PROJECT NO. 3 - A Comparison Report of a Pathological Bite vs A Well Managed Optimized Bite Using Scan 2

When using the kineseographic K7 Scan 2 opening and closing jaw tracking tests it has been often recognized on both the sagittal and frontal tracings various cross-over patterns can occur. What is the significance and meaning of these patterns? Since many in the NM arena did not adequately record what a healthy finished bite really looked like, whether in a properly managed orthosis and or FM, we at Occlusion Connections would like to perform a study. This will be titled Project 3: "A Comparison Report of a Pathological Bite vs A Well Managed Optimized Bite Using Scan 2" (this can be either a orthotic case, FM case or finished NM orthodontic case). 

 It is recognized that it is possible that cross over patterns are dependent on to what NM trajectory the final bite/occlusion was finished to. The following are various techniques and methods that have been used in determining a neuromuscular bite: 

1. Optimized Bite 
2. Chan Bite 
3. Classical NM Bite 
4. TENS bite Some NM clinicians may not know how to take an "optimized bite" neither do they fully understand this particular Scan 4/5 protocol which when comparing differences between the optimized, Chan Scan and classical NM bites it can influence the affects on the condyle/disc and mandibular jaw opening and closing paths movements relative to the final bite position. 

 The following interpretations to the meaning of the cross-over patterns on Scan 2 or 13 in the sagittal views have been the predominate views over the past 13 years: 

 Cross over in upper third means – 

• a) Cervical issues, 
• b) the highest third were C 4-8 issues (Dr. Mazzocco theory) 
• c) in the top 1/3 of your tracing is from tooth interference 

Cross over in Middle third – 

• a) Upper to middle back issues 
• b) combinations of occlusal and cervical C 1-3 issues (Dr. Mazzocco theory) 
• c) cervical cause C1-3 

Cross over in Lower third – 

• a) Lower back issues 
• b) exclusively occlusal issues (Dr, Mazzocco theory) 
• c) cervical C4-7 

Other thoughts: 

• a) crossover doesn't mean anything 
• b) crossover is always not wanted and pathologic 
• c) it might be ok. 

 ABSTRACT: 

Clinicians and researchers in NM dentistry over the years have been wondering what the crossover patterns in mandibular movement means? Many hypothesis have been formulated but lack clinical proofs, since majority of theses Scans were performed under pathological position and hardly any were evaluated under through physiological health movement. Common sense tells us that “Opening paths and closing paths on the human shouldn’t be coincident as long as there is an articular disc and condyle that translates and rotates down and forward and back!” 

Other facts that will influence this isotonic trajectory are: 

1. The condition of the condylar/disc health or unhealthy will also affect how the jaw track is displayed 
2. Influences by the existing bite/occlusion and muscle status 
3. Terminal tooth contact 
4. Postural influences 

As of to day clinical studies have only shown various patterns of unhealthy, but what do healthy patterns look like? 

PURPOSE:

The purpose of this research is to collect quality data of patients in an optimal bite position and posture and compare the before and after data. 

METHOD OF DATA COLLECTION: 

For the Project No. 3 On Line Forum Research we would need to ask the doctors for the following (minimally):

• Musculoskeletal Occlusal Signs and Symptoms Form on K7 filled out 
• Scan 2 pre treatment 
• Scan 13 pre treatment 
• Scan 2 Post treatment (Scan 7 technically is the after TENS Scan 2) 
• Scan 13 Post treatment 
• Scan 4/5 
• Pre treatment CO cheek retractor photo 
• Post treatment CO photo (whether orthotic, FM, ortho)
• Dental/skeletal classification (class I, II, III)
• Where there C1/C2 adjustments done?

K7 PROJECT NO. 2

SCAN 9 and Scan 18 BASELINE EMG Recordings of the Symptomatic Profile 

Data to be Gathered:

• Occlusal Signs Exam Form - Symptomatic Patient (Note the Chief Complaint)
• Scan 9 (Pre TENS)
• Scan 18 (Pre TENS) - Display 4 boxes
• Spectral Frequency Analysis (Graph)
• Frontal Profile Photo of Patient
• Cheek retracted view - Frontal CO 

DEFINING THE SYMPTOMATIC PATIENT using Scan 9 and Scan 18 Pre TENS
EMG patterns of symptomatic patients often come into question as to their meaning and interpretation. Baseline EMG parameters of the symptomatic patient needs to be studied to further qualify the meanings and interpretation of muscle pathology before diagnostic conclusions can be made as to the EMG pattern relevance to overall structural skelatal patterns.

We are testing a predefined group of patients who have “Signs and Symptoms" as per the Myotronics K7 software Occlusal Sign Exam Form parameters – boxes are checked off in this section indicating the presence of symptoms to define the "Symptomatic" group in this particular study.

We realize Symptomatic has a deeper definition than the patients subjective perspective and the doctors perspective who will use his/her insightful experience, trained eye, objective/subjective clinical judgment and measured tests to determine a level of symptomology.

We have already established that “asymptomatic” can be a very subjective thing. For the purposes of the previous K7 Project No. 1 study.  Working in the real world, we have decided to use identifiable patients who report SYMPTOMS to help us understand and interpret EMG recording norms. This study would like to identify the signs with the experienced symptoms.


We believe that the chance of finding patient's with signs and symptoms is high. We believe that most patients have various forms of signs and my not have subjective symptoms.  We are interested in those patients who report symptoms to help define the EMG resting patterns as well as the sustained 10 second clench patterns.

HYPOTHESIS:
Among a growing group of clinicians implementing K7 data gathering protocols there is common and well known assumptions about scan 9 and scan 18 as to their interpretation and meaning. This is the reason to further a study to further compare and define baseline parameters with the previous Asymptomatic K7 Project No. 1 study data to analyze and compare EMG patterns and trends between the asymptomatic and the symptomatic.  This will give insight as to whether there is validity in EMG interpretation of ascending or descending patterns based on mean spectral frequency analysis techniques between the two studies. Objective tests and research must be done to prove the "degree of confidence" to confirm such claims.


NULL HYPOTHESIS: No statistical difference between asymptomatic vs symptomatic patients exists.

Question(s): Are the findings between Study No. 1 and Study No. 2 to statistically validate conclusions regarding that Scan 18 and its significance.  Clinical relevance to the clinician's diagnostic and treatment decision making using such test is in question? If there is a degree of confidence in these findings, then Scan 18 as is presently advocated may be determined clinically relevant.  If no degree of confidence is found, then there may be no clinical relevance to such claims.  Protocols and parameters are being established through these studies to help establish scan 18 diagnostic interpretation can be made.

NOTE: This study at this time is purposely not following the classical Scan 18 protocol (Base line scan 18 first, followed by 45-60 minutes of ULF TENS then a second Scan 18 post TENS to evaluate the mean frequency analysis graph.

K7 PROJECT NO. 1

SCAN 18 BASELINE STUDY

• Occlusal Signs Exam Form - Symptom Free Patient ("Asymptomatic")
• Scan 9
• Scan 18 pre TENS with
• Spectral Frequency Analysis

DEFINING THE ASYMPTOMATIC PATIENT using Scan 9 and Scan 18 Pre TENS
EMG patterns of symptomatic patients often come into question as to their meaning and interpretation. Baseline EMG parameters of the asymptomatic patient needs to be studied to further qualify the meanings and interpretation of muscle pathology.

We are testing a predefined group of patients who do not have any “Symptoms" as per the Myotronics K7 software Occlusal Sign Exam Form parameters – no boxes that are checked off in this section only will define the "Asymptomatic" group in this particular study.

We realize asymptomatic has a deeper definition than the patients subjective perspective and the doctors perspective who will use his/her insightful experience, trained eye, objective/subjective clinical judgment and measured tests to determine a level of asymptomatic or symptomatic.

We have already established that “asymptomatic” can be a very subjective thing. For the purposes of this study, working in the real world, we have decided to use a simple and easily understood definition of asymptomatic. What we want to find is patients with NO SYMPTOMS to help us understand and interpret EMG recording norms. Most patient's will most likely show some signs.

We believe that the chance of finding patient's with absolutely no signs and no symptoms is almost impossible. We do not believe that a patient can be considered 100% free of all NM signs and symptoms. We do not believe there exists any who have zero tooth wear or zero intra oral or extra oral problems to the NM standards.

HYPOTHESIS:Among a growing group of clinicians implementing K7 data gathering protocols there is common and well known assumptions about scan 18 and scan 9 as to their interpretation and meaning. This is the reason to begin a study as this to further establish baseline parameters to determine whether there is any validity to interpretation of ascending or descending patterns based on mean spectral frequency analysis. Objective tests and research must be done to prove the "degree of confidence" to confirm such claims.

NULL HYPOTHESIS: No statistical difference between asymptomatic vs symptomatic patients exists.

Question(s): Are the findings in this study statistically valid to make a conclusion that Scan 18 is significant and clinically relevant to the clinician's diagnostic and treatment decision making? If this is true, then Scan 18 as is presently advocated may need further investigative study before any claims of relevance can be made to the dental profession. Further protocols and parameters must be established first before scan 18 diagnostic interpretation can be made definitely.

BACKGROUND:
"Neurophysiological studies have established that noxious stimulation results in local responses including postural and autonomic effects. Unresolved postural and anatomic responses to noxious irritation also become a further source of pain and dysfunction. Thus, with respect to the craniocervical system, the pain dysfunction processes may be classified into descending and ascending according to whether the site of pain origin is primarily in the masticatory system or outside of it."

Achieving maximum dental improvement of the craniomandibular compromised patient requires an attention to various factors including: Establishing an isotonic trajectory of mandibular closure, terminal contacts must be established on an optimal NM trajectory at a proper vertical with the discs reduced, the NM centric contacts must be balanced and simultaneous on an anatomic surface, canine rise and incisal balance in all lateral movements with no posterior interferences, all Cl. IV interferences must be eliminated, all retrusive contacts balanced and protrusive movements are incisally balanced.

There is no hope of accomplishing maximum dental improvement unless the patient is TENSed for each adjustment, green wax is used and meticulous coronoplasty technique is followed. Additionally; the cervical spine, occiput and pelvis must be balanced.

Any symptoms remaining after the this has been accomplished may then be considered not-resolvable or due to a situation beyond the dentist’s ability. In light of these clinical factors scan 18 must be reviewed and further studied to establish whether unresolved symptoms are truely ascending or descending. Establishing a clearer diagnostic picture and interpretation of EMG data will further assist in a more conservative approach to optimal care and effective treatment for the craniomandibular dysfunctional patient population.

In the original scan 18 protocol cottonrolls were never mentioned, advocated or used. Using wet cottonrolls although it sounds good, may be reasonable, but it still does not address the underlying issues whether the quality of occlusion (clench) effects the readings and interpretation of scan 18. Baseline parameters still must be determined. By using cottonrolls you would be removing the noxious inputs that stimulate muscles. Would this have a tendency to skew the data and cause it to appear better than it really is?

PROCEDURE:

This is designed to be a very simple research data gathering K7 project.

Normal healthy "asymptomatic" patient's are identified by filling out the "Occlusal Signs Exam Form of the K7 Evaluation System". Patient's with no symptoms will be determined as asymptomatic. (The Asymptomatic patient was defined in former postings as per “Chan’s K7 Project No.1- Defining Parameters of Asymptomatic” on Monday, July 27, 2009 9:59 PM on the Occlusion Connections Study Club forum).
To keep it very simple for the sake of this initial baseline study this group defined the "Asymptomatic patient group" as those who do not have the symptoms listed on the “Occlusal Signs Exam Form” on the K7 program? (“Occ Sign” icon button at top of K7 tool bar). See below.





















Baseline recordings of Scan 9 and 18 pre Myomonitor TENS will be gathered to help establish EMG baseline profiles and normality patterns. Determining what Scan 18 indicates as it relates to mean frequency spectral analysis and normal baseline states.
We will be collecting baseline data of the defined Asymptomatic patient using Scan 9 sweep EMGs monitoring the AH group and Scan 18 pre TENs.

Please fill out the “extra oral” and “intra oral signs”, with “patient name”, “date” and “age”. You will, of course, be leaving the “Chief Complaint” box empty.

NOTE: You will fill out the “Occlusal Signs Exam Form”, your asymptomatic patient will have no boxes checked in the Symptoms section.

For this K7 Project we are asking the participants to follow exactly what were the instructions in the equipment. That is Scan 9 at patient rest. No light CO (this was never in the original NM protocols). Scan 18 will be run with patient clenching in THEIR CO. No wet cottonrolls.

Scan 9 Habitual Resting EMGs is recorded before Scan 18 (sustained 10 second clench).

Facial photos as well as retracted intra oral photos with teeth together in their centric occlusion will also be gathered to confirm what an asymptomatic profile is.Calibrating the Research Group:

• In preparation of all K7 participants instrumentation, please make sure your EMGs “Muscles Set to Monitor” is set on AH not AG.
• For this up and coming study we will be following the standard duotrode placements (LTA/RTA, LMM/RMM, LCG/RCG, LDA/RDA) as per the photographs supplied by Myotronics.
• See “Images” – EMG – Placement Side view 1.

Duotrode Placement - Standard Placement Side View 1

Instructions:

K7 Participants will run 2 scans in the following manner:

Step 1: Record Scan 9 of Defined Asymptomatic Patient. Do the following;
Follow normal Scan 9 resting EMG protocols.
Make sure you are monitoring the correct muscle groups (temporalis anterior, masseter, cervical group and digastric/ suprahyoid).
F5 to Save data
Step 2: Record Scan 18 (no Myomonitor TENS) of Defined Asymptomatic Patient. Do the following;

1. Press the SPACE BAR and let the tracing sweep at least 2 second (2 boxes) and then ask the patient to bite down on his back teeth and hold it. (Patient needs to sustain the hold and not let up until 10 seconds elapses).
2. After 10 seconds of clenching (10 boxes on the screen), ask the patient to relax.
3. Let the tracings sweep for 2 seconds to record rest activity
4. Press the SPACE BAR to stop recording data.

F5 to Save
Press A to analyze the tracing. (You will need to do this before you can do the following,
Press M to display Mean Frequency graphs.

DATA TO BE GATHERED AND SUBMITTED FOR EVALUATION:

Email the following:
1) Occlusal Signs Exam Form
2) Scan 9 resting EMG data
3) Scan 18 tracing Analysis data (A) with 4 boxes displayed and
4) Mean Frequency Analysis data (M) with graphs showing up/down arrows and %.
5) Frontal face photo of Defined Asymptomatic Patient
6) Cheek retracted intra oral view of teeth at CO (Defined Asymptomatic patient).
EXAMPLE DATA TO BE SENT IN:
This is an example of the type of data all K7 Project No. 1 participants are gathering and will submit for evaluation.

The following data will be collected:

1) Occlusal Signs Exam Form













2) Scan 9 resting EMG data














3) Scan 18 tracing Analysis data (A) with 4 boxes displayed















4) Mean Frequency Analysis data (M) with graphs showing up/down arrows and %.














5) Frontal face photo of Defined Asymptomatic Patient























6) Cheek retracted intra oral view of teeth at CO















Deadline to turn in the gathered data is: August 30thLooking forward to seeing the incoming data from the NM Research Group!!!




STANDARDIZING RULES FOR ALL K7 PROJECT PARTICIPANTS TO FOLLOW during data collection procedures:
Make sure your patient has signed Consent for Treatment.

2. Make sure patient is Medication Free and its documented (it won’t be fair data if we are looking for asymptomatic/symptom free patient baselines with patients who are taking pain meds, etc. masking as pain free.
3. When taking your scan 9 and scan 18 data make sure the patient is sitting in an upright chair (not reclining dental op chairs neither standing).
4. Use normal sitting chair that the patient is correctly sitting in an upright manner.
5. Both feet should be comfortably on the floor. No crossing legs during data collection.
6. Make sure your Scan 9 is showing the correct muscles that will be monitored for this project. We will be monitoring the standard default muscle groups – LTP/RTP, LMM/RMM, LCG/RCG and LDA/RDA (AH group). We do not want you to monitor the LSM/RSM muscle group (AG).
7. Scan 9 data commands should be: “Both feet on the floor”, “hands in your lap”…. “RELAX”…..wait a few moments for patient to calm….have patient relax their eyes closed (eyes can be open for some patients who balance or brace with their teeth, I don’t tell the patient to keep their teeth apart, etc…least amount of coaching the better. I don’t want to pose the data or influence their habitual rest)… hit SPACE BAR to activate recording. Room should be quiet while taking data.
8. Scan 18 data taking protocol as per Myotronics (Kevin’s Pearls) are:

A. “Press the SPACE BAR and let the tracing sweep 2 second (2 boxes) and then ask the patient to bite down on his back teeth and hold it. It is important that the patient gives you maximum bite during the entire 10 seconds. It is helpful to instruct the patient during the clenching to keep biting something like "bite bite ..." or "harder harder ..." etc.

B. After 10 seconds of clenching, ask the patient to relax.
C. Let the tracings sweep for at least 2 seconds to record rest activity.
D. Press the SPACE BAR to stop recording data.

E-mail Data Instructions:
Please email K7 Project No.1 data as an ATTACHMENT: ( You may want to print the following for reference).


From your K7 patient screen:
Open Occlusion Sign Exam Form.
Do the following for each K7 scan as well as the Occlusal Sign Exam Form you want to email:
Use “Cntrl I” (or click on "Tools", click on "Capture Image").
Box opens and asks you where you want to save the current jpg image, fill in the required boxes:
Drive and folder Name where you want save image.
Select and Enter the folder where you want the image to go: Example - C:\K7 Email
Name you want to save image under: image.JPG
Enter the name you want to call the data, example: Baseline Study Scan 9 or Occlusal SS Form.
Compression: Choose "Low" for e-mailing
Check the box: Capture the Entire Screen
Open your Folder where you place the images (scan data) to verify if image has been imported.
Open e-mail account and attach image - Click “Insert” and click “Attach File” to send email.
Remember to attach images of:

• Occlusal Sign Exam Form
• Scan 9
• Scan 18 (Press A key, then M key to get- Mean Frequency Graph)
• Scan 18 (Press ESC to get 4 boxes of sweep analysis)
• Frontal photos of patient
• Cheek retracted view in CO

E-mail folder and images to Ramin Mehregan our data collector for this study at:
drramin.mehregan92@gmail.com

Thank you.

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