Article

The effect of the physiological rest position of the mandible on cerebral blood flow and physical balance: An observational study

Authors:
To read the full-text of this research, you can request a copy directly from the authors.

Abstract

Aims: There has been much published evidence that balance can improve by changing the mandible's position relative to the maxilla as it comes together with the teeth (or oral device) as the endpoint. To help with the complexity of this topic, a definitions table* (in Appendix) has been included at the end of the manuscript for reference as needed. The aim of the current study is to evaluate whether the physiologic rest position of the jaw* (oral device overtop of the teeth as endpoint where the muscles of mastication are optimized) can have an effect on cerebral blood flow and physical balance using measurable data relative to the person's natural, or habitual bite (teeth as endpoint) in both healthy and diseased volunteers. Methodology: Seven healthy male professional football athletes and two females with multiple sclerosis were included in this observational study, which tested the subjects in both jaw positions. Cerebral blood flow was measured non-invasively by ultrasound over the temporal region of the skull using mean flow velocity (MFV)* and pulsatility index (PI)* of the right and left middle cerebral arteries while the subject clenched the teeth together in both jaw positions. The MFV is the average speed of the blood flow in a given region of a blood vessel. The PI measures cerebral intravascular resistance. Physiologic balance of the whole body was also tested while the subjects were in both jaw positions using the y-excursion balance test* and by videotape. Results: (i) Cerebral blood flow. On the natural teeth, the MFV dropped from baseline to clenching position (mean drop -2.6±7.7 cm/second, whereas, the MFV was slightly enhanced with the physiologic rest position (PRP) [mean enhancement is 0.82±3.7 cm/second (P=0.07)]. At baseline on natural teeth, the PI dropped slightly from baseline to clenching (mean drop 0.015±0.19). Whereas with PRP, the PI dropped by mean of 0.059±0.072 (P=0.15). (ii) Balance. The mean balance measurement while using the PRP was 119.54±12.56 cm (P=0.001), whereas the mean balance measurement on natural teeth was 110.72±9.47 cm. Balance improved subjectively in both MS patients on videotape. Conclusion: The physiologic rest position of the mandible might have an effect on balance by showing a trend (demonstrating a tendency) in enhancing cerebral blood flow as measured by transcranial Doppler. Further studies are needed to confirm this study's finding.

No full-text available

Request Full-text Paper PDF

To read the full-text of this research,
you can request a copy directly from the authors.

... Dr. Bernard Jankelson created the Myomonitor (Myotronics, Seattle WA, USA), an ultra-low frequency TENS (ULF-TENS) that stimulates the trigeminal nerves bilaterally and, simultaneously, also stimulates the sympathetic and parasympathetic nerves associated with the sphenopalatine ganglion, where it sits on the maxillary division of the trigeminal nerve within the pterygopalatine fossa. Heit et al. [14] answered question three, "Does Neuromuscular Dentistry address Axis 2 (H-P-A) as simultaneously with Axis 1 treatment compared to other mechanical approaches?" in her landmark paper published in CRANIO on cerebral blood flow. Heit's paper further went to show that the neuromuscular physiologic rest position achieved by neuromuscular occlusion can maintain changes in cerebral blood flow on a long-term basis. ...
... Heit's paper further went to show that the neuromuscular physiologic rest position achieved by neuromuscular occlusion can maintain changes in cerebral blood flow on a long-term basis. Heit's work gives a definitive rationale for considering long-term occlusal changes in the treatment of TMD patients to maintain a healthy physiologic rest position [14]. ...
... This author's results differ with published reports of effects of SPG blocks on myofascial pain [14,15]. I believe this has to do with the protocol for delivering the blocks. ...
Article
Full-text available
The Sphenopalatine Ganglion (SPG) is known to play an integral role in the pathophysiology of a wide variety of orofacial pains involving the jaws, sinuses, eyes and the trigeminal autonomic cephalalgias. It supplies direct parasympathetic innervation to the trigeminal and facial nerves. Sympathetic innervation from the superior sympathetic chain passes thru the SPG to the trigeminal and facial nerves.This paper reviews relevant and significant literature on SPG Blocks and Neuromodulation published in peer reviewed medical and dental journals. Neuromuscular Dentistry employs ULF-TENS to relax musculature and simultaneously provide neuromodulation to the ganglion.Conclusion: The effects of ULF-TENS on the autonomic nervous system acts on the Limbic System and Hypothalamus (H-P-A) to address Axis II issues during neuromuscular dental procedures. It also directly affects the autonomic component of the trigeminal nerve involved in almost all headaches and migraines as well as the Myofascial and Joint disorders of TMD.
... Dr. Bernard Jankelson created the Myomonitor (Myotronics, Seattle WA, USA), an ultra-low frequency TENS (ULF-TENS) that stimulates the trigeminal nerves bilaterally and, simultaneously, also stimulates the sympathetic and parasympathetic nerves associated with the sphenopalatine ganglion, where it sits on the maxillary division of the trigeminal nerve within the pterygopalatine fossa. Heit et al. [14] answered question three, "Does Neuromuscular Dentistry address Axis 2 (H-P-A) as simultaneously with Axis 1 treatment compared to other mechanical approaches?" in her landmark paper published in CRANIO on cerebral blood flow. Heit's paper further went to show that the neuromuscular physiologic rest position achieved by neuromuscular occlusion can maintain changes in cerebral blood flow on a long-term basis. ...
... Heit's paper further went to show that the neuromuscular physiologic rest position achieved by neuromuscular occlusion can maintain changes in cerebral blood flow on a long-term basis. Heit's work gives a definitive rationale for considering long-term occlusal changes in the treatment of TMD patients to maintain a healthy physiologic rest position [14]. ...
... The immense amount of information on effectiveness did not prevent the sphenopalatine ganglion block from almost being lost. This author's results differ with published reports of effects of SPG blocks on myofascial pain [14,15]. I believe this has to do with the protocol for delivering the blocks. ...
Article
Full-text available
... The objectives of the paper were achieved by analyzing the electromyograph and the electromyographic signal, first providing a general view of it and then applying it to the sports field. The present study corroborated the usefulness of in-sports practice, as it can quantify the extent and timing of muscle activation, at rest, and during physical activities, and the way they qualitatively affect movement through joint stabilization and coordination [37][38][39]. Consequences and perspectives of the data collected influence the possibility of therapeutic choices aimed at balancing the neuromotor component, such as the use of the bite, found to be effective in 72% of cases, and in the programming of work and recovery cycles tailored to the needs of each athlete, whether for rehabilitation purposes, for the purpose of implementing sports performance or, more simply, for the prevention of muscle damage. ...
... The influence of occlusal status on stability was also demonstrated in a paper by Heit et al. who found a significant increase in balance at rest rather than at maximum intercuspation [39]. Ferrillo et al., in their systematic review, sought to determine how occlusal splints affected the spinal posture of TMD patients. ...
Article
Full-text available
Background: Cranial surface electromyography is assumed to analyze the correlation between the stomatognathic apparatus and the muscular system and its implications on the physical status of professional athletes. The purpose of this paper is to evaluate surface cranial electromyography as an aid in the diagnosis and treatment of occlusal and muscular disorders in professional athletes. Methods: A sample of 25 athletes (mean age 23 years, 20 men and 5 women) underwent electromyographic recording; among them, 13 had a sports injury condition (symptomatic athletes), while 12 were in perfect physical condition (asymptomatic athletes). At odontostomatological examination, 6 showed cranio-mandibular disorders (dysfunctional athletes), while 19 showed no disorders (functional athletes). The treatment plan to resolve the symptoms of the dysfunctional athletes was chosen based on the electromyographic data. One month after the start of therapy with an occlusal splint, a follow-up was performed, and the results were compared with the initial data. Results: Statistical analysis showed that the chosen therapy following the use of electromyography was effective in 72% of cases, while 28% of patients did not respond to therapy (p = 0.028). Conclusions: The use of cranial electromyography in competitive athletes is a valuable tool in therapeutic choice aimed at balancing occlusal loads and improving the patient's global tonic postural attitude, resulting in positive feedback in the qualitative assessment of sports performance.
... In short, different mandible positions alter the masticatory muscle pattern, which can influence cervical chains, presumably resulting in postural control changes. Recent studies investigated the effect of sub-maximum jaw clenching on postural control and found that concurrent muscle activation while clenching the jaw significantly improved postural control compared with habitual standing [9,[20][21][22]. Jaw and neck muscles co-contract at the sub-maximum bite force generated during jaw clenching to improve proprioception and balance control [20,23]. ...
... Additionally, neuroanatomical connections between the cervical and masticatory muscles can influence postural imbalances in patients with TMD [19,20]. Increasing evidence suggests a clinical improvement in TMD symptoms when the mandible is permitted to function from the mandible rest position [22,28]. Our results support the positive outcomes of some manual therapies and therapeutic exercises, such as joint mobilization and chiropractic and jaw exercises. ...
Article
Full-text available
Background There is no consensus on the association between body posture and temporomandibular disorders (TMDs). This study aimed to assess differences in static balance between healthy participants and patients with temporomandibular joint disc displacement without reduction. Material/Methods Sixteen patients with temporomandibular joint disc displacement without reduction and 14 healthy participants were included. Static balance tests were performed in the rest and “cotton rolls” (participants biting 2 cotton rolls with their upper and lower teeth) mandibular positions. The mean body’s center of gravity (COG) sway velocity was tested in each mandibular position on a firm surface with and without eyes open and on a foam surface with and without eyes open. Results The COG sway velocity did not differ between the TMD and healthy groups regarding mandibular position or testing condition (P>0.05). However, in the control group, the COG sway velocity in the mandibular rest position was significantly higher than that in the “cotton rolls” mandibular position when standing on a foam surface with the eyes closed (P=0.024). In the TMD group, there was no difference in the COG sway velocity between the 2 mandible positions under any condition (P>0.05). Conclusions This study provides new evidence for static balance alterations in patients with temporomandibular joint disc displacement without reduction. Further studies are needed to investigate postural control changes in patients with arthrogenous TMDs. This study was registered in the Chinese Clinical Trial Registry (no. ChiCTR1800018369).
... 1 Various designs of mandibular orthopedic repositioning appliances have been reported to reposition the mandible so as to increase the vertical dimension, which theoretically prevents overloading of the joint and decreases aberrant vascular and neurological signaling from the stomatognathic system. [2][3][4][5][6] This optimal positioning of the mandible enhances posture and ultimately muscular activation and performance in the rest of the body. [2][3][4][5][6] These proposed muscular and neurological benefits of mandibular repositioning have been researched in subjects with symptomatic and asymptomatic muscles and TMJ dysfunction. ...
... [2][3][4][5][6] This optimal positioning of the mandible enhances posture and ultimately muscular activation and performance in the rest of the body. [2][3][4][5][6] These proposed muscular and neurological benefits of mandibular repositioning have been researched in subjects with symptomatic and asymptomatic muscles and TMJ dysfunction. [6][7][8] However, the physiological effects of mandibular repositioning in a healthy population are still unclear. ...
Article
Full-text available
Mandibular repositioning and subsequent neuromuscular signaling are proposed mechanisms of action for commercial mouthguards marketed for performance enhancement. A prospective cross-sectional study of 24 healthy adult weightlifters with normal occlusal relationships was designed to determine whether 2 self-fit performance mouthguards; a custom-fabricated, bilaterally balanced, dual-laminated mouthguard; and no mouthguard (control) differed in their effects on vertical dimension, muscle activation, and user preference during a 75% maximum power clean lift. Each subject was tested for each of the mouthguard categories: Power Balance POWERUP, Under Armour ArmourBite, custom, and no mouthguard. Interocclusal distance was measured at baseline and with each mouthguard. Mean and peak activity of the anterior temporalis, masseter, sternocleidomastoid, and cervical paraspinal muscles was measured during sitting and during a 75% maximum power clean lift. A mouthguard preference questionnaire was completed. Analyses were conducted to determine whether interocclusal distance differed among mouthguard type and to examine the effect of mouthguard type on mean and peak muscle activation during the clean lift. Interocclusal distance was affected by mouthguard type (P = 0.01). Mean and peak activity of the anterior temporalis and masseter muscles and mean activity of the sternocleido-mastoid muscle differed among mouthguards (P < 0.05). Mouthguard type did not influence muscle activation of the cervical paraspinal muscle group. Overall, the Power Balance mouthguard produced more muscle activity. Participants preferred custom mouthguards nearly 2:1 over self-fit performance mouthguards (P = 0.05). Participants perceived that they were stronger and were less encumbered when using a custom mouth-guard during submaximum power clean lifts.
... An observational study of the effect of the mandibular resting position on cerebral circulation and physical balance was conducted by T. Heit et al. [33]. The researchers' observational study involved 9 participants, seven of whom were healthy male athletes and two were women with multiple sclerosis. ...
Article
Full-text available
This study was conducted to determine the effectiveness of orthodontic appliances in improving cerebral circulation. The 24 participants of the study underwent a rheoencephalographic examination before and during the use of mouth guards. Its results analysed the changes in blood filling and blood flow in the brain vessels and evaluated the dynamics of treatment. According to the results of the study, insignificant, and slight positive treatment dynamics were detected in 58.33% of the subjects, no negative dynamics were detected, and no significant changes were recorded in 41.67% of the participants. This effect of orthodontic appliances on improving cerebral circulation is explained by the fact that by alleviating the symptoms of craniomandibular dysfunction, they affect the balance of the centre of gravity of the skull, reduce tension and spasm in the neck muscles, and protect the joints from mechanical irritation, which helps to reduce vascular tone and improves blood filling and blood flow in the masticatory muscles and jaw joint. The blood filling of the chewing muscles and jaw joint has no direct connection with the blood filling of the brain vessels, as these structures are supplied from different arteries, However, a decrease in vascular tone in the craniomandibular system and in the muscle bed of the cervical spine can affect blood pressure reduction and venous outflow in the jaw joint, which will indirectly improve cerebral circulation. The obtained results indicate that orthodontic problems can be factors of deterioration of blood filling and blood flow in the vessels of the brain, so the use of mouth guards is an effective method that should be used in the complex treatment of patients with cerebral circulation disorders
... This connection between optimal jaw development, position, and optimal function has been demonstrated in adults clinically in several single case studies and small cohorts by dentists [35,[47][48][49][50] based on basic anatomy and physiology [20,51]. ...
Article
Full-text available
Obstructive sleep apnea (OSA) is a clinical disorder within the spectrum of sleep-related breathing disorders (SRDB) which is used to describe abnormal breathing during sleep resulting in gas exchange abnormalities and/or sleep disruption. OSA is a highly prevalent disorder with associated sequelae across multiple physical domains, overlapping with other chronic diseases, affecting development in children as well as increased health care utilization. More precise and personalized approaches are required to treat the complex constellation of symptoms with its associated comorbidities since not all children are cured by surgery (removal of the adenoids and tonsils). Given that dentists manage the teeth throughout the lifespan and have an important understanding of the anatomy and physiology involved with the airway from a dental perspective, it seems reasonable that better understanding and management from their field will give the opportunity to provide better integrated and optimized outcomes for children affected by OSA. With the emergence of therapies such as mandibular advancement devices and maxillary expansion, etc., dentists can be involved in providing care for OSA along with sleep medicine doctors. Furthermore, the evolving role of myofunctional therapy may also be indicated as adjunctive therapy in the management of children with OSA. The objective of this article is to discuss the important role of dentists and the collaborative approach between dentists, allied dental professionals such as myofunctional therapists, and sleep medicine specialists for identifying and managing children with OSA. Prevention and anticipatory guidance will also be addressed.
... When moving into a supine rest position, the mandible tends to rotate in a counterclockwise direction, with the center of rotation close to the incisors [61] . Heit et al. (20) [62] investigated the effect of the physiological rest position of the mandible on cerebral blood flow and physical balance. He concluded that the physiologic rest position of the mandible might have an effect on balance by showing a trend in enhancing cerebral blood flow as measured by transcranial Doppler. ...
Article
Full-text available
Physiologic rest position of the mandible is an important parameter to be considered in the fabrication of a complete denture as well as in a case of full mouth rehabilitation. Violation of the rest position would lead to detrimental effects on the facial musculature and the temporomandibular joint. This article reviews the various concepts pertaining to the rest position of mandible and its clinical implication.
... When moving into a supine rest position, the mandible tends to rotate in a counterclockwise direction, with the center of rotation close to the incisors [61] . Heit et al. (20) [62] investigated the effect of the physiological rest position of the mandible on cerebral blood flow and physical balance. He concluded that the physiologic rest position of the mandible might have an effect on balance by showing a trend in enhancing cerebral blood flow as measured by transcranial Doppler. ...
Article
Physiologic rest position of the mandible is an important parameter to be considered in the fabrication of a complete denture as well as in a case of full mouth rehabilitation. Violation of the rest position would lead to detrimental effects on the facial musculature and the temporomandibular joint. This article reviews the various concepts pertaining to the rest position of mandible and its clinical implication.
... When moving into a supine rest position, the mandible tends to rotate in a counterclockwise direction, with the center of rotation close to the incisors [61] . Heit et al. (20) [62] investigated the effect of the physiological rest position of the mandible on cerebral blood flow and physical balance. He concluded that the physiologic rest position of the mandible might have an effect on balance by showing a trend in enhancing cerebral blood flow as measured by transcranial Doppler. ...
Article
Physiologic rest position of the mandible is an important parameter to be considered in the fabrication of a complete denture as well as in a case of full mouth rehabilitation. Violation of the rest position would lead to detrimental effects on the facial musculature and the temporomandibular joint. This article reviews the various concepts pertaining to the rest position of mandible and its clinical implication.
... Our results indicated that dental occlusion differentially contributed to the dynamic stability, with an improvement when dental occlusion was set in CR disregarding the dominant and non-dominant lower limb (p < 0.001) (Figure 2). These findings are fairly consistent with the research of Heit et al. (2015) who observed a significant improvement (p < 0.001) in balance measured with the MSEBT when the mandible of the subjects were placed in a physiological rest position comparing with measurements made in ICP. The improvement in the SEBT score in the CR position supports the hypothesis of a relationship between balance ability and the stomatognathic system. ...
Article
Full-text available
Excellent postural control is essential to improve the physical performance of athletes. Stability of the body during motor tasks depends on different physiological systems. The influence of dental occlusion on body balance has been widely investigated in the past few years. It has been suggested that this relationship is strengthened by disturbing environments for balance control (i.e., unstable platform, fatigue, development tasks.). Moreover, dental occlusion may influence the muscle tone of both masticatory and postural muscles, which are involved in the preservation of balance. Therefore, we attempted to determine whether (i) there are differences in dynamic balance assessed by the modified star excursion balance test between opposed dental occlusion conditions (dental contact: intercuspal position/no dental contact: cotton rolls mandibular position) and (ii) dental occlusion influences the biomechanical and viscoelastic properties of the masticatory and postural muscles assessed with MyotonPRO®. Thirty physically active subjects were recruited for the study. The main findings were the following: (i) the Star Excursion Balance Test composite score was significantly higher for measurements made in cotton rolls mandibular position (p < 0.001) and also in subjects showing a correct occlusion (p = 0.04), and (ii) the biomechanic and viscolelastic properties of selected muscles showed different trend according to the presence of malocclusal traits. It is concluded that dental occlusion conditioned both dynamic stability and the biomechanic and viscoelastic properties of the analyzed muscles.
... Earlier literature supports the concept of bruxism as an auxiliary booster of cognitive abilities and lateralized mastication, good occlusion, and adequate rest position; and locally focused brain blood circulation have been found to correlate [20,[45][46][47]. Pollack and Cwik [48] have reported that cerebellar hemorrhage was followed by bruxism in a person who was not recognized as a bruxist in his or her earlier life. ...
Article
Objective: The aim of this study is to explore the relationships between early dental wear patterns and preschool IQ (Intelligence Quotient, by Stanford-Binet) of the child to illuminate the historic relationship of mental queries and bruxism. Methods: The dental study participants were 864 Euro-American preschool and school children whose IQs were tested for school maturity purposes at the age of 4 years, followed by dental data in a cross-sectional manner at the mean age of 7.8 years. Worn dentitions were classified as "symmetric" or "right-" and "left-sided," based on the faceting of the teeth. Results: In general, the relationships of tooth wear and intelligence were scarce, reflecting social background factors. Statistically significant results between asymmetric wear and gender groups suggest that direction of jaw function has a role in the regulation of processes responsible for individual mental performance in childhood. Discussion: Increased left-side tooth wear and early advantage in the intelligence test in girls is intriguing due to the fact that they reach maturity earlier than boys in verbal articulation, controlled in most cases by the limited area on the left side of the brain.
... Du fait de la complexité du processus de réaction (intervention de différentes aires cérébrales (cortex occipital, cortex inférotemporal, cortex moteur, etc.) et des nombreux paramètres l'influençant (âge, sexe, fatigue, latéralité (gaucher ou droitier), entraînement, etc.), seules des hypothèses peuvent être émises concernant le lien entre le port d'un protège-dents de performance et l'amélioration du temps de réaction. Selon certains auteurs, c'est la levée des tensions au niveau de l'ATM qui entraîne une meilleure irrigation sanguine, une meilleure oxygénation et une meilleure conduction nerveuse au niveau du cerveau [59,60]. L'amélioration du débit sanguin concerne des zones du cortex (associées à la mémoire, à l'attention et à la vigilance) et du cervelet (associées au contrôle moteur, à l'attention, à la peur et à la synchronisation) [17]. ...
Article
Full-text available
Introduction: Since their appearance in the 1890s, mouthguards have been the subject of numerous research studies. Based on the results of these studies, the use of mouthguard is recommended for the prevention of orofacial lesions in some sports. Since the mid-1960, a new type of mouthguard appeared: the performance mouthguard. According to its manufacturers and creators, this appliance particularly enables to improve endurance, strength, muscular power, reaction time, precision of movements, recovery capacity, range of motion, concentration and proprioception, and to decrease fatigue and stress. Literature review: A review of 50 years of medical research on performance mouthguards shows contradictory results. This reflects the inhomogeneity of studies which focus on different mouthguards, parameters recorded, muscular groups and sports. Conclusion: At the moment, the enhancement of performance by using a mouthguard is an assumption. However, the latest blinded controlled clinical trials tend to validate this assumption. Harmonization of research protocols would allow this assumption to become evidence.
... The physiological rest position is thus determined by measurable and repeatable data. 12 Upper and lower polyvinylsiloxane impressions were also obtained. The upper model was then mounted using the hammular notch-incisive papilla plane method on a Stratos articulator (Ivoclar-Vivadent, Amherst, NY, USA), and the lower model was mounted relative to the upper model, using the bite registration captured in the physiological rest position. ...
Research
Full-text available
Journal of Craniomandibular & Sleep Practice 34(1), 6-12, 2016
... LDF is a useful tool for examining changes in microvascular blood flow, which may be affected by many factors, including temperature, pulse, blood pressure, and the physical position of the patient. [34][35][36] The effects of these factors on the LDF measurements could not be determined; the patients had similar temperature, pulse, and blood pressure values because of the strict inclusion criteria. Furthermore, the same dental unit with the same seating position was used for all patients. ...
Article
Full-text available
Background: This study evaluated the effects of ozone therapy (OT) on the early healing period of de-epitheliazed gingival grafts(DGG) placed for non-root coverage gingival augmentation by laser Doppler flowmetry (LDF). Methods: Thirty three patients were assigned to one of the study groups: test groups: DGG + OT; control group: DGG alone and 30 completed the study. Ozone was applied on DGGs placed in the recipient bed and donor site immediately after surgery, and at 1 and 3 days post-surgery. Blood perfusion in the recipient site was measured by LDF on the day of surgery and at 1,2,3,6,8,10 and 13 days following surgery. Quality of life by using OHIP-14 and pain at the donor/recipient sites by using Visual Analog Scale(VAS) were also investigated. Results: The increase in blood perfusion units in the test group was significantly higher than that in the control group on 1, 2, 3, 6 and 8 days post-surgery(p<0.001). Significant differences occurred between the test and control groups in terms of the VAS values during the first week post-surgery both for donor and recipient sites(p<0.05). The ozone treated group showed significantly higher quality of life than the control group on post-operative day 6 (p=0.002). Conclusion: Ozone therapy enhanced blood perfusion units in the first post-operative week. This outcome is also consistent with improvement in wound healing accompanied by an increase in quality of life and decrease in post-operative pain in the test group.
... The physiological rest position is thus determined by measurable and repeatable data. 12 Upper and lower polyvinylsiloxane impressions were also obtained. The upper model was then mounted using the hammular notch-incisive papilla plane method on a Stratos articulator (Ivoclar-Vivadent, Amherst, NY, USA), and the lower model was mounted relative to the upper model, using the bite registration captured in the physiological rest position. ...
Article
Full-text available
Objective: In this study, the authors investigated 3D changes in nasal volume, to test the hypothesis that nasal cavity volume can be changed in adults. Methods: After obtaining informed consent, the authors undertook 3D cone-beam computerized axial tomographic (CBCT) scans of 11 consecutive adults (mean age: 37·9 years), before and after biomimetic oral appliance therapy (BOAT). The mean treatment time was 18·4±2·5 months. Volumetric reconstruction of the nasal cavity was undertaken, and the nasal volume was calculated in all cases. The findings were subjected to statistical analysis, using paired t-tests. Results: The mean nasal cavity volume was 41·9±12·0 cm(3) before treatment. After BOAT, the mean volume increased to 44·0±12·7 cm(3) (P = 0·022). Conclusions: These data support the notion that nasal cavity volume can be changed in adults. Use of BOAT might improve continuous positive airway pressure (CPAP) compliance in adults diagnosed with obstructive sleep apnea (OSA), by increasing the nasal cavity volume and decreasing nasal airflow resistance.
Chapter
This chapter delves into the crucial stomatognathic function of deglutition. By employing electromyography and mandibular scanning techniques, we can effectively identify various tongue dysfunctions that are of particular interest in the field of orthodontics. The author puts forth a hypothesis on primary and secondary tongue thrust, shedding light on this important aspect of the subject. It is imperative to note that an ideal dental occlusion cannot be achieved without an optimal swallow pattern. As such, identifying the correlation between tongue function and malocclusion is a crucial step in the diagnosis of neuromuscular orthodontic conditions. By exploring this link, we can gain a deeper understanding of the underlying factors contributing to the development of malocclusion and develop more effective treatment strategies. Continued exploration and investigation into the subject of deglutition and its relationship with orthodontic conditions is essential for advancing the field and improving patient outcomes.
Chapter
Athletes are constantly trying to get an “edge” on competition. As seen in the last chapter, they will turn to dangerous drugs to get such an edge over their competitors to include steroids and doping which are used to improve performance. Dentistry may have a non-pharmacologic solution to this issue. This chapter will review the history and the future of such appliances and discuss their promise and possibilities.
Article
Full-text available
The relationship between migraine headaches and craniofacial architecture remains tenuous. Indeed, there is a lack of evidence linking migraines to orthodontic status. However, this case report may be one of the first to document the effect of a biomimetic, orthodontic appliance eliminating symptoms associated with migraine headaches.
Article
Full-text available
The treatment of stroke remains a challenge. Animal studies showing that electrical stimulation of the sphenopalatine ganglion (SPG) exerts beneficial effects in the treatment of stroke have led to the initiation of clinical studies. However, the detailed effects of SPG stimulation on the injured brain are not known. The effect of acute SPG stimulation was studied by direct vascular imaging, fluorescent angiography and laser Doppler flowmetry in the sensory motor cortex of the anaesthetized rat. Focal cerebral ischemia was induced by the rose bengal (RB) photothrombosis method. In chronic experiments, SPG stimulation, starting 15 min or 24 h after photothrombosis, was given for 3 h per day on four consecutive days. Structural damage was assessed using histological and immunohistochemical methods. Cortical functions were assessed by quantitative analysis of epidural electro-corticographic (ECoG) activity continuously recorded in behaving animals. Stimulation induced intensity- and duration-dependent vasodilation and increased cerebral blood flow in both healthy and photothrombotic brains. In SPG-stimulated rats both blood brain-barrier (BBB) opening, pathological brain activity and lesion volume were attenuated compared to untreated stroke animals, with no apparent difference in the glial response surrounding the necrotic lesion. SPG-stimulation in rats induces vasodilation of cortical arterioles, partial reperfusion of the ischemic lesion, and normalization of brain functions with reduced BBB dysfunction and stroke volume. These findings support the potential therapeutic effect of SPG stimulation in focal cerebral ischemia even when applied 24 h after stroke onset and thus may extend the therapeutic window of currently administered stroke medications.
Article
Full-text available
Although upper extremity (UE) closed kinetic chain (CKC) exercises have become commonplace in most rehabilitation programs, a clinically meaningful UE CKC functional test of unilateral ability has continued to be elusive. To examine reliability of the Upper Quarter Y-Balance Test (UQYBT), evaluate the effects of arm dominance on UQYBT performance, and to determine how the UQYBT is related to specific components of the test (trunk rotation, core stability and UE function and performance) in a college-aged population. A sample of healthy college students performed the UQYBT and a series of 6 additional dynamic tests designed to assess trunk rotation, core stability, and UE performance. The relationship of these tests compared to the UQYBT was assessed. The effect of upper limb dominance for the UQYBT was also explored. Finally, test re-test reliability was established for the UQYBT. Thirty subjects (24 males, 6 females, mean ages 19.5 6 1.2 and 18.8 6 0.8 years) were assessed during the study. The test re-test reliability was excellent for UQYBT measurements (intraclass correlation coefficient > 0.9). A significant (p <0.05) fair to moderate association was observed between the UQYBT and several core stability and UE functional tests. There was no significant difference in UQYBT performance between dominant and non-dominant limbs. The UQYBT is a reliable UE CKC test that can be used to assess unilateral UE function in a closed chain manner. The UQYBT appears to be most related to dynamic tests involving core stability and UE performance. Similarity on the UQYBT between dominant and non-dominant limbs indicates that performance on this test using a non-injured UE may serve as a reasonable measure for "normal" when testing an injured UE. Future research is needed to determine the clinical applicability of the UQYBT. 2b.
Article
Full-text available
The inclusion of movement tests before performance training and sport participation is gaining popularity as part of musculoskeletal screening for injury. The identification of an athlete's asymmetries and poor performance in the preseason allows coaches and sports medicine clinicians the opportunity to proactively address these deficits to reduce the potential for injury. Currently, there are no tests reported in the literature that simultaneously require shoulder and core stability while taking the subjects through a large range of motion at the end range of their stability. Thus, the purpose of this article was to describe the Upper Quarter Y Balance Test and report the gender differences in the performance of the test. Upper extremity reach distances were measured in 95 active adults using a standardized upper extremity balance-and-reach protocol. Intraclass correlation coefficients were used to assess reliability, and gender differences were analyzed using an independent samples t-test, whereas bilateral differences were analyzed using a dependent samples t-test for the normalized composite reach scores. Intraclass correlation coefficient (3.1) for test-retest reliability ranged from 0.80 to 0.99. Intraclass correlation coefficient (3.1) for interrater reliability was 1.00. Average composite scores (right/left) reported as a percentage of limb length were 81.7/82.3% for men and 80.7/80.7% for women. The results of the study suggest that the Upper Quarter Y Balance Test is a reliable test for measuring upper extremity reach distance while in a closed-chain position. It was further determined that there was no significant difference in performance between genders or between sides on the test when normalized to limb length. Coaches and sports medicine professionals may consider incorporating the Upper Quarter Y Balance Test as part of their preprogram testing to identify movement limitations and asymmetries in athletes and thereby may reduce injury.
Article
Full-text available
A shortened dental arch without posterior occlusal support has been thought to maintain sufficient oral function. The mechanism of occlusal adaptation with a shortened dental arch is unclear. For a better understanding of the effects of molar teeth on brain function, the authors combined experimentally-shortened dental arches and a neuro-imaging technique. Regional cerebral blood volume was measured using near-infrared optical topography during maximum voluntary clenching tasks from 10 subjects on individually fabricated oral appliances, which can create experimentally complete and shortened dental arches. Results suggested that clenching on the complete dental arch showed a significantly higher brain blood volume than that on the shortened dental arch. Moreover, there were no differences between the two splints in the latency to the maximum oxyhemoglobin concentration. These findings suggest that occlusal status is closely related to brain blood flow and lack of occlusal molar support rapidly reduces cerebral blood volume in the maximum voluntary clenching condition.
Article
Full-text available
The relationship between the cranial, cervical, and hyoid regions can be modified by removable orthopedic appliances installed by the dentist and by manual orthopedic techniques applied to the cervical spine by the physical therapist. However, each of these disciplines evaluates and treats according to the patient's symptoms and various objective criteria that are primarily limited to that field.The author suggests that these two approaches to normalizing those relationships must be coordinated. He presents an objective method of evaluating x-rays to determine the impact of both disciplines, and suggests that this can help determine the normal biomechanical relationship of these structures.He also discusses the importance of the following points as they relate to this method: 1. The position of the hyoid bone in determining the appropriate curvature of the cervical spine.2. The distance between the occiput and the atlas and its relevance to the headache syndrome.3. The angular relationship of the cranium and the cervical spine.
Article
Full-text available
The objective of this study was to evaluate the yield of emergent transcranial Doppler (TCD) for the evaluation of acute cerebral ischemia. We performed urgent bedside non-contrast-enhanced TCD in patients with acute cerebral ischemia before or immediately after baseline CT scanning. A fast-track scanning protocol (</=15 minutes) and detailed diagnostic criteria were developed for portable single-channel TCD testing. TCD results were compared with angiography. Of 130 consecutive patients studied, 36 were eligible for thrombolytic therapy; 46 with ischemic strokes and 48 with transient ischemic attacks were not eligible for thrombolysis. TCD identified occlusions in 69% of thrombolysis-eligible patients, compared with 24% and 0% of patients with strokes and transient ischemic attacks, respectively, not eligible for thrombolysis (P<0.01). Stenosis was present in 17%, 33%, and 35%, and normal vessels were found in 14%, 43%, and 65% in the respective patient subgroups. TCD also identified abnormal pulsatility of flow (12 patients), abnormal flow velocities (12), microembolic signals (5), or early recanalization (5) (34 of 130; 26%). In 65% of all patients, TCD was compared with angiography (digital subtraction angiography, MR angiography, or CT angiography). Despite a 15% rate of absent temporal windows, TCD had 88% accuracy for abnormal (occlusion and stenosis) versus normal vessels: sensitivity 87.5%, specificity 88.6%, positive predictive value 87. 5%, and negative predictive value 88.6%. A proximal occlusion on TCD was found in 69% of thrombolysis-eligible patients. In 26% of all patients, TCD provided further relevant information that, in addition to angiography, helped to refine the severity of a stenosis and determine stroke pathogenesis. Emergent TCD is both sensitive and specific in determining arterial occlusion and stenosis in acute cerebral ischemia.
Article
Full-text available
There is a growing interest in the relationship between occlusion and posture because of a greater incidence of neck and trunk pain in patients with occlusal dysfunction. The study was designed to verify whether an alteration of the spinal column alignment may be experimentally induced in rats as a consequence of altering dental occlusion and also to investigate whether the spinal column underwent any further changes when normal occlusion was then restored. Thirty rats were divided into two groups. Fifteen (15) rats (test group) wore an occlusal bite pad made of composite resin on the maxillary right first molar for a week (T1). The same rats wore a second composite bite pad for another week on the left first molar in order to rebalance dental occlusion (T2). Fifteen rats were included in an untreated control group. All the rats underwent total body radiographs at T0 (before the occlusal pad was placed), at T1 (one week after application of a resin occlusal bite pad on the maxillary left first molar) and at T2 (one week after application of a second resin occlusal bite pad on the maxillary right first molar). A scoliotic curve developed in all the test rats at T1. There were no alterations of spinal position observed in any of the control rats. Additionally, the spinal column returned to normal condition in 83% of the test rats when the balance in occlusal function was restored. The alignment of the spinal column seemed to be influenced by the dental occlusion.
Article
Full-text available
Upper airway imaging techniques can be useful to identify the exact location and nature of the obstruction in obstructive sleep apnea (OSA) patients. Ten OSA patients and 10 non-OSA control subjects were imaged using cone-beam computed tomography (NewTom QR-DVT9000) to compare their upper airway structure. The OSA subjects presented higher BMI (OSA: 29.5 +/- 9.05 kg/m(2); non-OSA: 23.1 +/- 3.05 kg/m(2) [P = .034]), lower total volume (mm(3)) of the airway (OSA: 4868.4 +/- 1863.9; non-OSA: 6051.7 +/- 1756.4 [P = .054]), statistically significantly smaller anterior-posterior dimension (mm) of the minimum cross-section segment (OSA: 4.6 +/- 1.2; non-OSA: 7.8 +/- 3.31 [P = .009]), and smaller minimum cross-section area (OSA: 45.8+/-17.5 mm(2); non-OSA: 146.9 +/- 111.7 mm(2) [P = .011]) positioned below the occlusal plane in 70% of the cases (OSA:7 out of 10; non-OSA: 5 out of 10 [P = .030]). The OSA group presented a concave or elliptic shaped airway and the non-OSA group presented a concave, round, or square shaped airway.
Article
Full-text available
The influence between dental occlusion and body posture has been discussed in the past ten years by several authors with controversial conclusions. The objective of this study was to access, using surface electromyography (EMG), the rest activity of paired sternocleidomastoids, erectors spinae at L4 level, and soleus muscles in a group of 24 volunteer subjects (12 males, 12 females, aged 23-25 yrs) affected by sub-clinical dental malocclusions in different situations of dental occlusion. The subjects' occlusion was balanced (neuromuscularly) (registered on an acrylic wafer). Rest activity was assessed using the sEMG. The measurements were achieved on subjects while standing barefooted, before (Test 1), and 15 minutes after they wore the acrylic wafer (Test 2). The result was a significant reduction of the mean voltage for each muscle. Paired muscles were registered and the balancing rate between right and left muscles showed improvement for all the paired muscles (Wilcoxon test p < 0.05). No significant difference was noted in the relaxation and balancing rates between the muscles tested. The data confirmed a beneficial effect of balancing the occlusion with an acrylic wafer on the following paired postural muscles: sternocleidomostoid, erector spinae, and soleus.
Article
Full-text available
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.
Article
The purpose of this pilot study was to identify, measure and document an effect on the subjective multiple sclerosis symptoms and compare it to any objective data changes in the neuromuscular system of the head and neck, following the correction of the jaw position using a neuromuscular orthotic. The hope is to provide clinical evidence of improvement in the disease long-term without relying on the subjective evidence of remissions and exacerbations reported by the patient. The evidence found in the current pilot study measured improvement of head position, jaw position, jaw function, and airway in the neuromuscular bite position, which correlated with the improvement of subjective symptoms of craniomandibular dysfunction and multiple sclerosis. Studies show that the bite affects blood flow in the brain, which may explain the improvement of the patients in the current study.
Article
The sphenopalatine ganglion (SPG) neurons represent the parasympathetic branch of the autonomic nervous system involved in controlling cerebral blood flow. In the present study, we examined the coupling mechanism between mu (mu) opioid receptors (MOR) and muscarinic acetylcholine receptors (mAChR) with Ca(2+) channels in acutely dissociated adult rat SPG neurons. Successful MOR activation was recorded in approximately 40-45% of SPG neurons employing the whole cell variant of the patch-clamp technique. In addition, immunofluorescence assays indicated that MOR are not expressed in all SPG neurons while M(2) mAChR staining was evident in all neurons. The concentration-response relationships generated with morphine and [d-Ala2-N-Me-Phe4-Glycol5]-enkephalin (DAMGO) showed IC(50) values of 15.2 and 56.1 nM and maximal Ca(2+) current inhibition of 26.0 and 38.7%, respectively. Activation of MOR or M(2) mAChR with morphine or oxotremorine-methiodide (Oxo-M), respectively, resulted in voltage-dependent inhibition of Ca(2+) currents via coupling with Galpha(i/o) protein subunits. The acute prolonged exposure (10 min) of neurons to morphine or Oxo-M led to the homologous desensitization of MOR and M(2) mAChR, respectively. The prolonged stimulation of M(2) mAChR with Oxo-M resulted in heterologous desensitization of morphine-mediated Ca(2+) current inhibition, and was sensitive to the M(2) mAChR blocker methoctramine. On the other hand, when the neurons were exposed to morphine or DAMGO for 10 min, heterologous desensitization of M(2) mAChR was not observed. These results suggest that in rat SPG neurons activation of M(2) mAChR likely modulates opioid transmission in the brain vasculature to adequately maintain cerebral blood flow.
Article
Using functional magnetic resonance imaging (fMRI) in eight healthy human subjects, the present study measured blood oxygenation level-dependent (BOLD) signals during clenching in a malocclusion model, using a custom-made splint that forced the mandible to a retrusive position and a splint of no modification for control, and compared the results to the BOLD signals during the corresponding resting conditions. An individual visual analog scale (VAS) score was also examined during clenching to evaluate the interactions between fMRI data and psychiatric changes. During both clenchings, activations in four brain regions (premotor cortex, prefrontal cortex, sensorimotor cortex, and insula) were seen. However, clenching in the malocclusion model, with psychological discomfort, increased additionally BOLD signals in the anterior cingulate cortex and the amygdala. Furthermore, there was a parallel relationship between BOLD signal intensities and VAS scores in these two regions. The findings may suggest the involvement of clenching with malocclusal conditions in the emotion and/or pain-related neural processing in the brain.
Article
Blood flow velocity in the basal intracranial arteries can be reliably recorded using transcranial Doppler (TCD) ultrasonography. The utility of Doppler ultrasound in detecting stenosis of arteries has therefore been extended to include the intracranial basal arteries. This has been useful in detecting intracranial stenosis from a variety of causes including atherosclerosis and vasospasm induced by subarachnoid hemorrhage. Changes in cerebral hemodynamics during significantly increased intracranial pressure have also been detected, and have been useful in warning of compromise of the cerebral circulation in head injury. The assessment of the final hemodynamic effects of occlusive disease on the middle cerebral artery can be studied using the CO2 reactivity test. This offers additional diagnostic information in these patients. The direct detection of intracranial microemboli using TCD is also now possible and this has implications in the management of patients with stroke and transient ischemic attacks. Continuous monitoring of the middle cerebral artery velocity has been useful in indicating relative blood flow changes through this artery under certain specific circumstances. By providing continuous information on relative blood flow changes, the dynamics of the cerebral circulation can be studied in more detail. This has allowed the assessment of cerebral autoregulation, as well as blood flow changes, due to changes in cortical activity induced by visual stimulation. Further research on the dynamics of the human cerebral circulation will be possible using this technology.
Article
There are over 50 treatable conditions that can produce signs and symptoms of fatigue, weakness, sensory complaints, or muscle atrophy [Table 3]. The examiner should be able easily to identify, by history and physical examination, the affected site of the motor unit causing the patient's syndrome. Following this, by using other aspects of the history and physical examination, the clinician can decide which are treatable disorders by appropriate selection of the laboratory studies. Thus, any patient who complains of neuromuscular symptoms can be approached as if he had a potentially treatable disorder and not merely as a diagnostic curiosity.
Article
We compared relative changes in middle cerebral artery velocity and internal carotid artery flow during autoregulation testing to test the validity of using transcranial Doppler recordings of middle cerebral artery velocity to evaluate cerebral autoregulation in humans. Seven human volunteers had dynamic autoregulation tested during surgical procedures that included exposure of the internal carotid artery. The mean arterial blood pressure and middle cerebral artery velocity spectral outline (Vmax), using transcranial Doppler, and ipsilateral internal carotid artery flow, using an electromagnetic flowmeter, were continuously and simultaneously recorded during transient sharp decreases in blood pressure that were induced by rapid deflation of thigh blood pressure cuffs. The resulting responses of velocity in the middle cerebral artery and flow in the internal carotid artery were compared. Moderate decreases in blood pressure evoked responses in cerebral autoregulation. There were no significant (P = .97) differences between the responses in middle cerebral artery velocity and internal carotid artery flow to the blood pressure decreases. Relative changes in Vmax accurately reflect relative changes in internal carotid artery flow during dynamic autoregulation testing in humans. Therefore, alterations in middle cerebral artery diameter do not occur to the extent that they introduce a significant error in making these comparisons.
Article
The duration of cerebral blood flow impairment correlates with irreversibility of brain damage in animal models of cerebral ischemia. Our aim was to correlate clinical recovery from stroke with the timing of arterial recanalization after therapy with intravenous tissue plasminogen activator (tPA). Patients with symptoms of cerebral ischemia were treated with 0.9 mg/kg tPA IV within 3 hours after stroke onset (standard protocol) or with 0.6 mg/kg at 3 to 6 hours (an experimental institutional review board-approved protocol). National Institutes of Health Stroke Scale (NIHSS) scores were obtained before treatment, at the end of tPA infusion, and at 24 hours; Rankin Scores were obtained at long-term follow-up. Transcranial Doppler (TCD) was used to locate arterial occlusion before tPA and to monitor recanalization (Marc head frame, Spencer Technologies; Multigon 500M, DWL MultiDop-T). Recanalization on TCD was determined according to previously developed criteria. Forty patients were studied (age 70+/-16 years, baseline NIHSS score 18.6+/-6.2). A tPA bolus was administered at 132+/-54 minutes from symptom onset. Recanalization on TCD was found at the mean time of 251+/-171 minutes after stroke onset: complete recanalization occurred in 12 (30%) patients and partial recanalization occurred in 16 (40%) patients (maximum observation time 360 minutes). Recanalization occurred within 60 minutes of tPA bolus in 75% of patients who recanalized. The timing of recanalization inversely correlated with early improvement in the NIHSS scores within the next hour (polynomial curve, third order r(2)=0.429, P<0.01) as well as at 24 hours. Complete recanalization was common in patients who had follow-up Rankin Scores if 0 to 1 (P=0.006). No patients had early complete recovery if an occlusion persisted for >300 minutes. The timing of arterial recanalization after tPA therapy as determined with TCD correlates with clinical recovery from stroke and demonstrates a 300-minute window to achieve early complete recovery. These data parallel findings in animal models of cerebral ischemia and confirm the relevance of these models in the prediction of response to reperfusion therapy.
Article
Many practitioners will recognize that subjects with a large mandibular plane inclination are characterized by an extended head posture and a forward inclined cervical column, i.e. an extended cranio-cervical posture. It is also typical that subjects with a short-face morphology often carry their heads somewhat lowered, and have a markedly backward-curved upper cervical spine, i.e. cervical lordosis. The aim of the paper is to link together the findings of a series of studies that attempt to clarify this relationship, and bring into focus cranio-cervical posture, which is a functional factor that seems to be involved in many clinical orthodontic problems. To provide a background for the article, the concept of standardized posture of the head and the cervical column is developed, and procedures for recording this posture, as well as categories of cephalometric variables that express the different postural relationships, are described. Findings that relate cranio-cervical posture to upper airway obstruction, to craniofacial morphology, and to malocclusion are surveyed, and a post-natal developmental mechanism that explains the findings and leads to further questions is discussed. Recent findings of a relationship between extended cranio-cervical posture and signs and symptoms of temporomandibular disorders further emphasize the biological importance of this functional parameter.
Scientific rationale for biomedical instrumentation. Neuromuscular Dentistry The Next Millennium, ICCMO Anthology Volume V: 11-30
  • B C Cooper
TMD-an upper quarter condition. Neuromuscular Dentistry The Next Millennium
  • L Tilley
  • D M Hickman
The dental physician
  • A C Fonder
Clinical technique for determining appropriate orthopaedic-orthodontic mechanics as verified by the quint-sectograph, K6-1 mandibular kinesiograph, and advanced Sassouni analysis: a case report
  • G Bixby
How to stabilize the TMJ prior to treatment
  • Bhm Rondeau
Physiological optimal and critical limits
  • N A Miller
  • J H Stillman
Complete postural evaluation of CMD/TMD patients. The Application of the Principals of Neuromuscular Dentistry to Clinical Practice Anthology
  • I Bergamini
Optimizing the neuromuscular trajectory - A key to stabilizing the occlusal-cervical posture. ICCMO Anthology. An Application of the Principals of Neuromuscular Dentistry to Clinical Practice
  • C A Chan
Timing of recanalization after tissue plasminogenactivalor therapy determined by TCD correlates with clinical recovery from ischemic stroke
  • I Christou
  • A V Alexandrov
  • W S Burgin
  • A W Wojrer
  • R A Felberg
  • M Malkoff
Comparison of flow and velocity during dynamic auto-regulation in humans
  • D W Newell
  • R Aaslid
  • A Iam
  • T S Mayberg
  • H R Winn
Applying the neuromuscular principles in TMD and orthodontics
  • C A Clayton
Orthodontic course manual
  • J W Gerber
Bringing biometric diagnostics into dentistry
  • D Mahony
Neurally Mediatied ULF-TENs to relax upper cervical and upper thoracic musculature as an aid to obtaining improved cervical posture and mandibular posture. The application of the Principles of Neuromuscular Dentistry to Clinical Practice Anthology
  • P Raman