing had reduced as reported by their spouses or relatives. The patients who complained of pain near ear or TMJ, the frequency of pain greatly reduced but the clicking and popping persisted. These patients recalled over 3 years showed that the results were maintained and no recurrence was seen.
| Discussion|| |
From the data [Table 1] it is seen that, these problems are predominantly seen in women aged between 18 and 36 years; as 53 patients are women out of 75 and 52 patients are between 18 and 35 years of age out of 75.
As per Glickman's classification  the maximum number of iwnterferences were Class III followed by Class II and Class I. Removal of class III interferences on nonworking side during equilibration procedure, which is on the buccal inclines of the upper palatal cusps and lingual inclines of the lower buccal cusps will facilitate better visualisation of Class II and I interferences on the working side. Once all the faulty contacts are eliminated and anterior guidance established with all freedom of Jaw movements.
As reported by Williamson and Lundquist,  Dawson,  Kerstein and Farrell, , there will be masticatory muscle activity leading to contraction in the muscles during closed position and this will continue when the posterior teeth are in contact during excursive movement. In turn this will lead to release of contractile by-products like lactic acid which results in muscle spasm, muscle fatigue, pain. Due to spasmic contractions, blood supply is reduced with decreased muscle function, oxygen and increased ischemic changes.  This will lead to increased pain as nerve endings are sensitive to lactic acid and ischemic changes.
Since the nonworking and working interference were removed and anterior guidance was established, the excessive muscle activity is being interrupted during closing contacts giving rest to muscles. This will eliminate the muscle hyperactivity, fatigueness, tenderness and pain in the muscles reliving the symptoms of all myofascial pain symptoms from musculoskelatally based issues.
In all the 75 patients, 49 (65%) of them have developed symptoms long after their orthodontic treatment. This gives a direction to think about, mere establishment of ideal vertical tooth relation may not lead to functionally and neuromuscularly healthy excursive movements. If free excursive mandibular movements are not established after postorthodontic treatment may lead to muscle dysfunction at later years. Thus, equilibration should be done to establish good and free functional movements without any interference after orthodontic treatment is completed and the teeth have assumed stable positions.
| Conclusion|| |
In this report, it is seen that the treatment of 75 patients having myofascial pain with occlusal equilibration using digital analysis of occlusion by T-scan, EMG and JVA technology; which is quantifying of occlusal forces against time has brought relief of symptoms in about week to 10 days time. Further long term and control studies are required to know the relation between neuromuscular health and teeth contacts.
| References|| |
Berlin R, Dessner L. Bruxism and chronic headache. Lancet 1960;2:289-91.
Berlin R, Dessner L, Aberg S. Chronic headache and dysfunction of the temporo-mandibular joint. Acta Med Scand 1956;154:167-76.
Greene CS, Laskin DM. Long-term evaluation of conservative treatment for myofascial pain-dysfunction syndrome. J Am Dent Assoc 1974;89:1365-8.
Lederman KH, Clayton JA. Patients with restored occlusions. Part III: The effect of occlusal splint therapy and occlusal adjustments on TMJ dysfunction. J Prosthet Dent 1983;50:95-100.
Solberg WK, Clark GT, Rugh JD. Nocturnal electromyographic evaluation of bruxism patients undergoing short term splint therapy. J Oral Rehabil 1975;2:215-23.
Solberg WK. Myofascial pain and dysfunction. In: Clark J, editor. Clinical Dentistry. Vol. II, Ch. 37. Hagerstown, MD: Harper and Row; 1976.
Butler JH, Folke LE, Bandt CL. A descriptive survey of signs and symptoms associated with the myofascial pain-dysfunction syndrome. J Am Dent Assoc 1975;90:635-9.
Kerstein RB, Farrell S. Treatment of myofascial pain-dysfunction syndrome with occlusal equilibration. J Prosthet Dent 1990;63:695-700.
Riise C, Sheikholeslam A. The influence of experimental interfering occlusal contacts on the postural activity of the anterior temporal and masseter muscles in young adults. J Oral Rehabil 1982;9:419-25.
Helsing G. Occlusal adjustment and occlusal stability. J Prosthet Dent 1978;40:438-41.
Glickman I. Clinical Periodontology. 5 th
ed. Philadelphia: WB Saunders Co.; 1979. p. 953.
Williamson EH, Lundquist DO. Anterior guidance: Its effect on electromyographic activity of the temporal and masseter muscles. J Prosthet Dent 1983;49:816-23.
Dawson PE. Evaluation, Diagnosis and Treatment of Occlusal Problems. 2 nd
ed. St Louis: CV Mosby Co.; 1988. p. 96.
Kerstein RB, Radke J. Masseter and temporalis excursive hyperactivity decreased by measured anterior guidance development. Cranio 2012;30:243-54.
[Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5], [Figure 6]
[Table 1], [Table 2], [Table 3]