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Difference between revisions of "3° Clinical case: Meningioma"
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As anticipated in the introductory chapter 'Occlusion and posture', the greatest danger in medical science is to underestimate the vast range of neuromotor responses that are modulated by as many indeterministic biophysical effects and to build clinical axioms on them. This induces the clinician into a deterministic mindset where the axioms are a certainty but, as will be seen during the implementation of Masticationpedia, this language logic model should leave room for a quantum-like language logic where one does not try to limit the uncertainty error with Bayesan statistical models but accept the limit of the probabilistic uncertainty. Following the first approach (classical model), a subject who reports chewing disorders related to a postural disorder is 99.9% (t-student, P-value, etc.) affected by malocclusion while following a quantum-like approach one wonders what is the 'state' of this subject's system beyond the clinical conclusion that it is and will always remain a probabilistic event. As we will see, this innovative quantum-like approach would speed up the diagnostic finalization. | |||
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=== | ===Introduzion=== | ||
{{Bookind2}} | {{Bookind2}} | ||
As now implicit, this clinical case too, which from now on we will call with a fancy name '''<u>Balancer</u>''<nowiki/>' due to its related symptoms of postural and gait disturbance after being prosthetically rehabilitated, will follow the presentation model of the previous clinical cases. The introduction will present topics relating to the diagnostic model in question on which we will make the first conceptual reflections highlighted by our dear and thoughtful Linus.[[File:Question 2.jpg|50x50px|link=https://wiki.masticationpedia.org/index.php/File:Question_2.jpg|left]]A recent article by Minervini et al.<ref>Giuseppe Minervini, Rocco Franco, Maria Maddalena Marrapodi, Salvatore Crimi, Almir Badnjević, Gabriele Cervino, Alberto Bianchi, and Marco Cicciù. Correlation between Temporomandibular Disorders (TMD) and Posture Evaluated trough the Diagnostic Criteria for Temporomandibular Disorders (DC/TMD): A Systematic Review with Meta-Analysis. J Clin Med. 2023 Apr; 12(7): 2652. Published online 2023 Apr 2. doi: 10.3390/jcm12072652.PMCID: PMC10095000.PMID: 37048735 | |||
</ref> asserts the following: TMD has ligament and muscle connections with the cervical area, therefore these connections have led to the hypothesis that posture problems may influence the development of TMD, <ref>An J.-S., Jeon D.-M., Jung W.-S., Yang I.-H., Lim W.H., Ahn S.-J. Influence of temporomandibular joint disc displacement on craniocervical posture and hyoid bone position. Am. J. Orthod. Dentofac. Orthop. 2015;147:72–79. doi: 10.1016/j.ajodo.2014.09.015.</ref><ref>Lee W.Y., Okeson J.P., Lindroth J. The relationship between forward head posture and temporomandibular disorders. J. Orofac. Pain. 1995;9 </ref><ref>Minervini G., Mariani P., Fiorillo L., Cervino G., Cicciù M., Laino L. Prevalence of temporomandibular disorders in people with multiple sclerosis: A systematic review and meta-analysis. CRANIO® 2022:1–9. doi: 10.1080/08869634.2022.2137129.</ref><ref>Minervini G.D., Del Mondo D.D., Russo D.D., Cervino G.D., D’Amico C.D., Fiorillo L.D. Stem Cells in Temporomandibular Joint Engineering: State of Art and Future Persectives. J. Craniofacial Surg. 2022;33:2181–2187. doi: 10.1097/SCS.0000000000008771.</ref><ref>Crescente G., Minervini G., Spagnuolo C., Moccia S. Cannabis Bioactive Compound-Based Formulations: New Per-spectives for the Management of Orofacial Pain. Molecules. 2022;28:106. doi: 10.3390/molecules28010106.</ref> therefore masticatory cycles should be balanced as unilateral chewing could alter the postural balance of the body. Stabilization splints can bring about neuromuscular balance, removing posterior interference and providing a stable occlusal relationship and an optimization of the centric relationship. The relationship between craniometric posture and TMD has been studied, however, despite the huge number of studies, clinicians and academics still remain unconvinced.<ref>Abe S., Kawano F., Matsuka Y., Masuda T., Okawa T., Tanaka E. Relationship between Oral Parafunctional and Postural Habits and the Symptoms of Temporomandibular Disorders: A Survey-Based Cross-Sectional Cohort Study Using Propensity Score Matching Analysis. J. Clin. Med. 2022;11:6396. doi: 10.3390/jcm11216396.</ref><blockquote>[[File:Question 2.jpg|50x50px|link=https://wiki.masticationpedia.org/index.php/File:Question_2.jpg|left]]'''Centric Relationship and Posture''' | |||
The conclusion is mandatory: 'however, despite the huge number of studies, clinical and academic remain unconvincing.' This always turns out to be a diplomatic way to avoid trouble but if we carefully read the salient points of this extract it seems that everything derives from a sort of balance due to occlusal stability and an exact Mandibular Centric Relationship. But the question that arises is: | |||
{{q2|What Centric Relationship are we talking about!!!|perhaps the forced terminal or the guided one but no!! we do the myocentric which is more suitable perhaps using TENS.}}Without going into specific topics referred to the reference chapters, we want to highlight the inconsistencies encountered in such important statements of correlation between Centric Relationship and Posture. We report a clinical case already presented in the chapter '[[Conclusions on the status quo in the logic of medical language regarding the masticatory system]]' because it is very relevant to the topic 'Masticatory correlation' which highlights the discrepancy between a manual Centric Relation obtained intraoperatively to fix the mandibular and condylar bone structures in orthognathic surgery and the spatial position called Neuro Evoked Centric Relationship obtained through Transcranial Electric stimulation of the trigeminal roots. Figure 1a shows the spatial position of the jaws after orthognathic surgery in which the positions are established through a manual method of 'Centric Relationship'. The surgeon has no other means than the manual mandibular positioning procedure. Despite bilateral edentulism, which he would face after a few months, the patient was considered to be in excellent occlusal stability. The previous chapters demonstrated that after performing the trigeminal reflexes, the patient's masticatory system was far from intact. In figure 1b an enlarged detail of the incisal area to visualize the mandibular incisal line moved towards the left side of the patient while in figure 1c we see a spatial symmetrization of the mandible (moving towards the right side of the patient) using a "Neuro Evoked Centric Registration" through transcranial electrical stimulation of the trigeminal roots (<sub>b</sub>Root-MEPs) <center><gallery widths="240" heights="200" perrow="3" slideshow""=""> | |||
File:Chirurgia Ortognatica 1.jpeg|'''Figure 1a:''' Patient discharged from the orthognathic surgery department | |||
File:ETCS post ortognatica modificata.jpeg|'''Figure 1b:''' Mandibular spatial position misalignment | |||
File:ETCS post ortognatica.jpeg|'''Figure 1c:''' Mandibular position alignment after 'Neuro Evoked Centric position' | |||
</gallery></center>In conclusion, at this point the problem is no longer the correlation between posture and occlusal stability but the correlation between the Centric Relation and occlusal stability because this relationship is the primus movens of the whole pathophysiological phenomenon and if we are not sure of the assertions we cannot go beyond . {{q2|Be careful, therefore, to use the term 'correlation' between Centric Relation and Posture or Occlusal stability and Posture.|}}</blockquote> | |||
Another recent study Inchingolo et al.<ref>Alessio Danilo Inchingolo, Carmela Pezzolla, Assunta Patano, Sabino Ceci, Anna Maria Ciocia, Grazia Marinelli, Giuseppina Malcangi, Valentina Montenegro, Filippo Cardarelli, Fabio Piras, Irene Ferrara, Biagio Rapone, Ioana Roxana Bordea, Dario Di Stasio, Antonio Scarano, Felice Lorusso, Andrea Palermo, Kenan Ferati, Angelo Michele Inchingolo, Francesco Inchingolo, Daniela Di Venere, Gianna Dipalma . Experimental Analysis of the Use of Cranial Electromyography in Athletes and Clinical Implications. Int J Environ Res Public Health. 2022 Jun 29;19(13):7975. doi: 10.3390/ijerph19137975. | |||
</ref> asserts the following: the cranial surface electromyography allows the evaluation of the occlusal state and the quantification of the neuromuscular postural balance, thus understanding the dental occlusion from a functional point of view. It therefore represents a diagnostic revolution because it allows you to see what until now was only perceptible by palpation, and therefore not quantifiable.<ref>Falla D., Dall’Alba P., Rainoldi A., Merletti R., Jull G. Repeatability of Surface EMG Variables in the Sternocleidomastoid and Anterior Scalene Muscles. Eur. J. Appl. Physiol. 2002;87:542–549. doi: 10.1007/s00421-002-0661-x</ref> A meta-analysis on the use of sEMG to evaluate the relationships between masticatory muscles and postural muscles found that the correlation between the masticatory system and the muscle activity of other parts of the body can be detected experimentally using sEMG, but this correlation has little clinic relevance .<ref>Perinetti G., Türp J.C., Primožič J., Di Lenarda R., Contardo L. Associations between the Masticatory System and Muscle Activity of Other Body Districts. A Meta-Analysis of Surface Electromyography Studies. J. Electromyogr. Kinesiol. 2011;21:877–884. doi: 10.1016/j.jelekin.2011.05.014.</ref> However, Julià-Sánchez et al. found that dental occlusion affects the biomechanical and viscoelastic properties of masticatory and postural muscles using the MyotonPRO® system.<ref>Julià-Sánchez S., Álvarez-Herms J., Cirer-Sastre R., Corbi F., Burtscher M. The Influence of Dental Occlusion on Dynamic Balance and Muscular Tone. Front. Physiol. 2020;10:1626. doi: 10.3389/fphys.2019.01626</ref> The influence of the occlusal state on stability was also demonstrated in an article by Heit et al. who found a significant increase in balance at rest rather than at maximal intercuspidation.<ref>Heit T., Derkson C., Bierkos J., Saqqur M. The Effect of the Physiological Rest Position of the Mandible on Cerebral Blood Flow and Physical Balance: An Observational Study. Cranio. 2015;33:195–205. doi: 10.1179/0886963414Z.00000000063.</ref> These results are consistent with previous studies that used sEMG to measure both the muscle balance of the masticatory muscles and its influence on the activity of some postural muscles. A substantial reduction in resting postural muscle activity (sternocleidomastoid, erector spinae, and soleus) was found in participants with dental malocclusions after balancing with a bite.<ref>Bergamini M., Pierleoni F., Gizdulich A., Bergamini C. Dental Occlusion and Body Posture: A Surface EMG Study. Cranio. 2008;26:25–32. doi: 10.1179/crn.2008.041.</ref><blockquote>[[File:Question 2.jpg|50x50px|link=https://wiki.masticationpedia.org/index.php/File:Question_2.jpg|left]]'''Simmetria:''' Quando si parla di equilibrio neuromotorio in riferimento a procedure elettromiografiche implicitamente si evocano termini come sincronicità e simmetria. La simmetria tra lati delle scariche delle unità motorie EMG è una procedura complessa da registrare ed interpretare. Molti fattori entrano in gioco e non solo il livello di contrazione muscolare ma anche il tipo di elettrodo e elettromiografo impiegato. Se si focalizza il concetto di simmetria riferendosi alle EMG interferenziale allora la situazione si complica ulteriormente per la sommazione spazio-temporale delle unità motorie che scaricano in modo asincrono ed a frequenza variabile. Ciò può determinare collisioni e cancellazioni del potenziale registrabile sulla cute. Unico modo per poter estrapolare un dato significativo è l'analisi di Fourier<ref>Ishii T, Narita N, Endo H.Evaluation of jaw and neck muscle activities while chewing using EMG-EMGtransfer function and EMG-EMG coherence function analyses in healthy subjects.. Physiol Behav. 2016 Jun 1;160:35-42. doi: 10.1016/j.physbeh.2016.03.023. Epub 2016 Apr 5.PMID: 27059322 </ref> ed il modello Wavelet<ref>Sharma T, Veer K. EMG classification using wavelet functions to determine muscle contraction.. J Med Eng Technol. 2016;40(3):99-105. doi: 10.3109/03091902.2016.1139202. Epub 2016 Mar 4.PMID: 26942656</ref> che, con le solite limitazioni di indeterminazione ed incertezza della misura già discusse in altri capitoli (K<sub>brain</sub>) si cerca di decomporre il segnale già complesso per la sua natura biochimica ed estrapolarne una informazione di biofisica. Ma la domanda che sorge è:{{q2|Siamo sicuri di essere di fronte ad una 'Asimmetria'?|....stiamo parlando di una asimmetria funzionale oppure organica?}}Anche riguardo questo punto molto delicato dell'equilibrio e simmetria neuromuscolare, senza entrare in argomenti specifici rimandati ai capitoli di riferimento, vorremmo far risaltare le incongruenze che si incontrano in affermazioni di tipo 'simmetria/asimmetria' tra lati della EMG interferenziale. In figura 2a viene riportato un tracciato EMG interferenziale (massetere destro e sinistro, traccia superiore ed inferiore rispettivamente) in cui, ovviamente, si riconosce una asimmetria di lato già ad un primo approccio visivo senza ulteriori decomposizioni matematiche. In figura 2c, invece, con la stessa disposizione elettrodica si può altresì apprezzare una buona simmetria di lati. <gallery widths="240" heights="200" perrow="3" slideshow""=""> | |||
</ref> | |||
File:EMG2.jpg|'''Figura 2a:''' EMG interferenziale funzionalmente asimmetrico | File:EMG2.jpg|'''Figura 2a:''' EMG interferenziale funzionalmente asimmetrico | ||
File:Bruxer MEP.jpeg|'''Figura 2b:''' Potenziale Evocato Motorio delle Radici trigeminali | File:Bruxer MEP.jpeg|'''Figura 2b:''' Potenziale Evocato Motorio delle Radici trigeminali | ||