Muscle Programming / Orthodontic Courses by Indian Dental Academy

INDIAN DENTAL ACADEMY
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www.indiandentalacademy.com

Contents

Introduction
Muscle physiology
Role of Muscles in orthodontics
Muscle programming
Muscle deprogramming
Summary
Paradigm
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Paradigm
Shift in Paradigm
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Cause of Malocclusion Cause of Relapse Muscular Imbalance
Shift in Paradigm
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Admittedly, the mission of an
Orthodontist is no longer Divine (i.e.
carrying out Natures plan) but Human.
What is Muscle?
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Elasticity and Contractility
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Myotatic Reflex
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These are reflex contractions of Healthy
muscle which results from a pull on its
tendon.
All or None Law
The intensity of the contraction of any muscle
fiber is independent of the strength of the
exciting stimulus.
Concept By Melvin Moss
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Orofacial capsule
Neurocranial capsule
Muscles as basis of Myofunctional Therapy
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Post Treatment Retention
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Muscle Programming is a term
applied to process by which muscles are
trained in a specific way to attain proper
form, function and stability of hard and
soft tissues in surrounding.
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Muscle Programming
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Muscle Exercise Myofunctional
Therapy
Muscle Exercise
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Alfred P. Rogers, was the first person to
propose Muscle Exercises

He is known for his concept of Muscle as
Living Orthodontic Appliance
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Muscle Exercise as applied to
Orthodontics and Dentofacial
Orthopedics is defined as the Controlled
Rhythmic contraction of the muscles
around the teeth and jaws to achieve
normal function and development of these
structures.
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Muscles exercises are
divided into following
Lip exercises
Tongue exercises
Mastication muscle exercises
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Various Muscle Exercises are
Blowing Baloons
Button Pull Exercise
Gum Drop Exercise
Weighted String
Lip Pull Exercise
Lip Puffer
Mechanical
Stimulator
Card pull Exercise
Wooden Spatula
Exercise
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Blowing Baloons
Gum Drop Exercise
Weighted String
Lip Pull Exercise
Lip Puffer
Mechanical
Stimulator
Card pull Exercise
Wooden Spatula
Exercise
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Blowing Baloons
Gum Drop Exercise
Weighted String
Lip Pull Exercise
Lip Puffer
Mechanical
Stimulator
Card pull Exercise
Wooden Spatula
Exercise
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Blowing Baloons
Gum Drop Exercise
Weighted String
Lip Pull Exercise
Lip Puffer
Mechanical
Stimulator
Card pull Exercise
Wooden Spatula
Exercise
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Blowing Baloons
Gum Drop Exercise
Weighted String
Lip Pull Exercise
Lip Puffer
Mechanical
Stimulator
Card pull Exercise
Wooden Spatula
Exercise
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Blowing Baloons
Gum Drop Exercise
Weighted String
Lip Pull Exercise
Lip Puffer
Mechanical
Stimulator
Card pull Exercise
Wooden Spatula
Exercise
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Blowing Baloons
Gum Drop Exercise
Weighted String
Lip Pull Exercise
Lip Puffer
Mechanical
Stimulator
Card pull Exercise
Wooden Spatula
Exercise
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Blowing Baloons
Gum Drop Exercise
Weighted String
Lip Pull Exercise
Lip Puffer
Mechanical
Stimulator
Card pull Exercise
Wooden Spatula
Exercise
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Blowing Baloons
Gum Drop Exercise
Weighted String
Lip Pull Exercise
Lip Puffer
Mechanical
Stimulator
Card pull Exercise
Wooden Spatula
Exercise
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Blowing Baloons
Gum Drop Exercise
Weighted String
Lip Pull Exercise
Lip Puffer
Mechanical
Stimulator
Card pull Exercise
Wooden Spatula
Exercise
Patient is asked to hold
the wooden spatula (with
little amount of weight)
between upper and lower
lips

Holding time 1520secs
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Ask the patient to stretch the upper lip over the
labial surfaces of upper anteriors and hold it
lingual to the lower incisors.
Holding time 30 second
Frequency 15 to 20 times a day
This will improve the tonicity of upper lip
For Hypotonicity of Upper Lip
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For Hypotonicity of Upper Lip
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Ask the patient to raise the lower lip over the
labial surfaces of upper lip and hold it in close
approximation with the upper lip.
Holding time 30 second
This will improve the tonicity of lower lip
For Hypotonicity of Lower Lip
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For Hypotonicity of Lower Lip
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Ask the patient to lower down the chin
with the help of forefinger and thumb
Raise the lower lip to contact with upper
lip
Holding time 10-15 secs
Frequency 10 15 times a day
Mentalis Muscle Exercise
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Mentalis Muscle Exercise
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Wilsons Exercise

Ask the patient to stand in front of mirror
Close the jaws in centric occlusion
Contract the left corner of mouth so that it will move
laterally and downwards
With the palmer surface of the left hand press the
right cheek medially and close the right nostril with
the forefinger of left hand, simultaneously.
Take deep breath from left nostril and hold it for 10
to 15 secs and then exhale slowly
This exercise is performed 3-4 times on one side
and then same procedure is repeated for the other
side
This whole procedure is done twice a day
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Wilsons Exercise

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It is indicated in cases in mild mandibular
deficiencies.
Care should be taken that incisors should have
normal inclination
Ask the patient to protrude the lower jaw so as to
engage the lower incisors labial to the upper
incisors
Holding time 10-15 secs
Pterygoid Exercises
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Pterygoid Exercises
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Ask the patient to touch the tip of the
tongue in the rugae area of palate and
swallow with teeth in occlusion.
( Teeth together Swallow)
This will correct the abnormal swallowing
pattern.
Tongue Exercise
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Tongue Exercise
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Ask the patient to clench the teeth on right
and left side alternatively.
While doing so patient should feel
(palpate) at the angle of jaws for
massater and at the temple region for
temporalis
Temporalis and Masseter Ex.
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VoiceGym is designed to correct tongue position
and rebalance face muscles in favor of the tongue
being suspended in the palate.

Programming of Face and tongue
muscles using Voice Gym
- Angela Caine
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If the palate is underdeveloped however, it may
be necessary to coordinate VoiceGym Exercises
with functional orthodontics to restore the width
of the arch.
Arch width is then maintained by the tongue
articulating against the palate, thus stimulating
bone development
Programming of Face and tongue
muscles using Voice Gym
- Angela Caine
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Studies related to Muscle Exercise
J.D. English, M. Tran, P. Buschang, and
G. Throckmorton, Baylor College of
Dentistry, Dallas, TX, USA studied Muscle
Exercise Effects on the Early Treatment of
Skeletal Open Bite Malocclusions

Sample - 31

They found that clenching exercises helped
control the vertical dimension and its
effects on facial morphology may help to
reduce aberrant vertical growth patterns
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Orthodontic treatment and masticatory muscle exercises
to correct a Class I open bite in an adult patient.
English JD, Lindsey CA, AJO-DO 2003

Results were similar to their previous study
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Masticatory Exercise as an Adjunctive Treatment for
Hyperdivergent Patients
Laurie R. Parks; Peter H. Buschang; Richard A. Alexander;
Paul Dechow; Paul Emile Rossouwc
The Angle Orthodontist: Vol. 77, No. 3, pp. 457462

Sample - 50

They concluded that Masticatory muscle
exercise performed during the treatment of
hyperdivergent patients produced greater
increases in overbite than treatment alone.
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Urs Ther and Bengt Ingervall studied the effect of
muscle exercise with an oral screen on lip function
The European Journal of Orthodontics 1990 12(2):198-208
They drew following conclusions
The treatment resulted in a decrease of the overjet
and upper dental arch length, but with some relapse
after the treatment.
The strength of the lips increased during the
treatment, but decreased afterwards.
The pressure from the lips on the teeth at rest and
during swallowing was unaffected by the lip
training.
The pressure from the lower lip during chewing
increased temporarily during the treatment period.
Muscle Deprogramming is a term
applied to process by which muscles are
allowed to revert back to unstrained,
normal functional relationship by the
means of some kind of inter-occlusal
appliance.
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Inter-Occlusal Splints
(Deprogramming Splints)
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Diagnostic Splints Therapeutic Splints
Occlusal splints are removable appliances that are
usually made of hard acrylic and fit over the
occlusal surface of either the maxillary or
mandibular dentition to create a precise occlusal
relationship with the teeth of the opposing arch or
to eliminate occlusal contacts
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Diagnostic Splints
These type of Splints are used to diagnose
the discrepancy between Centric Relation
(CR) and Centric Occlusion (CO).
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Diagnostic Splints
If there is an improper relationship between the
upper and lower jaws and/or the upper and
lower teeth, the patient will be required to
wear temporary oral appliances (Splint).

The objective of the splint is to try and establish
the correct position of the mandible to the
maxilla in three dimensions; namely,
transverse, sagittal and vertical
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Diagnostic Splints
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Diagnostic Splints
A temporary deprogramming splint is
frequently used for breaking Neuro-
muscular imbalances.

The MAGO (Maxillary Anterior Guided
Orthotic) is just one example of a
modern attempt to aid identification and
then recording of a stable condylar
position - H. Stean
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Diagnostic Splints
The "CR" splint captures the orientation of the condyle
during the last few millimeters of closure, when the
condyle has been seated and braced against the slope of
the eminence
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Diagnostic Splints
Ronald Roth (Functional Occlusion for Orthodontist)

Two greatest causes of failure of orthodontic
treatment

Failure to stabilize and then capture true centric
relation prior to occlusal therapy.

Failure to alter the occlusion with a high enough degree
of precision to hold centric and still clear on movement.
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Diagnostic Splints
Ronald Roth (Functional Occlusion for Orthodontist)

Unmasking the Discrepancy
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Therapeutic Splints
Therapeutic splints are Interocclusal
appliances generally used to relieve TMJ
pain originating due to some kind of
pathology like Bruxism
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Therapeutic Splints
Progressive Appliance therapy
Christopher J. Stevens

Mandibular Decompression Appliance (MDA)
Hard Pivotal Appliance
Muscle Rehabilitation Appliance
Neuromuscular Demand Appliance

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Therapeutic Splints
Mandibular Decompression Appliance

May be utilized in the diagnosis & treatment of
all occlusal dysfunctions & cranio-mandibular
disorders

Bioplast Splint
Soft Pivot Appliance
Pain Release Splint
Temporary Diagnostic Appliance

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Therapeutic Splints
Mandibular Decompression Appliance

The primary indication for the MDA is TMJ
pain.
The secondary indication is dysfunction.
It can also be helpful in diagnosis.
The appliance allows proprioceptive
deprogramming of masticatory muscles, and
support of vertical dimension.
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Therapeutic Splints
Hard Pivotal Appliance

Features of the pivot appliance:

1. Used as an initial follow up to the MDA

2. Provides further decompression of the joints.

3. Assists in reprogramming vertical, A-P, and
lateral orientation of the mandible.

4. It is worn 24 hours, even when eating.
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Therapeutic Splints
Muscle Rehabilitation Appliance

Features of the muscle rehabilitation appliance:

1. Used as a follow up to the hard pivotal
appliance

2. Improves and rehabilitates muscle tone

3. Improves mandibular stability

4. It is worn 24 hours, even when eating
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Therapeutic Splints
Neuromuscular Demand Appliance

This appliance has occlusal anatomy which
maintains the 3-D craniomandibular relationship.

Features of the mandibular demand appliance:
Predicts mandibular position for
stabilization procedures

Can be used for long term maintenance
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Therapeutic Splints
Anterior Repositioning Splint

Rationale of anterior repositioning splint is to
diminish TMJ pain by unloading the Articular
Disk
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Therapeutic Splints
Occlusal Splint therapy for Bruxism
Soft vacuum-formed
polyvinyl splints
The stabilization splint
with canine ramps
The NTI tension
suppression system.
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Therapeutic Splints
Mechanisms Proposed for Oral Splint
Efficacy/Effectiveness

Myofacial pain
Change in the vertical dimension of occlusion

Repositioning of the temporomandibular joints

Decrease in the level of muscle activity

Reducing bruxism

Removal of occlusal interferences
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Therapeutic Splints
Mechanisms Proposed for Oral Splint
Efficacy/Effectiveness

Disc displacement disorders
"Recapturing" the disc
Unloading" the joints

Arthritis/arthralgia
"Unloading" the joints

Sleep bruxism
Removal of occlusal interferences
Change in muscle activity
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Dr. N.R. Krishnaswamy (7
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IOS P.G. Convention)
outlined the objectives of Splint therapy as follows

To find the true anatomic relationship of the mandible
to the maxilla by deprogramming the muscle to eliminate
the neuromuscular reflexes.
To test the patients response to a change in the
occlusion
To determine if the craniomandible relationship can be
stabilized.

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ARMAMENTARIUM FOR FABRICATION OF
OCCLUSAL SPLINT

Vacuum adapter e.g. Omnivac, Biostar, etc.
Acetate marking pen: e.g. any waterproof felt tip.
Acrylic trim bur.
Small metal spatula for mixing acrylic in dappen dish.
Dropper bottle (oz.) for acrylic monomer
Squeeze-type dispenser (3oz.) . for acrylic polymer
powder.
Articulating paper
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Fabrication of Splint

Accurate Impressions

Pouring of Stone Models

Construction of splint base with 0.08 Omnivac material
or Biocryl II material on Biostar machine

Trial of splint base in mouth

Splint base should be of minimum vertical dimension and
should extend upto last erupted teeth
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Fabrication of Splint

Occlusal Lining of Splint using Biocryl acrylic

Polish the splint

Insert the splint in mouth and check for even contact

Adjustment of splint in mouth in subsequent visits
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Some Commercially available Splints
DSG Relaxer
Dental Services Group has recently developed a new muscle
deprogramming splint that is designed to use the body s natural reflex
protection to relax the muscular components of bite-related migraines,
chronic headaches and jaw disorders.
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DSG Relaxer
Super Splint
(Dentech Services)
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Flexible inner Layer
Hard Outer Layer
Thermo-Splint Classic-- Soft thermo-plastic polymer throughout

Thermo-Splint Hard Face --Two layers the softer, flexible, thermo-plastic
layer plus an additional harder acrylic layer for added durability on occlusal
and incisal surfaces. (See diagram at right)

Thermo-Splint Custom Fit --Monomer free, reprogrammable, self aligning,
versatility plus
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Developed by Prof.Dr.Martin Lerman, the Scientific Director at the
Temporo Mandibular Joint Center at the University of Illinois
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Studies related to Splint Therapy
Solange Mongelli de Fantini et al (Braz Oral Res
2005;19(3):176-82 ) studied effect of occlusal splint
therapy on condylar displacement between centric
relation and maximal habitual intercuspation

Sample 22 Subjects 11 male 11 female

They concluded that use of occlusal splints results in
greater mean condylar displacement values, especially
vertically, between CR and MHI positions, which
contributed to a more accurate orthodontic diagnosis.

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John Grubb (Angle Ortho 1999 210-213) presented a
Case report of a Patient suffering from TMJ pain.

Deprogramming Splint was used as Diagnostic as well as
therapeutic device
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Donald Joondeph (Angle Ortho 1999 201-209) studied
the Long Term stability of Anterior Repositioning Splint

Treated 12 patients
Complete Relapse
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Ahlin et al 1991 found that use of splint with only anterior
flat bite plane can cause an open bite
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T.T.T. Dao and G.J. Lavigne (Crit Rev Oral Biol
Med 9(3):345-361 1998) from a review of Literature on
Occlusal splints, concluded that true efficacy for oral
splints in treatment of TMJ dysfunction remains
unknown

However, the results of a controlled clinical trial
lend support to the effectiveness of the stabilizing splint in
the control of myofacial pain.

Thus oral splints should be used as an adjunct for
pain management rather than a definitive treatment.
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Alexander S Fu et al studied the Maxillomandibular
relationship in TMD patients before and after short-term
flat plane bite plate therapy.
Cranio. 2003 Jul ;21 (3):172-9

Sample 20 with Deviated mandible

After Flat Bite plane Therapy, the mandibular position of all
subjects shifted toward the midline position

Significant movement of both condyles in the anterio-posterior
plane as well as the vertical plane

There was also significant reduction in TMJ pain and clicking
Role of Muscles and soft tissue in
orthodontics is gaining importance in
recent times

Both, Muscle Programming and
Deprogramming are becoming part and
parcel of Orthodontists Life

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