Difference between revisions of "4° Clinical case: Temporomandibular disorders"

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4° Clinical case: Temporomandibular disorders

Article by Gianni Frisardi

Abstract: This article explores the complex relationship between Temporomandibular Joint Disorders (TMD) and Orofacial Pain, as highlighted by Ahmad and Schiffman, who reported that 4.6% of the U.S. population is affected by these conditions. The cost of managing TMDs is considerable, yet their diagnostic complexity often leads to delays in appropriate care. A critical element in the differential diagnosis between orofacial pain and TMD is the high incidence rate of the condition, which can distort the predictive value of diagnostic tools like Bayes' theorem. Moreover, while TMD is the second most common chronic musculoskeletal condition after low back pain, its symptoms often overlap with other pathologies, making diagnosis even more challenging.

Through clinical case examples, this study underlines the limitations of current gnathological approaches, which focus predominantly on dental occlusion without sufficiently considering the neuromotor network. The Neurognathological Functional (NGF) method is introduced as a paradigm shift in diagnosing and treating TMDs, emphasizing the role of trigeminal neuromotor responses over occlusal parameters alone. This method utilizes advanced trigeminal electrophysiological techniques, such as the bRoot-MEPs (bilateral motor evoked potentials), to assess the organic and functional integrity of the trigeminal system and restore masticatory function through neuro-evoked centric rehabilitation.

The study also discusses mandibular spatial analysis and its role in determining the optimal occlusal position, moving away from manual and traditional methods. Clinical results from patients treated with the NGF method reveal improvements in both neurophysiological symmetry and masticatory function. Furthermore, the article delves into the broader neuro-occlusal correlation, showing that chewing and occlusal patterns can influence brain activity and potentially affect neurodegenerative diseases.

In conclusion, TMD and orofacial pain require a more integrated diagnostic approach that considers the trigeminal system's role in masticatory and neuromotor function. The NGF method offers a new perspective on TMD management, addressing both the dental and neurological aspects of the condition for a more precise and effective treatment.

Introduction

An article by Ahmad and Schiffman^[1] revealed interesting elements that call for a more in-depth analysis of the TMD phenomenon. The authors reported, in fact, that about 5-12% of the US population is affected by TMD and the annual cost of TMD management, excluding imaging costs, is about $4 billion. Interview Survey (NHIS) that included a total of 189,977 people, 4.6% (n = 8964) had temporomandibular joint and muscle disorders (TMJD).

As we have already mentioned several times in the previous chapters, one of the critical elements in the differential diagnosis between orofacial pain and TMD is the datum of the incidence of the disease, which necessarily pollutes the result of the predictive value of Bayes' theorem. In this case, from the authors' considerations^[1] we are at 4.6 per cent.

We know by now that 'TMD' is the second most common chronic musculoskeletal condition after chronic low back pain^[2] and although Ahmad and Schiffman^[1] have exhaustively reported on the importance of imaging to make correct intra-articular diagnoses of TMJ, the doubt arises of the overlapping of symptomatic-clinical states as we have seen in the clinical cases reported in the previous chapters of Masticationpedia.

This interference does not depend on the physician's ability but on the deterministic forma mentis that leaves no room for the phenomenon of overlapping pathologies simulating the same TMD symptomatology. A quick roundup of clinical cases reported in the chapters of Masticationpedia can remind us better of the complexity and truthfulness of this statement. (Figure 1)

Figure 1a: Patient previously diagnosed following the DRC model as suffering from Temporomandibular Disorders.
Figure 1b: Machine language code decrypted in 'Hephaptic transmission'. Definitive diagnosis ' Hemimasticatory spasm '.
Figure 1c: Patient previously diagnosed following the DRC model as suffering from Temporomandibular Disorders.
Figure 1d: Machine language code decrypted in 'Trigeminal hyperexcitability'. Definitive diagnosis ' Cavernous Pineal '
Figure 1e: Patient previously diagnosed following the DRC model as suffering from Temporomandibular Disorders.
Figure 1f: Decrypted machine language code in 'Latency Period Silence'. Definitive diagnosis ' Meningioma '

Rightly says Magda Krasińska-Mazur et al.^[3] that the correct diagnosis of temporomandibular disorders is based on anamnesis and a thorough physical examination, as well as the results of additional tests.....but which ones?

«What could be the best approach to TMDs patients?»
(.... we will present in this context a diagnostic model in the context of restoring the functional masticatory condition of the patient in question)

So far we have discussed many aspects that in some way delay the differential diagnosis in patients who report overlapping symptomatology and various clinical manifestations, a differential diagnosis that if, on the other hand, performed correctly and quickly could save the subject's life as happened to our 'Bruxer' and unfortunately not to our 'Balancer'. The doctor's forma mentis in these cases is fundamental and the decisive element remains that of stepping out of the 'specialist context' in order to take an indeterministic and probabilistic view of medicine at the same time. This is no different with regard to patients actually suffering from TMDs because there is no real neuro-gnathological discipline, the diagnosis as well as the therapy of these subjects remains the standard one, namely gnathological. The discipline of gnathology, although very valid, is also limited because it restricts the field of the 'observable' to the occlusal parameter, disregarding everything else that is part of the masticatory neuromotor network and beyond.^[4] We will present this clinical case of a patient with DTMs to give a significant clinical diagnostic/therapeutic change in the field of 'Functional Neuro Gnathology' calling it, precisely, the NGF method.

Anamnesis

Figure 2: Oral situation of the patient affected by TMDs showing the ant erior cross bite

As usual, we call our patient with a fancy name and precisely 'Clicker' because the patient had been suffering from temporomandibular joint (TMJ) clicks for years. Clicker presented to our neuropathology department complaining of severe orofacial pain and reporting a chronic right TMJ joint removal. She arrived after having already been diagnosed as DTMs always following the RDC protocol and treated with a biteplane to manage the nocturnal teeth grinding only. She, a 40-year-old patient who reported orofacial pain with joint noises such as clicks and crashes on both sides of the face and difficulty in chewing.

A first clinical occlusal examination shows a functional occlusal class III with sliding in protrusion in reaching the maximum intercuspidation. On palpation, the masseters, temporals, and external pterygoids on both sides were tender. No balance and gait disturbances, no vertigo, no tinnitus but as our routine we immediately performed trigeminal electrophysiological tests in order to avoid any structural involvement of the trigeminal Central Nevous System (_tNCS). As already explained in the chapter concerning the 'Balancer' patient with Meningioma in which the interference EMG examination performed by the dental colleagues did not give indications of organic pathology of the tNCS in our Diagnostic Center we only perform Evoked Potentials and the battery of trigmeinal reflexes. In this chapter, taking into account the clinical situation, we have bypassed the purely dental context as, after an initial objective examination, the malocclusive disorder is striking but not certain (figure 2).

Figure 3: Neurognathological Functional electrophysiological tests

Trigeminal electrophysiology

As has now been documented in the previous chapters of Masticationpedia, the heart of the scientific philosophy of Masticationpedia is substantially the normalization of masticatory functions to the Central Nervous System and trigeminal peripheral _tCNS and not to dental occlusion. This is able to couple the occlusal abnormality to the 'state' conditions of the tCNS as well documented in the first chapter 'Introduction' where we showed a perfect trigeminal electrophysiological symmetry in the subject with severe dental malocclusion and a frankly asymmetric neuromotor condition in a subject with perfect occlusion after being treated with orthognathic surgery. The electrophysiological tests in subjects with TMDs are limited to the bilateral Motor Evoked Potentials of the trigeminal roots which we have precisely put over the years called bRoot-MEPs,^[5] from the jaw jerk^[6] performed while keeping the mandible in the rest position (Jaw jerk in rest position) and the jaw jerk keeping the jaw closed with moderate muscle activity (jaw jerk in occlusal position).

_bRoot-MEPs

In figure 3 we can see the responses of the motor evoked potentials of the two trigeminal roots, the jaw jerk in the rest position and in the position of maximum intercuspidation. In particular, the Nervous system responds to Transcranial Electrical Stimulation of the trigeminal roots with two evoked potentials that are perfectly symmetrical both in latency and in amplitude and specifically the latencies are positioned at an onset of $1R=2,01$ ms and $1L=1,99$ ms while the peak-to-peak amplitudes $2R-3R=5$ mV and $2L-3L=5,2$ mV. This result is fundamental for the differential diagnosis between organic and functional pathologies, in fact, it demonstrates that the system is organically symmetrical and synchronous and this determines the term that we will see recur in a decisive way in the continuation of the Masticationpedia chapters called 'Organic Symmetry'. Bear in mind right now that the 'Organic Symmetry' parameter will be considered an element of 'Normalization' of the trigeminal reflex responses as its latency and amplitude symmetry indicates a perfect 'state' of integrity of the _tCNS and that at the same time one should expect an equally 'state' of functional symmetry due to trigeminal reflex responses. Let's see, therefore, the trigeminal functional 'state' of the _tCNS by analyzing the jaw jerk.

Jaw jerk in rest position

The stretch reflex test called jaw jerk was performed keeping the mandible in rest position to distinguish the input component to the tCNS excluding the input of the periodonatal receptors. The results were not encouraging due to the relative asymmetry of latency ( $1R=8,5$ ms and $1L=7,5$ ms) and peak-to-peak amplitude ( $2R-3R=0,3$ mV; $2L-3L=0,6$ mV). In particular, the latency delay could be explained by a facilitation on gamma motor neurons, in contrast with the study by Kitagawa et al.^[7] in which it is asserted that the facilitation on the ipsilateral side could be produced by an enhancement of the gamma drive induced by a prolonged nociceptive stimulation. In our case the most significant datum is the difference of $\simeq 50\%$ with reduction on the right affected side. We have noticed in our studies that in the rest position the jaw jerk also shows a dependence not only on the acceleration of the trigger stroke but also on the spatial position of the jaw as it is not conditioned by the occlusal position.^[6]

Jaw jerk in rest position

The jaw jerk, keeping the mandible in a position of centric occlusion, performed to verify the contribution of the periodontal receptors together with the muscle and tendon proprioceptors, was obviously facilitated by the dental contact but the asymmetry in amplitude ( $2R-3R=0,1$ mV; $2L-3L=1$ mV) increased. This result agrees with what was stated in a study by Yoshino T et al.^[8] in which the mandibular position was deviated by 0.5, 1.0, 1.5, 2.0 and 3.0 mm to the right and left from a reference position corresponding to the rest position. Jaw jerk amplitude on the mediotrusive side increased primarily in proportion to mandibular deviation. The study concludes by suggesting that jaw jerk may aid the clinical examination of minor mandibular deviations. The conclusion of this 1st trigeminal electrophysiological step was to ascertain the organic integrity of the _tCNS through the symmetry and synchronics of the _bRoot-MEPs,^[5] and consider it as an 'Organic Symmetry',^[9] i.e. normalizer of the masticatory neurophysiological process while the asymmetries of the jaw jerk a functional disorder due to an unbalanced peripheral input or an inhibitory process on the trigeminal motoneurons of the nociceptive type. In essence, the conclusion of a mandibular spatial disorder would seem more indicative, which we will ascertain later when the Neuro Evoked Centric Relationship is performed to verify the physiological spatial position.

Silent period of the masticator muscles

Figure 4: Silent period of masticatory muscles and representation of areas of interest marked with arrows.

Figure 4 shows the neuromuscular responses of the silent period to chin percussion through a triggered neurological hammer when the patient was asked to clench her teeth maximally. If from a neurological point of view it is not possible to highlight elements referable to organic alterations of the _tCNS, some electrophysiological characteristics, however, are to be referred to a functional disorder of the system. In the upper trace, a decrease in the motor neuron reactivation phase can be seen immediately following the silent period. The possible neurophysiological mechanism capable of determining a similar decrease in facilitatory activities on the mandibular silent period can be ascribed to a change in the spindle motor drive induced by the input of muscle proprioceptors and nociceptors. The neuronal network of this process would take place through a loop formed by: muscle nociceptive afferents, the subnucleus caudalis of the V, inhibitory interneurons on static motor neurons and, as a last link, the modulation of the sensitivity of the neuromuscular spindles..^[10] ^[11]^[12]^[13]^[14]^[15] Also in this context the inhibitory component most likely prevails over the excitatory one and this could be ascribed to a malocclusion as we will see later. In particular, it can be noted the overlapping of the jaw jerk behavior, previously tested, in a path rectification condition. The arrow indicates the jaw jerk on all traces and the decrease in amplitude can be observed for the right masseter while it is relatively symmetrical on the temporal muscles.

Mandibular spatial analysis

On this subject unfortunately there are innumerable conceptual conflicts redundant regularly coming back into vogue after a period of years such as the gothic arch tracing method to determine the centric relationship of full dentures, as suggested by Zhou TF et al.^[16] From what has been exposed in all the chapters previously published on Masticationpedia, it is clear that the approximation of manual methods or vague interpretations derived from a logic of verbal language cannot be represented in the scientific philosophy of Masticationpedia which tends to focus on a mesoscopic model more than macroscopically descriptive and formal through statistical mathematical models as we will see below. Therefore we do not share the opinion of Zhou TF et al but absolutely in line with the concepts expressed by Silva Ulloa S. et al.^[17] in which it is concluded that the sensorimotor cortex is affected by changes in occlusion and it is hypothesized that occlusion may play an important role in the development of diseases, from anxiety and stress to Alzheimer's disease and senile dementia. We also share the heartfelt suggestion of Silva Ulloa S. et al. in which she urges dentists to consider that alterations in the occlusal pattern during chewing can lead to changes in the activation of several brain regions related to memory, learning, anticipatory pain and anxiety.

«This suggests that chewing maintains the integrity of some areas of the brain and that it may be a key factor in the onset of neurodegenerative diseases.»
(Relationship between dental occlusion and brain activity: A narrative review Sebastian Silva Ulloa, Ana Lucía Cordero Ordóñez, Vinicio Egidio Barzallo Sardi)

Therefore, it is essential to operate in synergy with the trigeminal neuromotor content in order to have an 'Observable' more indicative of the masticatory reality and in this case of the real spatial position that the jaw wants to reach beyond the dental interference. To achieve this target we have developed a method of simultaneous Transcranial Electrical Stimulation of the trigeminal roots which evokes a direct response of all the masticatory muscles which we call _bRoot-MEPs as previously mentioned which has an indication of the 'state' integrity of the _tCNS and at the same time it determines an elevation of the mandible from the rest position to the Occlusal Centric. This Centric has been named by us Functional Neuro Evoked Centric. (Figure 5)

Figure 5a: Presumably pathological usual occlusal position, with anterior crossbite and wear of the central incisors
Figure 5b: Positioning of the recording electrodes on the masseters on both sides and of the electrodes to evoke the direct response from the trigeminal roots
Figure 5c: Result of mandibular elevation from resting position to Centric Neuro Evoked Functional via bRoot-MEPs

As we can see, starting directly from a neurological context, using advanced trigeminal electrophysiological technologies, we have avoided the presence of destructuring of the _tCNS and contextually highlighted a spatial-type occlusal disorder. The mandible with this method which generates a synchronous action potential of all the muscles innervated by the trigeminal roots, apart from conditions of marked destructuring of the ATM, generates a perfectly physiological closure which in this case is interrupted by the presence of a dental interference of the element 21 which comforts us in continuing the functional neurognathological treatment.

Functional Neuro Gnathological rehabilitation

Regarding the treatment of patients with TMDs there are still many strategic-conceptual conflicts such as, for example, the use of TENS^[18] which the RDC protocol has considered clinically invalid as much as from a neurophysiological point of view TENS is not an appropriate method for not being able to evoke a response from all masticatory muscles but only the superficial ones. In this limitation lies the spatial error of the mandibular position which would be in a more anterior position due exclusively to the motor response of the masseter muscle (a topic which will be dealt with in the section 'Crisis of the Paradigm').

For this reason we bypass the manufacture of a bite plane to arrive directly at the definitive neurognathological prosthetic rehabilitation. In this specific case it was a Functional Neuro Evoked Centric rehabilitation of the anterior incisors and the four lower molars, two per side. The realization, however, followed some particularly obligatory pre-ordered steps which represent the best way to achieve real neuro-occlusal stability, as we will see in detail below. (figure 6)

Figure 6a: Positioning of frameworks in Empress to accommodate the wax for Functional Neuro Evoked Centric
Figure 6b: Frozen Functional Neuro Evoked Centric Registration by placing crown structures in Empress with interdigitating wax. Note the slight increase in the vertical dimension purposely wanted.
Figure 6c: Frozen Functional Neuro Evoked Centric Registration by placing crown structures in Empress with wax and brought back into the articular.

In figure 6a we can see the structures of the crowns in the mouth on which the ceramic will be stratified and which will be covered with Aluvax wax to determine the Functional Neuro Evoked Centric. The decision to incorporate the four molars in the rehabilitation was made because these elements are crucial for occlusal stability but also for mediotrusion as we will see below. The exact mandibular position requires a third anterior point and for this reason, also considering the wear of the incisions and the importance of a normocclusion of the anterior sector, the involvement of the incisors was decisive for Centering the mandible in the optimal position (figure 6b) . Obviously, everything is brought back into articulate with mold waxes on Empress crowns. (figure 6c)

Functional Neuro Gnatologic Detail

For Neuro Gnatologic Functional detail, rehabilitation model called 'NGF Index' from which a whole scientific process will be initiated which will lead to a diagnostic paradigmatic model called 'NGF Index' in the 'Extraordinary Science' section, means an occlusal adjustment normalized to trigeminal neuromotor symmetry . To achieve this goal, gnathological replicates (articulated) and above all the ability to read the evoked and reflex responses of the tCNS in different occlusal situations are fundamental. For this reason, only the active centrics of the Empress crowns were stratified on the four lower molars. (figure 7)

Figure 7a: View of the Empress framework in the laboratory phase where only the active centric cusps of the molars were layered.
Figure 7b: View of the Empress structure in the clinical phase in the mouth on which to perform trigeminal electrophysiological tests.
Figure 7c: view of the crowns with active centric cusps in the right-sided mouth.

In figure 7a, b and c only the active centrics of the molars have been stratified because although the Centric Neuro Evocate Functional registration is of absolute precision, the mechanical transfer from the mouth to the laboratory (articulator) could incorporate minimal spatial variations. For this reason it was decided to stop the neuro-evoked closure of the slightly raised jaw in order to have the availability of the ceramic material to be remodeled following the trigeminal electrophysiological responses. In essence, the cusps were abraded sectorally and individually to then compare with the trigeminal electrophysiological responses up to the perfect symmetry and synchronicity of the _tCNS. Once the result of symmetry and synchronism has been achieved, the position reached will become the incisal rod at zero to conclude the stratification.

Figure 8a: Mechanical silent period recorded on the masseter and temporal muscles before the Neuro Gantholgic Functional treatment
Figure 8b: Mechanical silent period recorded on the masseter and temporal muscles after Neuro Gantholgic Functional treatment.

Figures 8a and 8b show the extraordinary differences in the trigeminal neuromotor response due, being of a functional type, to a mandibular spatial change and an accurate neurognathological occlusal balancing. In fact, one can see a symmetrization of the jaw jerk on the right masseter, a decrease in the duration of the mechanical silent period and above all an optimal motoneural reactivation after the silent period (rebound effect) which means safety in the total and immediate reactivation of the motoneural discharge. Once this trigeminal neuromotor re-symmetrization has been documented with irrefutable data, it is possible to move on to finalizing the clinical case.

NGF prosthetic rehabilitation

The finalization of the definitively diagnosed clinical case of DTMs resulted in a restoration of the masticatory function, disappearance of the symptoms as well as an aesthetic improvement. The various phases of the rehabilitation can be followed in the gallery of images in figure 9. In particular, the Functional Neuro-Evoked Centric position is not only centered having moved slightly to the right but also retruded. It is interesting to make a comparison with figure 5a to understand the spatial differences. Element 22, in fact, is no longer in crossbite but in a head-to-head position while element 23 has a much more incisal centric contact with respect to the previous clinical situation, so as to note the occlusal space in the medial area of element 24 which it was generated with the current mandibular spatial position determined with the Functional Neuro Evoked Centric. This new occlusal arrangement was only possible because the stable and mainly frozen centric position in the molar sector. The molars through the previously exposed neuromotor balance on the centric cusp stabilize the occlusion and generate a bilateral balance in the mandibular movements as will be shortly described.

Figure 9a: Frontal view of functional neuro-evoked rehabilitation
and incisal normocclusal restoration
with two crowns in Empress
(performed in 1992)
Figure 9b: Occlusal view of functional neuro-evoked rehabilitation and incisal normocclusal restoration with two crowns in Empress.
Figure 9c: Peculiarities of neurognathological parameters. Occlusal view of the left mediotrusive detail.
Figure 9d: Peculiarities of neurognathological parameters. Occlusal view of the right mediotrusive detail.

In figure 9c and 9d, we can see not only the well balanced centric contacts but above all the mediotrusive excursions. A few more words should be spent on this subject. Benedikt Sagl et al.^[19] state, in their study in which the contribution of tooth inclination, medio-otrusive and laterotrusive excursion and von Mises stresses on the articular disc was analysed, that mediotrusive bruxing generates higher loads than laterotrusive simulations. In this sense it is not clear whether the mediotrusive contacts are a protective or a pejorative element in the generation of temporomandibular joint disorders. So much so that an article by Walton TR and Layton DM^[20] increases the confusion as they first state that the presence of TM interference in patient populations is large and varies from 0% to 77% and then conclude that TM interference should be avoided in any occlusal treatment regimen to minimize pulpal, periodontal, structural and mechanical complications or exacerbation of temporomandibular disorders (TMD). The confusion increases when he concludes that natural molar MT interferences should only be eliminated if signs and symptoms of TMD are present. The question that arises is the following

«Which came first, the chicken or the egg?»
(.... are the interferences that cause the grinding and consequently damage to the atm or are the natural interferences protective on the system?)

It would be necessary to put some order on the subject starting with specifying what is meant by interference.

A study by Leitão AWA et al.^[21] is extraordinarily significant having objectively simulated the interference in the animal and histologically analyzed the changes in the trigmeinal ganglion contextually with the behavior of the animal when treated with or without selective cyclooxygenase 2 (COX-2) inhibitor. Furthermore, the authors treated the animals with a daily infusion of 0.1 ml/kg of saline (DOI+SAL) and 16 or 32 mg/kg of celecoxib (DOI+cel -8, -16, -32 ). They noted that animals subjected to masseter nociceptive stimulation and interference DOI + SAL showed an increase in isplateral (P < 0.001) and contralateral (P < 0.001) nociception, an increase in the number of bites (P = 0.010), scratching (P < 0.001) and grimacing scores (P = 0.032) while in the DOI+cel-32 group, these parameters were reduced.

This interesting study shows the correlation between interference, decrease in pain threshold and contextually recovery with celecoxib infusion and therefore neuro-occlusal correlation.

Si-Yi Mo et al.^[22] reinforces the above neuro-occlusal correlation by demonstrating that the descending pathway from serotonergic (5-HT) neurons in the rostral ventromedial medulla (RVM) to 5-HT3 receptors in the spinal trigeminal nucleus (Sp5), plays an important role in facilitating the maintenance of orofacial hyperalgesia after delayed removal of experimental occlusal interference (REOI).

Up to now we have a broader view on the subject of interference confirmed by the neuro-occlusal correlation but the phenomenon can also be seen locally in the articular disc. Another study by Cui SJ et al.^[23] experimentally demonstrated that the effect of mechanical overload on TMJ discs in an in vivo rat occlusal interference model, inhibition of transient mechanoinductive receptor vanilloid potential 4 (TRPV4) alleviated TMJ disc degeneration in the rat occlusal interference model.

In conclusion, as we hope to share, the question is much more complex than what clinicians think and they hurry to eliminate the interferences, for example, mediotrusive because if the load induced on the joint, perhaps by a neuromotor hyperexcitability (see chapter Spasm Eimasticatorio and Cavernosa Pineale) the mediotrusive excursion could be a protective element perhaps to the detriment of the tooth itself.

For this reason, the term 'Mediotrusive Interference' should be re-evaluated

In figure 9c and 9d the mediotrusive path highlighted with the articulation paper was constructed by calculating the angle determined by the unilateral Root-MEPs which displaces the mandible by about 1/2mm on each side. By programming the Denar joint (figure 10) it was possible to construct an excursion with different angles between the TMJ, molar and canine. This procedure generates a natural path in which the canine guides together with the mediotrusion to protect the TMJ from the masticatory load that exists beyond bruxism.

Bibliography & references

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↑ Walton TR, Layton DM. Mediotrusive Occlusal Contacts: Best Evidence Consensus Statement. J Prosthodont. 2021 Apr;30(S1):43-51. doi: 10.1111/jopr.13328.PMID: 33783093
↑ Leitão AWA, Borges MMF, Martins JOL, Coelho AA, Carlos ACAM, Alves APNN, Silva PGB, Sousa FB. Celecoxib in the treatment of orofacial pain and discomfort in rats subjected to a dental occlusal interference model. Acta Cir Bras. 2022 Aug 15;37(5):e370506. doi: 10.1590/acb370506. eCollection 2022.PMID: 35976283
↑ Mo SY, Xue Y, Li Y, Zhang YJ, Xu XX, Fu KY, Sessle BJ, Xie QF, Cao Y. Descending serotonergic modulation from rostral ventromedial medulla to spinal trigeminal nucleus is involved in experimental occlusal interference-induced chronic orofacial hyperalgesia. J Headache Pain. 2023 May 10;24(1):50. doi: 10.1186/s10194-023-01584-3.PMID: 37165344
↑ Cui SJ, Yang FJ, Wang XD, Mao ZB, Gu Y. Mechanical overload induces TMJ disc degeneration via TRPV4 activation. Oral Dis. 2023 Apr 27. doi: 10.1111/odi.14595. Online ahead of print.PMID: 37103670

[:0-1] 1.0 ^1.1 ^1.2 Mansur Ahmad, Eric L Schiffman. Temporomandibular Joint Disorders and Orofacial Pain. Dent Clin North Am. 2016 Jan;60(1):105-24. doi: 10.1016/j.cden.2015.08.004.Epub 2015 Oct 21.

[2] Schiffman E, Ohrbach R, Truelove E, et al. Diagnostic criteria for temporomandibular disorders (DC/TMD) for clinical and research applications: recommendations of the International RDC/TMD Consortium Network* and orofacial pain special interest group†. J Oral Facial Pain Headache 2014;28(1):6–27

[3] Magda Krasińska-Mazur, Paulina Homel, Andrzej Gala, Justyna Stradomska, Małgorzata Pihut. Differential diagnosis of temporomandibular disorders - a review of the literature.Folia Med Cracov. 2022;62(2):121-137. doi: 10.24425/fmc.2022.141703.

[4] Chiara Vompi, Emanuela Serritella, Gabriella Galluccio, Santino Pistella, Alessandro Segnalini, Luca Giannelli, Carlo Di Paolo. Evaluation of Vision in Gnathological and Orthodontic Patients with Temporomandibular Disorders: A Prospective Experimental Observational Cohort Study. J Int Soc Prev Community Dent PMID: 33042891 PMCID: PMC7523923 DOI: 10.4103/jispcd.JISPCD_273_19

[:1-5] 5.0 ^5.1 Frisardi G. The use of transcranial stimulation in the fabrication of an occlusal splint.J Prosthet Dent. 1992 Aug;68(2):355-60. doi: 10.1016/0022-3913(92)90345-b.PMID: 1501190

[:2-6] 6.0 ^6.1 Cruccu G, Frisardi G, van Steenberghe D. Side asymmetry of the jaw jerk in human craniomandibular dysfunction. Arch Oral Biol. 1992 Apr;37(4):257-62. doi: 10.1016/0003-9969(92)90047-c.PMID: 1520092

[7] Kitagawa Y, Enomoto S, Nakamura Y, Hashimoto K. Asymmetry in jaw-jerk reflex latency in craniomandibular dysfunction patients with unilateral masseter pain. J Oral Rehabil. 2000 Oct;27(10):902-10. doi: 10.1046/j.1365-2842.2000.00595.x.PMID: 11065026

[8] Yoshino T.Kokubyo Gakkai Zasshi. Effects of lateral mandibular deviation on masseter muscle activity. 1996 Mar;63(1):70-87. doi: 10.5357/koubyou.63.70.PMID: 8725358

[9] G Frisardi, G Chessa, A Lumbau, S Okkesim, B Akdemir, S Kara, F.Frisardi. The Reliability of the Bilateral Trigeminal Roots-motor Evoked Potentials as an Organic Normalization Factor: Symmetry or Not Symmetry. Dentistry S2 8, 2161-1122

[10] Ro J.Y.,Capra N.F.: Physiological evidence for caudal brainstem projections of jaw muscle spindle afferents.Exp.Brain Res 1999;128: 425-434

[11] Capra N.F.,Ro J.Y.: Experimental muscle pain produces central modulation of proprioceptive signals arising from jaw muscle spindles. Pain 2000; 86: 151-162.

[12] Appelberg B.,Hulliger M.,Johansson H.Sojka P.: Actions on g-motoneurones elicited by electrical stimulation of group III muscle afferent fibers in the hind limb of the cat.J Physiol. 1983;335: 275-292.

[13] Macefield G.,Hagbarth E,Gorman R, Gandevia SC,, Burke D.: Decline in spindle support to a-motoneurones during sustained voluntary contractions.J.Physiol 1991;440:497-512.

[14] Mense S.,Skeppar P.: Discharge behavior of feline gamma-motoneurones following induction of an artificial myositis.Pain 1991; 46: 201-210.

[15] Pedersen J, Ljubisavljevic M, Bergenheim M.,Johansson H.: Alterations in information trasmission in ensembles of primary muscle spindle afferents after muscle fatigue in heteronymous muscle.Neuroscience 1998;84: 953-959.

[16] Zhou TF, Yang X, Wang RJ, Cheng MX, Zhang H, Wei JQ.Beijing Da Xue Xue Bao Yi Xue Ban. A clinical application study of digital manufacturing simple intraoral Gothic arch-tracing device in determining the centric relation of complete dentures. 2023 Feb 18;55(1):101-107. doi: 10.19723/j.issn.1671-167X.2023.01.015.PMID: 36718696

[17] Silva Ulloa S, Cordero Ordóñez AL, Barzallo Sardi VE. Relationship between dental occlusion and brain activity: A narrative review. Saudi Dent J. 2022 Nov;34(7):538-543. doi 10.1016/j.sdentj.2022.09.001. Epub 2022 Sep 16.PMID: 36267531

[18] Didier HA, Cappellari AM, Gaffuri F, Curone M, Tullo V, Didier AH, Giannì AB, Bussone G. Predictive role of gnathological techniques for the treatment of persistent idiopathic facial pain (PIFP). Neurol Sci. 2020 Nov;41(11):3315-3319. doi: 10.1007/s10072-020-04456-9. Epub 2020 May 21.PMID: 32440980

[19] Sagl B, Schmid-Schwap M, Piehslinger E, Rausch-Fan X, Stavness I. The effect of tooth cusp morphology and grinding direction on TMJ loading during bruxism. Front Physiol. 2022 Sep 15;13:964930. doi: 10.3389/fphys.2022.964930. eCollection 2022.PMID: 36187792

[20] Walton TR, Layton DM. Mediotrusive Occlusal Contacts: Best Evidence Consensus Statement. J Prosthodont. 2021 Apr;30(S1):43-51. doi: 10.1111/jopr.13328.PMID: 33783093

[21] Leitão AWA, Borges MMF, Martins JOL, Coelho AA, Carlos ACAM, Alves APNN, Silva PGB, Sousa FB. Celecoxib in the treatment of orofacial pain and discomfort in rats subjected to a dental occlusal interference model. Acta Cir Bras. 2022 Aug 15;37(5):e370506. doi: 10.1590/acb370506. eCollection 2022.PMID: 35976283

[22] Mo SY, Xue Y, Li Y, Zhang YJ, Xu XX, Fu KY, Sessle BJ, Xie QF, Cao Y. Descending serotonergic modulation from rostral ventromedial medulla to spinal trigeminal nucleus is involved in experimental occlusal interference-induced chronic orofacial hyperalgesia. J Headache Pain. 2023 May 10;24(1):50. doi: 10.1186/s10194-023-01584-3.PMID: 37165344

[23] Cui SJ, Yang FJ, Wang XD, Mao ZB, Gu Y. Mechanical overload induces TMJ disc degeneration via TRPV4 activation. Oral Dis. 2023 Apr 27. doi: 10.1111/odi.14595. Online ahead of print.PMID: 37103670

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-[[File:Clicker 00.jpg|left|300x300px|alt=]]
+{{main menu}}
-Nel capitolo 'Introduzione' abbiamo presentato un caso clinico dimostrativo che ha messo in dubbio il concetto di 'Malocclusione' nel senso che qualsiasi classe o morfologia occlusale dovrebbe sempre essere relazionata alle risposte neuromotorie trigeminali per confermare la presenza di un disturbo patologico masticatorio. In quel caso, il soggetto è risultato avere una perfetta simmetria in latenza, ampiezza ed aree integrali del Sistema Nervoso Centrale trigeminale (<sub>t</sub>CNS) per cui difficilmente classificabile come 'malocclusione'. Da tenere presente, però, che il soggetto in questione portatore di una evidente anomalia occlusale non aveva assolutamente nessun disturbo masticatorio ma cosa succede in un soggetto simile che riferisce dolori orofacciali e disturbi articolari. Vedremo in questo capitolo come va considerato un paziente di questo tipo e concluderemo con l'esposizione degli step impiegati per la riabilitazione protesica eseguita con un metodo elettrofisiologico trigeminale denominato 'Modello NGF' che si trasformerà, nel corso dell'edizione di Masticationpedia, in un modello diagnostico denominato 'Indice  <math>\Psi</math>'
 {{ArtBy|autore=Gianni Frisardi}}
+'''Abstract:''' This article explores the complex relationship between Temporomandibular Joint Disorders (TMD) and Orofacial Pain, as highlighted by Ahmad and Schiffman, who reported that 4.6% of the U.S. population is affected by these conditions. The cost of managing TMDs is considerable, yet their diagnostic complexity often leads to delays in appropriate care. A critical element in the differential diagnosis between orofacial pain and TMD is the high incidence rate of the condition, which can distort the predictive value of diagnostic tools like Bayes' theorem. Moreover, while TMD is the second most common chronic musculoskeletal condition after low back pain, its symptoms often overlap with other pathologies, making diagnosis even more challenging.
+Through clinical case examples, this study underlines the limitations of current gnathological approaches, which focus predominantly on dental occlusion without sufficiently considering the neuromotor network. The Neurognathological Functional (NGF) method is introduced as a paradigm shift in diagnosing and treating TMDs, emphasizing the role of trigeminal neuromotor responses over occlusal parameters alone. This method utilizes advanced trigeminal electrophysiological techniques, such as the bRoot-MEPs (bilateral motor evoked potentials), to assess the organic and functional integrity of the trigeminal system and restore masticatory function through neuro-evoked centric rehabilitation.
-=== Introduzione ===
+The study also discusses mandibular spatial analysis and its role in determining the optimal occlusal position, moving away from manual and traditional methods. Clinical results from patients treated with the NGF method reveal improvements in both neurophysiological symmetry and masticatory function. Furthermore, the article delves into the broader neuro-occlusal correlation, showing that chewing and occlusal patterns can influence brain activity and potentially affect neurodegenerative diseases.
-Un articoli di Ahmad e Schiffman<ref name=":0">Mansur Ahmad, Eric L Schiffman. Temporomandibular Joint Disorders and Orofacial Pain. Dent Clin North Am. 2016 Jan;60(1):105-24. doi: 10.1016/j.cden.2015.08.004.Epub 2015 Oct 21.</ref> sono emersi elementi interessanti che esigono una più approfondita analisi del fenomeno TMD. Gli autori hanno riportato, infatti, che circa il 5-12% della popolazione degli Stati Uniti è affetto da TMD e il costo annuale della gestione della TMD, esclusi i costi relativi all'imaging, è di circa 4 miliardi di dollari. Interview Survey (NHIS) che includeva un totale di 189.977 persone, il 4,6% (n = 8964) aveva avuto disturbi dell'articolazione temporo-mandibolare e dei muscoli (TMJD).<blockquote>Come abbiamo già più volte citato nel corso dei capitoli precedenti, uno degli elementi critici nella diagnostica differenziale tra Dolore orofacciale e TMD è il dato dell'incidenza della malattia che va ad inquinare obbligatoriamente il risultato del valore predittivo del teorema di Bayes. In questo caso, dalle considerazioni degli autori<ref name=":0" /> siamo sul 4,6%.</blockquote>
+In conclusion, TMD and orofacial pain require a more integrated diagnostic approach that considers the trigeminal system's role in masticatory and neuromotor function. The NGF method offers a new perspective on TMD management, addressing both the dental and neurological aspects of the condition for a more precise and effective treatment.
+===Introduction===
+An article by Ahmad and Schiffman<ref name=":0">Mansur Ahmad, Eric L Schiffman. [https://www.ncbi.nlm.nih.gov/pmc/articles/pmid/26614951/ Temporomandibular Joint Disorders and Orofacial Pain.] Dent Clin North Am. 2016 Jan;60(1):105-24. doi: 10.1016/j.cden.2015.08.004.Epub 2015 Oct 21.</ref> revealed interesting elements that call for a more in-depth analysis of the TMD phenomenon. The authors reported, in fact, that about 5-12% of the US population is affected by TMD and the annual cost of TMD management, excluding imaging costs, is about $4 billion. Interview Survey (NHIS) that included a total of 189,977 people, 4.6% (n = 8964) had temporomandibular joint and muscle disorders (TMJD).
-Sappiamo bene, ormai, che lo 'TMD' è la seconda condizione muscoloscheletrica cronica più comune dopo la lombalgia cronica<ref>Schiffman E, Ohrbach R, Truelove E, et al. Diagnostic criteria for temporomandibular disorders (DC/TMD) for clinical and research applications: recommendations of the International RDC/TMD Consortium Network* and orofacial pain special interest group†. J Oral Facial Pain Headache 2014;28(1):6–27</ref> e malgrado Ahmad e Schiffman<ref name=":0" /> hanno riportato in modo esaustivo l'importanza dell'imaging per rendere corrette le diagnosi intra-articolari dell'ATM, sorge il dubbio della sovrapposizioni di stati sintomatico-clinici come è capitato di vedere per i casi clinici riportati nei capitoli precedenti di Masticationpedia.
+<blockquote>As we have already mentioned several times in the previous chapters, one of the critical elements in the differential diagnosis between orofacial pain and TMD is the datum of the incidence of the disease, which necessarily pollutes the result of the predictive value of Bayes' theorem. In this case, from the authors' considerations<ref name=":0" /> we are at 4.6 per cent.</blockquote>
-Questa interferenza non dipende dalla capacità del medico ma dalla forma mentis deterministica che non lascia spazio al fenomeno di sovrapposizione di più patologie che simulano lo stessa sintomatologia del TMD. Una veloce carrellata di casi clinic riportati nei capitoli di Masticationpedia ci può far ricordare meglio la complessità e la veridicità di questa affermazione. (Figura 1)
+We know by now that 'TMD' is the second most common chronic musculoskeletal condition after chronic low back pain<ref>Schiffman E, Ohrbach R, Truelove E, et al. [https://www.ncbi.nlm.nih.gov/pmc/articles/pmid/24482784/ Diagnostic criteria for temporomandibular disorders (DC/TMD) for clinical and research applications: recommendations of the International RDC/TMD Consortium Network* and orofacial pain special interest group†]. J Oral Facial Pain Headache 2014;28(1):6–27</ref> and although Ahmad and Schiffman<ref name=":0" /> have exhaustively reported on the importance of imaging to make correct intra-articular diagnoses of TMJ, the doubt arises of the overlapping of symptomatic-clinical states as we have seen in the clinical cases reported in the previous chapters of Masticationpedia.
+This interference does not depend on the physician's ability but on the deterministic forma mentis that leaves no room for the phenomenon of overlapping pathologies simulating the same TMD symptomatology. A quick roundup of clinical cases reported in the chapters of Masticationpedia can remind us better of the complexity and truthfulness of this statement. (Figure 1)
 <center>
 <gallery widths="250" heights="200" perrow="2" slideshow""="">
-File:Spasmo emimasticatorio.jpg|'''Figure 1a:''' Paziente diagnosticata precedentemente seguendo il modello RDC come affetta da Disordini Temporomandibolari.
+File:Spasmo emimasticatorio.jpg|'''Figure 1a:''' Patient previously diagnosed following the DRC model as suffering from Temporomandibular Disorders.
-File:IMG0005 modified.jpg|'''Figura 1b:''' Codice linguaggio macchina decriptato in 'Trasmissione efaptica'. Diagnosi definitiva ' '''Spasmo Emimasticatorio''' '
+File:IMG0005 modified.jpg|'''Figure 1b:''' Machine language code decrypted in 'Hephaptic transmission'. Definitive diagnosis ' ''Hemimasticatory spasm'' '.
-File:IMG0103.jpg|'''Figure 1c:''' Paziente diagnosticato precedentemente seguendo il modello RDC come affetto da Disordini Temporomandibolari.
+File:IMG0103.jpg|'''Figure 1c:''' Patient previously diagnosed following the DRC model as suffering from Temporomandibular Disorders.
-File:Recovery cycle.jpeg|'''Figura 1d:''' Codice linguaggio macchina decriptato in 'Ipereccitabilità trigeminale'. Diagnosi definitiva '  '''Cavernosa Pineale''' '
+File:Recovery cycle.jpeg|'''Figure 1d:''' Machine language code decrypted in 'Trigeminal hyperexcitability'. Definitive diagnosis ' ''Cavernous Pineal'' '
-File:Meningioma 6 by Gianni Frisardi.jpeg|'''Figura 1e:''' Paziente diagnosticato precedentemente seguendo il modello RDC come affetto da Disordini Temporomandibolari.
+File:Meningioma 6 by Gianni Frisardi.jpeg|'''Figure 1e:''' Patient previously diagnosed following the DRC model as suffering from Temporomandibular Disorders.
-File:Meningioma 4 by Gianni Frisardi.jpeg|'''Figura 1f:''' Codice linguaggio macchina decriptato in 'Latenza Periodo Silente Elettrico '. Diagnosi definitiva ' '''Meningioma''' '
+File:Meningioma 4 by Gianni Frisardi.jpeg|'''Figure 1f:''' Decrypted machine language code in 'Latency Period Silence'. Definitive diagnosis ' ''Meningioma'' '
 </gallery>
 </center>
-Dice giusto Magda Krasińska-Mazur et al.<ref>Magda Krasińska-Mazur, Paulina Homel, Andrzej Gala, Justyna Stradomska, Małgorzata Pihut. Differential diagnosis of temporomandibular disorders - a review of the literature.Folia Med Cracov. 2022;62(2):121-137. doi: 10.24425/fmc.2022.141703.</ref> che la diagnosi corretta dei disturbi temporomandibolari si basa sull'anamnesi e su un esame fisico approfondito, nonché sui risultati di test aggiuntivi.....ma quali?{{q2|Quale potrebbe essere il migliore approccio ai pazienti TMDs?|....presenteremo in questo contesto un modello diagnostico contestualmente alla ripristino delle condizioni funzionali masticatorie del paziente in questione}}Fin qui abbiamo discusso su molti aspetti che in qualche modo ritardano la diagnosi differenziale in paziente che riferiscono una sintomatologia sovrapponibile a varie manifestazioni cliniche, diagnosi differenziale che se, invece, eseguita in tempi giusti e rapidi potrebbe salvare la vita al soggetto come è successo al nostro 'Bruxer' e purtroppo no al nostro 'Balancer'. La forma mentis del medico in questi casi è fondamentale e l'elemento determinante rimane quello di uscire dal 'contesto specialistico' per assumere contestualmente una visione indeterministica e probabilistica della medicina. Ciò non è diverso per quanto riguarda i pazienti affetti effettivamente da DTMs perchè non esistendo una vera e propria disciplina neuro gnatologica, la diagnosi nonché la terapia di questi soggetti rimane quella standard e cioè gnatologica. La disciplina gnatologica, seppur molto valida, anch'essa è limitata perchè restringe il campo dello 'Osservabile' al parametro occlusale disinteressandosi di tutto il resto che entra a far parte del network neuromotorio masticatorio e non solo. <ref>Chiara Vompi, Emanuela Serritella, Gabriella Galluccio, Santino Pistella, Alessandro Segnalini, Luca Giannelli, Carlo Di Paolo. Evaluation of Vision in Gnathological and Orthodontic Patients with Temporomandibular Disorders: A Prospective Experimental Observational Cohort Study. J Int Soc Prev Community Dent PMID: 33042891 PMCID: PMC7523923 DOI: 10.4103/jispcd.JISPCD_273_19</ref>Presenteremo questo caso clinico di un paziente con DTMs per dare un significativo cambiamento clinico diagnostico/terapeutico nel campo della 'Neuro Gnatologia Funzionale' chiamandolo, appunto, metodo NGF.
+Rightly says Magda Krasińska-Mazur et al.<ref>Magda Krasińska-Mazur, Paulina Homel, Andrzej Gala, Justyna Stradomska, Małgorzata Pihut. Differential diagnosis of temporomandibular disorders - a review of the literature.Folia Med Cracov. 2022;62(2):121-137. doi: 10.24425/fmc.2022.141703.</ref> that the correct diagnosis of temporomandibular disorders is based on anamnesis and a thorough physical examination, as well as the results of additional tests.....but which ones?{{q2|What could be the best approach to TMDs patients?|.... we will present in this context a diagnostic model in the context of restoring the functional masticatory condition of the patient in question}}So far we have discussed many aspects that in some way delay the differential diagnosis in patients who report overlapping symptomatology and various clinical manifestations, a differential diagnosis that if, on the other hand, performed correctly and quickly could save the subject's life as happened to our 'Bruxer' and unfortunately not to our 'Balancer'. The doctor's forma mentis in these cases is fundamental and the decisive element remains that of stepping out of the 'specialist context' in order to take an indeterministic and probabilistic view of medicine at the same time. This is no different with regard to patients actually suffering from TMDs because there is no real neuro-gnathological discipline, the diagnosis as well as the therapy of these subjects remains the standard one, namely gnathological. The discipline of gnathology, although very valid, is also limited because it restricts the field of the 'observable' to the occlusal parameter, disregarding everything else that is part of the masticatory neuromotor network and beyond.<ref>Chiara Vompi, Emanuela Serritella, Gabriella Galluccio, Santino Pistella, Alessandro Segnalini, Luca Giannelli, Carlo Di Paolo. [https://www.ncbi.nlm.nih.gov/pmc/articles/pmid/33042891/ Evaluation of Vision in Gnathological and Orthodontic Patients with Temporomandibular Disorders: A Prospective Experimental Observational Cohort Study.] J Int Soc Prev Community Dent PMID: 33042891 PMCID: PMC7523923 DOI: 10.4103/jispcd.JISPCD_273_19</ref> We will present this clinical case of a patient with DTMs to give a significant clinical diagnostic/therapeutic change in the field of 'Functional Neuro Gnathology' calling it, precisely, the NGF method.
+===Anamnesis===
+[[File:Clicker 00.jpg|thumb|'''Figure 2:''' Oral situation of the patient affected by TMDs showing the ant erior cross bite]]
+As usual, we call our patient with a fancy name and precisely 'Clicker' because the patient had been suffering from temporomandibular joint (TMJ) clicks for years. Clicker presented to our neuropathology department complaining of severe orofacial pain and reporting a chronic right TMJ joint removal. She arrived after having already been diagnosed as DTMs always following the RDC protocol and treated with a biteplane to manage the nocturnal teeth grinding only. She, a 40-year-old patient who reported orofacial pain with joint noises such as clicks and crashes on both sides of the face and difficulty in chewing.
-=== Anamnesi  ===
+A first clinical occlusal examination shows a functional occlusal class III with sliding in protrusion in reaching the maximum intercuspidation. On palpation, the masseters, temporals, and external pterygoids on both sides were tender. No balance and gait disturbances, no vertigo, no tinnitus but as our routine we immediately performed trigeminal electrophysiological tests in order to avoid any structural involvement of the trigeminal Central Nevous System (<sub>t</sub>NCS). As already explained in the chapter concerning the 'Balancer' patient with Meningioma in which the interference EMG examination performed by the dental colleagues did not give indications of organic pathology of the tNCS in our Diagnostic Center we only perform Evoked Potentials and the battery of trigmeinal reflexes. In this chapter, taking into account the clinical situation, we have bypassed the purely dental context as, after an initial objective examination, the malocclusive disorder is striking but not certain (figure 2).
-[[File:Clicker 00.jpg|thumb|'''Figura 2:''' Situazione orla del paziente affetto da DTMs in cui si evince il cross bite anteriore]]
-Chiamiamo come di consueto il nostro paziente con un nome di fantasia e precisamente 'Clicker' perchè la paziente soffriva da anni di click dell'articolazione temporomandibolare (TMJ). Clicker si presentò nel nostro dipartimento di neuropatologia accusando forti dolori orofacciali e riferendo un cronico rimuove articolare a livello della TMJ di destra. Arrivò dopo essere già stata diagnosticata come DTMs seguendo sempre il protocollo RDC e trattata con biteplane per gestire il digrignamento solo notturno. Paziente di circa 40 anni che riferiva dolore orofacciale con rumori articolari quali click e scrosci da ambedue i lati della faccia e difficoltà nella masticazione.
+[[File:Clicker 01.jpg|thumb|alt=|left|615x615px|'''Figure 3:''' Neurognathological Functional electrophysiological tests]]
-Ad un primo esame clinico occlusale si evince una III classe occlusale funzionale con scivolamento in protrusa nel raggiungimento della massima intercuspidazione. Alla palpazione risultavano dolenti i masseteri, temporali e pterigoidei esterni di ambo i lati. No disturbi di equilibrio e deambulazione, no vertigini no acufeni ma come nostra routine eseguimmo immediatamente gli esami elettrofisiologici trigeminali nell'intento di scongiurare qualsiasi coinvolgimento strutturale del Sistema Nevoso Centrale trigeminale (<sub>t</sub>NCS). Come già esposto nel capitolo riguardante il paziente 'Balancer' con Meningioma in cui l'esame dello EMG interferenziale eseguito dai colleghi odontoiatrici non dava indicazioni di patologia organica del <sub>t</sub>NCS nel nostro Centro Diagnostico eseguiamo esclusivamente Potenziali Evocati e la batteria dei riflessi trigmeinali. In questo capitolo, tenendo conto della situazione clinica abbiamo bypassato il contesto puramente odontoiatrico essendo eclatante ma non certo, dopo un primo esame obiettivo, il disturbo malocclusivo (figura 2) [[File:Clicker 01.jpg|thumb|alt=|left|615x615px|Figura 3: Esami elettrofiologici di tipo Neuro Gnatologico Funzionale]]
+====Trigeminal electrophysiology====
+As has now been documented in the previous chapters of Masticationpedia, the heart of the scientific philosophy of Masticationpedia is substantially the normalization of masticatory functions to the Central Nervous System and trigeminal peripheral <sub>t</sub>CNS and not to dental occlusion. This is able to couple the occlusal abnormality to the 'state' conditions of the tCNS as well documented in the first chapter '[[Introduction]]' where we showed a perfect trigeminal electrophysiological symmetry in the subject with severe dental malocclusion and a frankly asymmetric neuromotor condition in a subject with perfect occlusion after being treated with orthognathic surgery. The electrophysiological tests in subjects with TMDs are limited to the bilateral Motor Evoked Potentials of the trigeminal roots which we have precisely put over the years called bRoot-MEPs,<ref name=":1">Frisardi G. The use of transcranial stimulation in the fabrication of an occlusal splint.J Prosthet Dent. 1992 Aug;68(2):355-60. doi: 10.1016/0022-3913(92)90345-b.PMID: 1501190</ref> from the jaw jerk<ref name=":2">Cruccu G, Frisardi G, van Steenberghe D. Side asymmetry of the jaw jerk in human craniomandibular dysfunction. Arch Oral Biol. 1992 Apr;37(4):257-62. doi: 10.1016/0003-9969(92)90047-c.PMID: 1520092</ref> performed while keeping the mandible in the rest position (Jaw jerk in rest position) and the jaw jerk keeping the jaw closed with moderate muscle activity (jaw jerk in occlusal position).
-==== Elettrofisiologia trigeminale ====
+=====<sub>b</sub>Root-MEPs=====
-Come si è ormai documentato nei capitoli precedenti di Masticationpedia, il cuore della filosofia scientifica di Masticationpedia, è sostanzialmente il normalizzare le funzioni masticatorie al Sistema Nervoso Centrale e periferico trigeminale <sub>t</sub>CNS e non all'occlusione dentaria. Ciò è in grado di accoppiare la anormalità occlusale alle condizioni di 'stato' del <sub>t</sub>CNS come ben documentato nel primo capitolo '[[Introduzione]]' dove abbiamo mostrato una perfetta simmetria elettrofisiologica trigeminale nel soggetto con grave malocclusione dentale ed una condizione neuromotoria francamente asimmetrica in un soggetto con perfetta occlusione dopo essere stato trattato con chirurgia ortognatica. I test elettrofisiologici nei soggetti con DTMs sono limitati ai Potenziali Evocati Motori bilaterali delle radici trigeminali da noi messi appunto nel corso di anni denominati <sub>b</sub>Root-MEPs,<ref name=":1">Frisardi G. The use of transcranial stimulation in the fabrication of an occlusal splint.J Prosthet Dent. 1992 Aug;68(2):355-60. doi: 10.1016/0022-3913(92)90345-b.PMID: 1501190</ref> dal jaw jerk<ref name=":2">Cruccu G, Frisardi G, van Steenberghe D. Side asymmetry of the jaw jerk in human craniomandibular dysfunction. Arch Oral Biol. 1992 Apr;37(4):257-62. doi: 10.1016/0003-9969(92)90047-c.PMID: 1520092</ref> eseguito mantenendo la mandibola in posizione di riposo ( Jaw jerk in rest position) ed il jaw jerk mantenendo la mandibola in chiusura con moderata attività muscolare ( jaw jerk in occlusal position).
+In figure 3 we can see the responses of the motor evoked potentials of the two trigeminal roots, the jaw jerk in the rest position and in the position of maximum intercuspidation. In particular, the Nervous system responds to Transcranial Electrical Stimulation of the trigeminal roots with two evoked potentials that are perfectly symmetrical both in latency and in amplitude and specifically the latencies are positioned at an onset of <math>1R= 2,01</math>ms and <math>1L= 1,99 </math>ms while the peak-to-peak amplitudes <math>2R-3R= 5</math> mV and <math>2L-3L= 5,2</math> mV. This result is fundamental for the differential diagnosis between organic and functional pathologies, in fact, it demonstrates that the system is organically symmetrical and synchronous and this determines the term that we will see recur in a decisive way in the continuation of the Masticationpedia chapters called 'Organic Symmetry'. Bear in mind right now that the 'Organic Symmetry' parameter will be considered an element of 'Normalization' of the trigeminal reflex responses as its latency and amplitude symmetry indicates a perfect 'state' of integrity of the  <sub>t</sub>CNS and that at the same time one should expect an equally 'state' of functional symmetry due to trigeminal reflex responses. Let's see, therefore, the trigeminal functional 'state' of the  <sub>t</sub>CNS by analyzing the jaw jerk.
-===== <sub>b</sub>Root-MEPs =====
+=====Jaw jerk in rest position=====
-In figura 3 possiamo assistere alle risposte dei potenziali evocati motori delle due radici trigeminali, il jaw jerk in posizione di riposo ed in posizione di massima intercuspidazione. In particolare alla Stimolazione Transcraniale Elettrica delle radici trigeminale il sistema Nervoso risponde conn due potenziali evocati perfettamente simmetrici sia in latenza che in ampiezza e nello specifico le latenze si posizionano ad un onset di <math>1R= 2,01</math>ms e <math>1L= 1,99 </math>ms mentre le ampiezze picco-picco  <math>2R-3R= 5</math> mV e <math>2L-3L= 5,2</math> mV. Questo risultato è fondamentale per la diagnosi differenziale tra patologie organiche e funzionale, infatti, sta a dimostrare che il sistema organicamente è simmetrico e sincrono e ciò determina il termine che vedremo ripresentarsi in modo determinante nel proseguitò dei capitoli di Masticationpedia denominato 'Organic Symmetry'. Si tenga presente fin da ora che il parametro 'Organic Symmetry' sarà considerato elemento di 'Normalizzazione' delle risposte riflesse trigeminali in quanto la propria simmetria di latenza ed ampiezza indica un perfetto 'stato' di integrità del <sub>t</sub>CNS e che contestualmente dovrebbe aspettarsi un altrettanto 'stato' di simmetria funzionale dovuto alle risposte riflesse trigeminali. Vediamo, dunque, lo 'stato' funzionale trigeminale del  <sub>t</sub>CNS analizzando il jaw jerk.
+The stretch reflex test called jaw jerk was performed keeping the mandible in rest position to distinguish the input component to the tCNS excluding the input of the periodonatal receptors. The results were not encouraging due to the relative asymmetry of latency (<math>1R= 8,5</math>ms and <math>1L= 7,5</math> ms) and peak-to-peak amplitude (<math>2R-3R= 0,3
+</math>mV; <math>2L-3L= 0,6</math>mV). In particular, the latency delay could be explained by a facilitation on gamma motor neurons, in contrast with the study by Kitagawa et al.<ref>Kitagawa Y, Enomoto S, Nakamura Y, Hashimoto K. Asymmetry in jaw-jerk reflex latency in craniomandibular dysfunction patients with unilateral masseter pain. J Oral Rehabil. 2000 Oct;27(10):902-10. doi: 10.1046/j.1365-2842.2000.00595.x.PMID: 11065026</ref> in which it is asserted that the facilitation on the ipsilateral side could be produced by an enhancement of the gamma drive induced by a prolonged nociceptive stimulation. In our case the most significant datum is the difference of <math>\simeq 50%</math> with reduction on the right affected side. We have noticed in our studies that in the rest position the jaw jerk also shows a dependence not only on the acceleration of the trigger stroke but also on the spatial position of the jaw as it is not conditioned by the occlusal position.<ref name=":2" />
-===== Jaw jerk in posizione di riposo =====
+=====Jaw jerk in rest position =====
-É stato eseguito il test del riflesso da stiramento denominato jaw jerk mantenendo la mandibola in posizione di riposo per distinguere la componente in entrata al <sub>t</sub>CNS escludendo l'input dei recettori periodonatali. I risultai sono stati non incoraggiantei per la relativa asimmetria di latenza (<math>1R= 8,5</math> ms <math>1L= 7,5</math> ms) e di ampiezza picco-picco (<math>2R-3R= 0,3
+The jaw jerk, keeping the mandible in a position of centric occlusion, performed to verify the contribution of the periodontal receptors together with the muscle and tendon proprioceptors, was obviously facilitated by the dental contact but the asymmetry in amplitude (<math>2R-3R= 0, 1
-</math>mV; <math>2L-3L= 0,6</math>mV ). In particolare il ritardo in latenza potrebbe spiegarsi con una facilitazione sui motoneuroni gamma andando in contrasto con lo studio di Kitagawa et al.<ref>Kitagawa Y, Enomoto S, Nakamura Y, Hashimoto K. Asymmetry in jaw-jerk reflex latency in craniomandibular dysfunction patients with unilateral masseter pain. J Oral Rehabil. 2000 Oct;27(10):902-10. doi: 10.1046/j.1365-2842.2000.00595.x.PMID: 11065026</ref> in cui si asserisce che la facilitazione sul lato omolaterale potrebbe essere prodotta da un potenziamento del gamma drive indotto da una stimolazione nocicettiva prolungata. Nel nostro caso il dato più significativo è la differenza di <math>\simeq 50%</math>con riduzione sul lato algido destro. Abbiamo notato nei nostri studi che in posizione di riposo il jaw jerk mostra anche una dipendenza non solo alla accelerazione del colpo del trigger ma anche alla posizione spaziale della mandibola non essendo condizionata dalla posizione occlusale.<ref name=":2" />
+</math>mV; <math>2L-3L= 1</math> mV) increased. This result agrees with what was stated in a study by Yoshino T et al.<ref>Yoshino T.Kokubyo Gakkai Zasshi. Effects of lateral mandibular deviation on masseter muscle activity. 1996 Mar;63(1):70-87. doi: 10.5357/koubyou.63.70.PMID: 8725358 </ref> in which the mandibular position was deviated by 0.5, 1.0, 1.5, 2.0 and 3.0 mm to the right and left from a reference position corresponding to the rest position. Jaw jerk amplitude on the mediotrusive side increased primarily in proportion to mandibular deviation. The study concludes by suggesting that jaw jerk may aid the clinical examination of minor mandibular deviations. The conclusion of this 1st trigeminal electrophysiological step was to ascertain the organic integrity of the <sub>t</sub>CNS through the symmetry and synchronics of the <sub>b</sub>Root-MEPs,<ref name=":1" /> and consider it as an 'Organic Symmetry',<ref>G Frisardi, G Chessa, A Lumbau, S Okkesim, B Akdemir, S Kara, F.Frisardi. The Reliability of the Bilateral Trigeminal Roots-motor Evoked Potentials as an Organic Normalization Factor: Symmetry or Not Symmetry. Dentistry S2 8, [tel:2161-1122 2161-1122]</ref> i.e. normalizer of the masticatory neurophysiological process while the asymmetries of the jaw jerk a functional disorder due to an unbalanced peripheral input or an inhibitory process on the trigeminal motoneurons of the nociceptive type. In essence, the conclusion of a mandibular spatial disorder would seem more indicative, which we will ascertain later when the Neuro Evoked Centric Relationship is performed to verify the physiological spatial position.
-===== Jaw jerk in posizione di riposo =====
+=====Silent period of the masticator muscles=====
-Il jaw jerk, mantenendo la mandibola in posizione di occlusione centrica, eseguito per verificare il contributo dei recettori periodontali insieme ai propriocettori muscolari, tendine, è risultato, ovviamente, facilitato dal contatto dentario ma è aumentata la asimmetria in ampiezza (<math>2R-3R= 0, 1
+[[File:Clicker 3.jpg|'''Figure 4:''' Silent period of masticatory muscles and representation of areas of interest marked with arrows.|alt=|thumb|250x250px]]
-</math>mV; <math>2L-3L= 1</math> mV). Questo risultato concorda con quanto affermato in uno studio di Yoshino T et al.<ref>Yoshino T.Kokubyo Gakkai Zasshi. Effects of lateral mandibular deviation on masseter muscle activity. 1996 Mar;63(1):70-87. doi: 10.5357/koubyou.63.70.PMID: 8725358 </ref> in cui la posizione mandibolare era stata deviata di 0,5, 1,0, 1,5, 2,0 e 3,0 mm a destra ed a sinistra da una posizione di riferimento corrispondente alla posizione di riposo. L'ampiezza del jaw jerk sul lato mediotrusivo sono aumentate principalmente in proporzione alla deviazione mandibolare. Lo studio conclude suggerendo che suggerito che iil jaw jerk può aiutare l'esame clinico di piccole deviazioni mandibolari. La conclusione di questo 1° step eletttrofisiologico trigeminale è stata di appurare l'integrità organica del  <sub>t</sub>CNS attraverso la simmetria e sincronici del <sub>b</sub>Root-MEPs,<ref name=":1" /> e considerarlo come 'Organic Symmetry' <ref>G Frisardi, G Chessa, A Lumbau, S Okkesim, B Akdemir, S Kara, F.Frisardi. The Reliability of the Bilateral Trigeminal Roots-motor Evoked Potentials as an Organic Normalization Factor: Symmetry or Not Symmetry. Dentistry S2 8, 2161-1122</ref>cioè normalizzatore del processo neurofisiologico masticatorio mentre le asimmetrie del jaw jerk depongono per un disturbo funzionale dovuto ad un sbilanciato input periferico oppure un processo inibitorio sui motoneuroni trigeminali di tipo nocicettivo. In sostanza sembrerebbe maggiormente indicativa la conclusione di disturbo spaziale mandibolare che appureremo in secondo momento quando si eseguita la Relazione Centrica Neuro Evocata per verificare la posizione spaziale fisiologica.
+Figure 4 shows the neuromuscular responses of the silent period to chin percussion through a triggered neurological hammer when the patient was asked to clench her teeth maximally. If from a neurological point of view it is not possible to highlight elements referable to organic alterations of the <sub>t</sub>CNS, some electrophysiological characteristics, however, are to be referred to a functional disorder of the system. In the upper trace, a decrease in the motor neuron reactivation phase can be seen immediately following the silent period. The possible neurophysiological mechanism capable of determining a similar decrease in facilitatory activities on the mandibular silent period can be ascribed to a change in the spindle motor drive induced by the input of muscle proprioceptors and nociceptors. The neuronal network of this process would take place through a loop formed by: muscle nociceptive afferents, the subnucleus caudalis of the V, inhibitory interneurons on static motor neurons and, as a last link, the modulation of the sensitivity of the neuromuscular spindles..<ref>Ro J.Y.,Capra  N.F.: Physiological evidence for caudal brainstem projections of jaw muscle spindle afferents.Exp.Brain Res 1999;128: 425-434</ref> <ref>Capra N.F.,Ro J.Y.: Experimental muscle pain produces central modulation of proprioceptive signals arising from jaw muscle spindles. Pain 2000; 86: 151-162.</ref><ref>Appelberg B.,Hulliger M.,Johansson H.Sojka P.: [https://www.ncbi.nlm.nih.gov/pmc/articles/pmid/6875878/ Actions on g-motoneurones elicited by electrical stimulation of group III muscle afferent fibers in the hind limb of the cat].J Physiol. 1983;335: 275-292.</ref><ref>Macefield  G.,Hagbarth E,Gorman R, Gandevia SC,, Burke D.: [https://www.ncbi.nlm.nih.gov/pmc/articles/pmid/1839558/ Decline in spindle support to a-motoneurones during sustained voluntary contractions.]J.Physiol 1991;440:497-512.</ref><ref>Mense S.,Skeppar P.: Discharge behavior of feline gamma-motoneurones following induction of an  artificial myositis.Pain 1991; 46: 201-210.</ref><ref>Pedersen J, Ljubisavljevic M, Bergenheim M.,Johansson H.: Alterations in information trasmission  in ensembles  of primary muscle spindle afferents after muscle fatigue in heteronymous muscle.Neuroscience 1998;84: 953-959.</ref>  Also in this context the inhibitory component most likely prevails over the excitatory one and this could be ascribed to a malocclusion as we will see later. In particular, it can be noted the overlapping of the jaw jerk behavior, previously tested, in a path rectification condition. The arrow indicates the jaw jerk on all traces and the decrease in amplitude can be observed for the right masseter while it is relatively symmetrical on the temporal muscles.<br />
-===== Periodo Silente dei muscoli masticator =====
+===Mandibular spatial analysis===
-[[File:Clicker 3.jpg|thumb|'''Figura 4:''' Periodo silente dei muscoli masticatori e rappresentazione delle aree di interesse segnalate con frecce.|alt=|500x500px]]
+On this subject unfortunately there are innumerable conceptual conflicts redundant regularly coming back into vogue after a period of years such as the gothic arch tracing method to determine the centric relationship of full dentures, as suggested by Zhou TF et al.<ref>Zhou TF, Yang X, Wang RJ, Cheng MX, Zhang H, Wei JQ.Beijing Da Xue Xue Bao Yi Xue Ban. A clinical application study of digital manufacturing simple intraoral Gothic arch-tracing device in determining the '''centric''' relation of complete dentures. 2023 Feb 18;55(1):101-107. doi: 10.19723/j.issn.1671-167X.2023.01.015.PMID: 36718696 </ref> From what has been exposed in all the chapters previously published on Masticationpedia, it is clear that the approximation of manual methods or vague interpretations derived from a logic of verbal language cannot be represented in the scientific philosophy of Masticationpedia which tends to focus on a mesoscopic model more than macroscopically descriptive and formal through statistical mathematical models as we will see below. Therefore we do not share the opinion of Zhou TF et al but absolutely in line with the concepts expressed by Silva Ulloa S. et al.<ref>Silva Ulloa S, Cordero Ordóñez AL, Barzallo Sardi VE. Relationship between '''dental''' '''occlusion''' and brain activity: A narrative review. Saudi Dent J. 2022 Nov;34(7):538-543. doi 10.1016/j.sdentj.2022.09.001. Epub 2022 Sep 16.PMID: 36267531 </ref> in which it is concluded that the sensorimotor cortex is affected by changes in occlusion and it is hypothesized that occlusion may play an important role in the development of diseases, from anxiety and stress to Alzheimer's disease and senile dementia. We also share the heartfelt suggestion of Silva Ulloa S. et al. in which she urges dentists to consider that alterations in the occlusal pattern during chewing can lead to changes in the activation of several brain regions related to memory, learning, anticipatory pain and anxiety.
-Nella figura 4 vengono mostrate le risposte neuromuscolari del periodo silente da percussione del mento attraverso un martello neurologico triggerato quando alla paziente veniva chiesto di stringere con forza massimale i denti. Se da un punto di vista neurologico non si possono evidenziare elementi riferibili ad alterazioni organiche del <sub>t</sub>CNS, alcune caratteristiche elettrofisiologiche, tuttavia, sono da riferire ad un disturbo funzionale del sistema.  Nella traccia superiore si può notare un decremento della fase di  riattivazione motoneuronale immediatamente successivo al periodo silente. Il possibile meccanismo neurofisiologico capace di determinare un simile decremento delle attività facilitatorie sul periodo silente mandibolare può essere ascritto ad un cambiamento del drive fusomotorio indotto dall’input dei propriocettori e nocicettori muscolari. Il network neuronale di questo processo avverrebbe attraverso un loop formato da: afferenze nocicettive muscolari, il subnucleus caudalis del V, interneuroni  inibitori sui motoneuroni  <math>\gamma</math> statici e, come ultimo anello, la modulazione della sensibilità dei fusi neuromuscolari.<ref>Ro J.Y.,Capra  N.F.: Physiological evidence for caudal brainstem projections of jaw muscle spindle afferents.Exp.Brain Res 1999;128: 425-434</ref> <ref>Capra N.F.,Ro J.Y.: Experimental muscle pain produces central modulation of proprioceptive signals arising from jaw muscle spindles. Pain 2000; 86: 151-162.</ref><ref>Appelberg B.,Hulliger M.,Johansson H.Sojka P.: Actions on g-motoneurones elicited by electrical stimulation of group III muscle afferent fibers in the hind limb of the cat.J Physiol. 1983;335: 275-292.</ref><ref>Macefield  G.,Hagbarth E,Gorman R, Gandevia SC,, Burke D.: Decline in spindle support to a-motoneurones during sustained voluntary contractions.J.Physiol 1991;440:497-512.</ref><ref>Mense S.,Skeppar P.: Discharge behavior of feline gamma-motoneurones following induction of an  artificial myositis.Pain 1991; 46: 201-210.</ref><ref>Pedersen J, Ljubisavljevic M, Bergenheim M.,Johansson H.: Alterations in information trasmission  in ensembles  of primary muscle spindle afferents after muscle fatigue in heteronymous muscle.Neuroscience 1998;84: 953-959.</ref>  Anche in questo contesto molto probabilmente la componente inibitoria prevale su quella eccitatori e ciò potrebbe essere ascritto ad una malocclusione come vedremo successivamente. In particolare si può notare la sovrapposizione del comportamento del jaw jerk, testato in precedenza, in una condizione di rettificazione del tracciato. La freccia indica, appunto, il jaw jerk su tutte le tracce e si può osservare la diminuzione in ampiezza per il massetere destro mentre risulta relativamente simmetrico sui muscoli temporali.<br />
-=== Analisi spaziale mandibolare ===
+{{q2|This suggests that chewing maintains the integrity of some areas of the brain and that it may be a key factor in the onset of neurodegenerative diseases.|Relationship between dental occlusion and brain activity: A narrative review
-Su questo argomento purtroppo ci sono innumerevoli conflitti concettuali che ridondano ritornando regolarmente in voga dopo un periodo di anni come la metodica tracciamento dell'arco gotico per determinare la relazione centrica di protesi complete, come suggerito da Zhou TF et al .<ref>Zhou TF, Yang X, Wang RJ, Cheng MX, Zhang H, Wei JQ.Beijing Da Xue Xue Bao Yi Xue Ban. A clinical application study of digital manufacturing simple intraoral Gothic arch-tracing device in determining the '''centric''' relation of complete dentures. 2023 Feb 18;55(1):101-107. doi: 10.19723/j.issn.1671-167X.2023.01.015.PMID: 36718696 </ref> Da ciò che è stato esposto in tutti i capitoli precedentemente pubblicati su Masticationpedia, si evince che l'approssimazione delle metodiche manuali oppure interpretazioni vaghe derivate da una logica di linguaggio verbale non sono raffigurabili nella filosofia scientifica di Masticationpedia che tende a focalizzarsi su un modello mesoscopico più che macroscopicamente descrittivo e formale attraverso modelli matematico statistici come vedremo di seguito. Perciò non condividiamo l'opinione di Zhou TF et al ma assolutamente in linea con i concetti espressi da Silva Ulloa S. et al.<ref>Silva Ulloa S, Cordero Ordóñez AL, Barzallo Sardi VE. Relationship between '''dental''' '''occlusion''' and brain activity: A narrative review. Saudi Dent J. 2022 Nov;34(7):538-543. doi 10.1016/j.sdentj.2022.09.001. Epub 2022 Sep 16.PMID: 36267531 </ref> in cui si conclude che la corteccia sensomotoria è influenzata dai cambiamenti nell'occlusione e si ipotizza che l'occlusione possa svolgere un ruolo importante nello sviluppo di malattie, dall'ansia e dallo stress al morbo di Alzheimer e alla demenza senile. Condividiamo, inoltre, l'accorato suggerimento di Silva Ulloa S. et al. in cui esorta i dentisti a considerare che le alterazioni del pattern occlusale durante la masticazione possono portare a cambiamenti nell'attivazione di diverse regioni cerebrali correlate alla memoria, all'apprendimento, al dolore anticipatorio e all'ansia. {{q2|Ciò suggerisce che la masticazione mantiene l'integrità di alcune aree del cervello e che può essere un fattore chiave nell'insorgenza di malattie neurodegenerative.|Relationship between dental occlusion and brain activity: A narrative review
-Sebastian Silva Ulloa, Ana Lucía Cordero Ordóñez, Vinicio Egidio Barzallo Sardi  }}E' essenziale, perciò, operare in sinergia al contenuto neuromotorio trigeminale per avere un 'Osservabile' più indicativo della realtà masticatoria ed in questo caso della posizione spaziale reale che la mandibola al di là dell'interferenza dentaria vuole raggiungere. Per realizzare questo target abbiamo messo a punto un metodo di Stimolazione Transcraniale Elettrica simultanea delle radici trigeminali che evoca una risposta diretta di tutti i muscoli masticatori da noi denominata <sub>b</sub>Root-MEPs come precedentemente citata che ha una indicazione di integrità di 'stato' del  <sub>t</sub>CNS e contestualmente determina una elevazione della mandibola dalla posizione di riposo alla Centrica Occlusale. Questa Centrica è stata denominata da noi Centrica Neuro Evocata Funzionale. ( Figura 5)
+Sebastian Silva Ulloa, Ana Lucía Cordero Ordóñez, Vinicio Egidio Barzallo Sardi  }}Therefore, it is essential to operate in synergy with the trigeminal neuromotor content in order to have an 'Observable' more indicative of the masticatory reality and in this case of the real spatial position that the jaw wants to reach beyond the dental interference. To achieve this target we have developed a method of simultaneous Transcranial Electrical Stimulation of the trigeminal roots which evokes a direct response of all the masticatory muscles which we call <sub>b</sub>Root-MEPs as previously mentioned which has an indication of the 'state' integrity of the <sub>t</sub>CNS and at the same time it determines an elevation of the mandible from the rest position to the Occlusal Centric. This Centric has been named by us Functional Neuro Evoked Centric. (Figure 5)
 <center>
-<gallery widths="270" heights="200" perrow="3" slideshow""="">
+<gallery widths="230" heights="200" perrow="3" slideshow""="">
-File:Clicker 00.jpg|'''Figura 5a:''' Posizione occlusale abituale presumibilmente patologica, con crossbite anteriore ed usura degli incisivi centrali
+File:Clicker 00.jpg|'''Figure 5a:''' Presumably pathological usual occlusal position, with anterior crossbite and wear of the central incisors
-File:Barberini21.jpg|'''Figura 5b:''' Posizionamento degli elettrodi registranti sui masseteri di ambo i lati e degli elettrodi per evocare la risposta diretta dalle radici trigeminali
+File:Barberini21.jpg|'''Figure 5b:''' Positioning of the recording electrodes on the masseters on both sides and of the electrodes to evoke the direct response from the trigeminal roots
-File:Barberini2.jpg|'''Figura 5c:''' Risultato dell'elevazione mandibolare dalla posizione di riposo alla Centrica Neuro Evocata Funzionale attraverso i <sub>b</sub>Root-MEPs
+File:Barberini2.jpg|'''Figure 5c:''' Result of mandibular elevation from resting position to Centric Neuro Evoked Functional via bRoot-MEPs
 </gallery>
 </center>
-Come possiamo notare partendo direttamente da un contesto neurologico impiegando tecnologie avanzate elettrofisiologico trigeminali abbiamo scongiurato la presenza di destrutturazione del <sub>t</sub>CNS e contestualmente evidenziato un disturbo occlusale di tipo spaziale. La mandibola con questa metodica che genera un potenziale d'azione sincrono di tutti i muscoli innervati dalle radici trigeminali, a parte condizioni di destrutturazione marcata della ATM, genera una chiusura perfettamente fisiologica che in questo caso viene interrotta dalla presenza di una interferenza dentaria dell'elemento 21 che ci conforta nel proseguire il trattamento neuro gnatologico funzionale.
+As we can see, starting directly from a neurological context, using advanced trigeminal electrophysiological technologies, we have avoided the presence of destructuring of the <sub>t</sub>CNS and contextually highlighted a spatial-type occlusal disorder. The mandible with this method which generates a synchronous action potential of all the muscles innervated by the trigeminal roots, apart from conditions of marked destructuring of the ATM, generates a perfectly physiological closure which in this case is interrupted by the presence of a dental interference of the element 21 which comforts us in continuing the functional neurognathological treatment.
+===Functional Neuro Gnathological rehabilitation===
+Regarding the treatment of patients with TMDs there are still many strategic-conceptual conflicts such as, for example, the use of TENS<ref>Didier HA, Cappellari AM, Gaffuri F, Curone M, Tullo V, Didier AH, Giannì AB, Bussone G. Predictive role of '''gnathological''' techniques for the '''treatment''' of persistent idiopathic facial pain (PIFP). Neurol Sci. 2020 Nov;41(11):[tel:3315-3319 3315-3319]. doi: 10.1007/s10072-020-04456-9. Epub 2020 May 21.PMID: 32440980</ref> which the RDC protocol has considered clinically invalid as much as from a neurophysiological point of view TENS is not an appropriate method for not being able to evoke a response from all masticatory muscles but only the superficial ones. In this limitation lies the spatial error of the mandibular position which would be in a more anterior position due exclusively to the motor response of the masseter muscle (a topic which will be dealt with in the section 'Crisis of the Paradigm').
+For this reason we bypass the manufacture of a bite plane to arrive directly at the definitive neurognathological prosthetic rehabilitation. In this specific case it was a Functional Neuro Evoked Centric rehabilitation of the anterior incisors and the four lower molars, two per side. The realization, however, followed some particularly obligatory pre-ordered steps which represent the best way to achieve real neuro-occlusal stability, as we will see in detail below. (figure 6)
-=== Riabilitazione Neuro Gnatologica Funzionale  ===
-Riguardo al trattamento dei pazienti con DTMs ci sono ancora molte conflittualità strategico concettuali quali, per esempio, l'impiego della TENS<ref>Didier HA, Cappellari AM, Gaffuri F, Curone M, Tullo V, Didier AH, Giannì AB, Bussone G. Predictive role of '''gnathological''' techniques for the '''treatment''' of persistent idiopathic facial pain (PIFP). Neurol Sci. 2020 Nov;41(11):3315-3319. doi: 10.1007/s10072-020-04456-9. Epub 2020 May 21.PMID: 32440980</ref> che il protocollo RDC ha considerato non valido clinicamente tanto quanto da un punto di vista neurofisiologico la TENS non è un metodo appropriato per non essere in grado di evocare una risposta di tutti i muscoli masticatori ma solo di quelli superficiali. In questo limite risiede l'errore spaziale della posizione mandibolare che si troverebbe in una posizione più anteriorizzata dovuta esclusivamente alla risposta motoria del muscolo massetere ( argomento che si tratterà nella sezione 'Crisi del Paradigma').
-Per questo motivo bypassiamo la fabbricazione di un bite plane per arrivare direttamente alla riabilitazione protesica neuro gnatologica definitiva. In questo caso specifico si è trattato di una riabilitazione in Centrica Neuro Evocata Funzionale degli incisivi anteriori e dei quattro molari inferiori due per lato. La realizzazione, però, ha seguito degli step pre-ordinati particolarmente obbligati che rappresentano il miglior modo per raggiungere una reale stabilità neuro occlusale, come vedremo dettagliatamente di seguito.(figura 6)
+ <center>
-<center>
+<gallery widths="230" heights="200" perrow="3" slideshow""="">
-<gallery widths="270" heights="200" perrow="3" slideshow""="">
+File:IMG0010.jpg|'''Figure 6a:''' Positioning of frameworks in Empress to accommodate the wax for Functional Neuro Evoked Centric
-File:IMG0010.jpg|'''Figura 6:''' Posizionamento delle strutture in Empress per accogliere la cera per la Centrica Neuro Evocata Funzionale
+File:Clicker CR .jpg|'''Figure 6b:''' Frozen Functional Neuro Evoked Centric Registration by placing crown structures in Empress with interdigitating wax. Note the slight increase in the vertical dimension purposely wanted.
-File:Clicker CR .jpg|'''Figura 6:''' Registrazione Centrica Neuro Evocata Funzionale congelata posizionando strutture corone in Empress con cera da interdigitare. Notare il lieve rialzo della dimensione verticale appositamente voluto.
+File:IMG0006.jpg|'''Figure 6c:''' Frozen Functional Neuro Evoked Centric Registration by placing crown structures in Empress with wax and brought back into the articular.
-File:IMG0006.jpg|'''Figura 6:''' Registrazione Centrica Neuro Evocata Funzionale congelata posizionando strutture corone in Empress con cera e riportata in articolare.
 </gallery>
 </center>
-In figura 6a possiamo notare le strutture delle corone in bocca su cui andrà stratificata la ceramica e che verranno ricoperte di cera Aluvax per determinare la Centrica Neuro Evocata Funzionale. La scelta di incorporare nella riabilitazione i quattro molari è stata presa perchè questi elementi sono determinanti per la stabilità occlusale ma anche per la mediotrusione come vedremo di seguito. La posizione mandibolare esatta necessita di un terzo punto anteriore ed è per questo, visto anche l'usura degli incisi e l'importanza di una normocclusione del settore anteriore il coinvolgimento degli incisivi è stato determinante per Centrare la mandibola nella posizione ottimale (figura 6b). Il tutto, ovviamente, con cere di stampo su corone EMpress viene riportato in articolare. (figura 6c)
+In figure 6a we can see the structures of the crowns in the mouth on which the ceramic will be stratified and which will be covered with Aluvax wax to determine the Functional Neuro Evoked Centric. The decision to incorporate the four molars in the rehabilitation was made because these elements are crucial for occlusal stability but also for mediotrusion as we will see below. The exact mandibular position requires a third anterior point and for this reason, also considering the wear of the incisions and the importance of a normocclusion of the anterior sector, the involvement of the incisors was decisive for Centering the mandible in the optimal position (figure 6b) . Obviously, everything is brought back into articulate with mold waxes on Empress crowns. (figure 6c)
-==== Dettaglio Neuro Gnatologico Funzionale ====
+====Functional Neuro Gnatologic Detail====
-Per dettaglio Neuro Gnatologico Funzionale, modello riabilitativo denominato 'Indice NGF' da cui si inizializzerà tutto un processo scientifico che porterà ad un modello paradigmatico diagnostico denominato 'Indice NGF' nella sezione 'Scienza Straordinaria', si intende una aggiustamento occlusale normalizzato alla simmetria neuromotoria trigeminale. Per raggiungere questo obiettivo sono fondamentali replicato gnatologici ( articolatosi) e soprattutto la capacità di leggere le risposte evocate e riflesse del  <sub>t</sub>CNS in diverse situazioni occlusali. Per questo motivo si è proceduto alla stratificazione delle sole centriche attive delle corone in Empress sui quattro molari inferiori. ( figura 7)
+For Neuro Gnatologic Functional detail, rehabilitation model called 'NGF Index' from which a whole scientific process will be initiated which will lead to a diagnostic paradigmatic model called 'NGF Index' in the 'Extraordinary Science' section, means an occlusal adjustment normalized to trigeminal neuromotor symmetry . To achieve this goal, gnathological replicates (articulated) and above all the ability to read the evoked and reflex responses of the tCNS in different occlusal situations are fundamental. For this reason, only the active centrics of the Empress crowns were stratified on the four lower molars. (figure 7)
 <center>
-<gallery widths="270" heights="200" perrow="3" slideshow""="">
+<gallery widths="230" heights="200" perrow="3" slideshow""="">
-File:Clicker NGF2 .jpg|'''Figura 7a:''' Vista delle struttura in Empress nella fase di laboratorio dove sono state stratificate soltanto le cuspidi centriche attive dei molari.
+File:Clicker NGF2 .jpg|'''Figure 7a:''' View of the Empress framework in the laboratory phase where only the active centric cusps of the molars were layered.
-File:Clicker NGF1.jpg|'''Figura 7b:''' Vista delle struttura in Empress nella fase clinica in bocca su cui eseguire i test elettrofisiologici trigeminali.
+File:Clicker NGF1.jpg|'''Figure 7b:''' View of the Empress structure in the clinical phase in the mouth on which to perform trigeminal electrophysiological tests.
-File:Clicker NGF3.jpg|'''Figura 7c:''' vista delle corone con cuspidi centriche attive in bocca lato destro.
+File:Clicker NGF3.jpg|'''Figure 7c:''' view of the crowns with active centric cusps in the right-sided mouth.
 </gallery>
 </center>
-In figura 7a,b e c sono state stratificate soltanto le centriche attive dei molari perchè nonostante la registrazione Centrica Neuro Evocate Funzionale sia di assoluta precisione, il trasferimento meccanico dalla bocca al laboratorio ( articolatore) potrebbe incorporare minimi variazioni spaziali. Per questo motivo si è deciso di fermare la chiusura neuro evocata della mandibola leggermente rialzata per poter aver la disponibilità del materiale ceramico da rimodellare seguendo le risposte elettrofisiologiche trigeminali. In sostanza le cuspidi venivano abrase settorialmente e singolarmente per poi comparare con le risposte elettrofisiologiche trigeminali fino alla perfetta simmetria e sincornicità del  <sub>t</sub>CNS. Una volta raggiunto il risultato di simmetria e sincronici la posizione raggiunta diventerà l'asta incisale a zero per concludere la stratificazione.
+In figure 7a, b and c only the active centrics of the molars have been stratified because although the Centric Neuro Evocate Functional registration is of absolute precision, the mechanical transfer from the mouth to the laboratory (articulator) could incorporate minimal spatial variations. For this reason it was decided to stop the neuro-evoked closure of the slightly raised jaw in order to have the availability of the ceramic material to be remodeled following the trigeminal electrophysiological responses. In essence, the cusps were abraded sectorally and individually to then compare with the trigeminal electrophysiological responses up to the perfect symmetry and synchronicity of the <sub>t</sub>CNS. Once the result of symmetry and synchronism has been achieved, the position reached will become the incisal rod at zero to conclude the stratification.
 <center>
 <gallery widths="600" heights="200" perrow="2" slideshow""="">
-File:Clicker 3.jpg|'''Figura 8a:''' Periodo silente meccanico registrato sui muscoli masseteri e temporali prima del trattamento Neuro Gantolgico Funzionale
+File:Clicker 3.jpg|'''Figure 8a:''' Mechanical silent period recorded on the masseter and temporal muscles before the Neuro Gantholgic Functional treatment
-File:Clicker SP post.jpg|'''Figura 8b:''' Periodo silente meccanico registrato sui muscoli masseteri e temporali dopo trattamento Neuro Gantolgico Funzionale
+File:Clicker SP post.jpg|'''Figure 8b:''' Mechanical silent period recorded on the masseter and temporal muscles after Neuro Gantholgic Functional treatment.
 </gallery></center>
-In figura 8a ed 8b si possono notare le straordinarie differenze nella risposta neuromotoria trigeminale dovute, essendo di tipo funzionale, ad un cambiamento spaziale mandibolare ed un accurato equilibratura neurognatologica occlusale. Si può assistere, infatti, ad una simmetrizzazione del jaw jerk sul massetere destro, ad una diminuzione della durata del periodo silente meccanico e soprattutto una ottimale riattivazione motoneurale dopo il periodo silente (effetto rebound) che sta a significare sicurezza nella riattivazione totale ed immediata della scarica motoneurale. Una volta documentato con dati inconfutabili questa re-simmetrizzazione neuromotoria trigeminale si può passare alla finalizzazione del caso clinico.
+Figures 8a and 8b show the extraordinary differences in the trigeminal neuromotor response due, being of a functional type, to a mandibular spatial change and an accurate neurognathological occlusal balancing. In fact, one can see a symmetrization of the jaw jerk on the right masseter, a decrease in the duration of the mechanical silent period and above all an optimal motoneural reactivation after the silent period (rebound effect) which means safety in the total and immediate reactivation of the motoneural discharge. Once this trigeminal neuromotor re-symmetrization has been documented with irrefutable data, it is possible to move on to finalizing the clinical case.
-==== Riabilitazione protesica NGF ====
-La finalizzazione del caso clinico diagnosticato definitivamente DTMs ha determinato un ripristino della funzione masticatoria, scomparsa dei sintomi nonché un miglioramento estetico. Le varie fasi della riabilitazioni si possono seguire nella galleria delle immagini della figura 9. In particolare la posizione Centrica Neuro Evocata Funzionale non solo è centrata essendosi spostata leggermente a destra ma anche retrusa. E' interessante fare una comparazione conn la figura 5a per rendersi conto delle differenze spaziali. L'elemento 22, infatti, non è più in crossbite ma  in una posizione di testa a testa mentre il 23 ha un contatto centrica molto più incisale rispetto alla situazione clinica precedente, così pure da notare lo spazio occlusale nell'area mediale del 24 che si è venuto a generare con la attuale posizione spaziale mandibolare determinata con la Centrica Neuro Evocata Funzionale. Questo nuovo assetto occlusale è stato possibile solo perchè la posizione centrica stabile e principalmente congelata nel settore dei molari. I molari attraverso l'equilibrio neuromotorio esposto precedentemente sulla cuspide centrica stabilizza l'occlusione e genera un bilanciamento bilaterale nei movimenti mandibolari come sarà a breve descritto.
+====NGF prosthetic rehabilitation ====
+The finalization of the definitively diagnosed clinical case of DTMs resulted in a restoration of the masticatory function, disappearance of the symptoms as well as an aesthetic improvement. The various phases of the rehabilitation can be followed in the gallery of images in figure 9. In particular, the Functional Neuro-Evoked Centric position is not only centered having moved slightly to the right but also retruded. It is interesting to make a comparison with figure 5a to understand the spatial differences. Element 22, in fact, is no longer in crossbite but in a head-to-head position while element 23 has a much more incisal centric contact with respect to the previous clinical situation, so as to note the occlusal space in the medial area of element 24 which it was generated with the current mandibular spatial position determined with the Functional Neuro Evoked Centric. This new occlusal arrangement was only possible because the stable and mainly frozen centric position in the molar sector. The molars through the previously exposed neuromotor balance on the centric cusp stabilize the occlusion and generate a bilateral balance in the mandibular movements as will be shortly described.
 <center>
-<gallery widths="130" heights="200" perrow="5" slideshow""="" mode="slideshow">
+<gallery mode="slideshow">
-File:Clicker end1.jpg|'''Figura 9a:''' Vista frontale della riabilitazione Neuro evocata Funzionale e ripristino normocclusale incisale con due corone in Empress ( lavoro eseguito nel 1992)
+File:Clicker end1.jpg|'''Figure 9a:''' Frontal view of functional neuro-evoked rehabilitation<br>and incisal normocclusal restoration<br>with two crowns in Empress<br>(performed in 1992)
-File:Clicker end2 .jpg|'''Figura 9b:''' Vista occlusale della riabilitazione Neuro evocata Funzionale e ripristino normocclusale incisale con due corone in Empress ( lavoro eseguito nel 1992)
+File:Clicker end2 .jpg|'''Figure 9b:''' Occlusal view of functional neuro-evoked rehabilitation and incisal normocclusal restoration with two crowns in Empress.
-File:Clicker end3.jpg|'''Figura 9c:''' Particolarità dei parametri neurognatologici. Vista occlusale del dettaglio mediotrusivo di sinistra. ( lavoro eseguito nel 1992)
+File:Clicker end3.jpg|'''Figure 9c:''' Peculiarities of neurognathological parameters. Occlusal view of the left mediotrusive detail.
-File:Clicker end4.jpg|'''Figura 9d:''' Particolarità dei parametri neurognatologici. Vista occlusale del dettaglio mediotrusivo di destro. ( lavoro eseguito nel 1992)
+File:Clicker end4.jpg|'''Figure 9d:''' Peculiarities of neurognathological parameters. Occlusal view of the right mediotrusive detail.
-</gallery>
+</gallery></center>
+In figure 9c and 9d, we can see not only the well balanced centric contacts but above all the mediotrusive excursions. A few more words should be spent on this subject. Benedikt Sagl et al.<ref>Sagl B, Schmid-Schwap M, Piehslinger E, Rausch-Fan X, Stavness I. [https://www.ncbi.nlm.nih.gov/pmc/articles/pmid/36187792/ The effect of tooth cusp morphology and grinding direction on TMJ loading during bruxism]. Front Physiol. 2022 Sep 15;13:964930. doi: 10.3389/fphys.2022.964930. eCollection 2022.PMID: 36187792 </ref> state, in their study in which the contribution of tooth inclination, medio-otrusive and laterotrusive excursion and von Mises stresses on the articular disc was analysed, that mediotrusive bruxing generates higher loads than laterotrusive simulations. In this sense it is not clear whether the mediotrusive contacts are a protective or a pejorative element in the generation of temporomandibular joint disorders. So much so that an article by Walton TR and Layton DM<ref>Walton TR, Layton DM. Mediotrusive Occlusal Contacts: Best Evidence Consensus Statement. J Prosthodont. 2021 Apr;30(S1):43-51. doi: 10.1111/jopr.13328.PMID: 33783093</ref> increases the confusion as they first state that the presence of TM interference in patient populations is large and varies from 0% to 77% and then conclude that TM interference should be avoided in any occlusal treatment regimen to minimize pulpal, periodontal, structural and mechanical complications or exacerbation of temporomandibular disorders (TMD). The confusion increases when he concludes that natural molar MT interferences should only be eliminated if signs and symptoms of TMD are present. The question that arises is the following
+{{q2|Which came first, the chicken or the egg?|.... are the interferences that cause the grinding and consequently damage to the atm or are the natural interferences protective on the system?}}It would be necessary to put some order on the subject starting with specifying what is meant by interference.
-</center>In figura 9c e 9d, possiamo notare non solo i contatti centrici ben bilanciati ma soprattutto le escursioni mediotrusive. Su questo argomento bisognerebbe spendere qualche parola in più.
+A study by Leitão AWA et al.<ref>Leitão AWA, Borges MMF, Martins JOL, Coelho AA, Carlos ACAM, Alves APNN, Silva PGB, Sousa FB. [https://www.ncbi.nlm.nih.gov/pmc/articles/pmid/35976283/ Celecoxib in the treatment of orofacial pain and discomfort in rats subjected to a dental '''occlusal''' '''interference''' model]. Acta Cir Bras. 2022 Aug 15;37(5):e370506. doi: 10.1590/acb370506. eCollection 2022.PMID: 35976283</ref> is extraordinarily significant having objectively simulated the interference in the animal and histologically analyzed the changes in the trigmeinal ganglion contextually with the behavior of the animal when treated with or without selective cyclooxygenase 2 (COX-2) inhibitor. Furthermore, the authors treated the animals with a daily infusion of 0.1 ml/kg of saline (DOI+SAL) and 16 or 32 mg/kg of celecoxib (DOI+cel -8, -16, -32 ). They noted that animals subjected to masseter nociceptive stimulation and interference DOI + SAL showed an increase in isplateral (P < 0.001) and contralateral (P < 0.001) nociception, an increase in the number of bites (P = 0.010), scratching (P < 0.001) and grimacing scores (P = 0.032) while in the DOI+cel-32 group, these parameters were reduced.
-Benedikt Sagl et al.<ref>Sagl B, Schmid-Schwap M, Piehslinger E, Rausch-Fan X, Stavness I. The effect of tooth cusp morphology and grinding direction on TMJ loading during bruxism. Front Physiol. 2022 Sep 15;13:964930. doi: 10.3389/fphys.2022.964930. eCollection 2022.PMID: 36187792 </ref> affermano, nel loro studio in cui si è analizzato il contributo dell'inclinazione dei denti, dell'escursione mediottrusiva e laterotrusiva e gli stress von Mises sul disco articolare, che il bruxing mediotrusivo genera carichi più elevati rispetto alle simulazioni laterotrusive. In questo senso non si capisce bene se i contatti mediotrusivi siano un elemento protettivo oppure peggiorativo nella generazione di disturbi dell'articolazione temporomandibolare. Tanto è vero che un articolo di Walton TR e  Layton DM<ref>Walton TR, Layton DM. Mediotrusive Occlusal Contacts: Best Evidence Consensus Statement. J Prosthodont. 2021 Apr;30(S1):43-51. doi: 10.1111/jopr.13328.PMID: 33783093</ref> la confusione aumenta in quanto affermano dapprima che la presenza di interferenze MT nelle popolazioni di pazienti, è ampia e varia dallo 0% al 77% per poi concludere che le interferenze MT dovrebbero essere evitate in qualsiasi schema terapeutico occlusale per ridurre al minimo le complicanze pulpari, parodontali, strutturali e meccaniche o l'esacerbazione dei disturbi temporomandibolari (TMD). La confusione aumenta quando conclude che le interferenze MT molari naturali dovrebbero essere eliminate solo se sono presenti segni e sintomi di TMD. La domanda che sorge è la seguente{{q2|E' nato prima l'uovo o la gallina?|....sono le interferenze che provocano il digrignamento e di conseguenza danni all'atm oppure le interferenze naturali sono protettive sul sistema?}}Bisognerebbe fare un pò d'ordine sull'argomento iniziando con lo specificare che cosa si intende per interferenza.
+This interesting study shows the correlation between interference, decrease in pain threshold and contextually recovery with celecoxib infusion and therefore neuro-occlusal correlation.
-Uno studio di Leitão AWA et al.<ref>Leitão AWA, Borges MMF, Martins JOL, Coelho AA, Carlos ACAM, Alves APNN, Silva PGB, Sousa FB. Celecoxib in the treatment of orofacial pain and discomfort in rats subjected to a dental '''occlusal''' '''interference''' model. Acta Cir Bras. 2022 Aug 15;37(5):e370506. doi: 10.1590/acb370506. eCollection 2022.PMID: 35976283</ref> è straordinariamente significativo avendo simulato oggettivamente l'interferenza sull'animale ed analizzato istologicamente i cambiamenti a livello del ganglio trigmeinale contestualmente al comportamento dell'animale quando trattati con o senza inibitore selettivo della cicloossigenasi 2 (COX-2). Gli autori, inoltre, hanno trattato gli animali con infusione giornaliera di con 0,1 ml/kg di soluzione fisiologica (DOI+SAL) e , 16 o 32 mg/kg di celecoxib (DOI+cel -8, -16, -32). Hanno notato che gli animali sottoposti ad interferenze ed alla stimolazione nocicettiva del massetere lo DOI + SAL ha mostrato un aumento della nocicezione isplaterale (P <0,001) e controlaterale (P <0,001), un aumento del numero di morsi (P = 0,010), graffi (P <0,001) e punteggi delle smorfie (P = 0,032) mentre nel gruppo di DOI+cel-32, questi parametri sono stati ridotti.
+Si-Yi Mo et al.<ref>Mo SY, Xue Y, Li Y, Zhang YJ, Xu XX, Fu KY, Sessle BJ, Xie QF, Cao Y. [https://www.ncbi.nlm.nih.gov/pmc/articles/pmid/37165344/ Descending serotonergic modulation from rostral ventromedial medulla to spinal trigeminal nucleus is involved in experimental occlusal interference-induced chronic orofacial hyperalgesia]. J Headache Pain. 2023 May 10;24(1):50. doi: 10.1186/s10194-023-01584-3.PMID: 37165344 </ref> reinforces the above neuro-occlusal correlation by demonstrating that the descending pathway from serotonergic (5-HT) neurons in the rostral ventromedial medulla (RVM) to 5-HT3 receptors in the spinal trigeminal nucleus (Sp5), plays an important role in facilitating the maintenance of orofacial hyperalgesia after delayed removal of experimental occlusal interference (REOI).
-Questo studio interessante mostra la correlazione tra interferenza, diminuzione della soglia per il doloro e contestualmente il ripristino con infusione di celecoxib  e dunque correlazione neuro-occlusale.
+Up to now we have a broader view on the subject of interference confirmed by the neuro-occlusal correlation but the phenomenon can also be seen locally in the articular disc. Another study by Cui SJ et al.<ref>Cui SJ, Yang FJ, Wang XD, Mao ZB, Gu Y. Mechanical overload induces TMJ disc degeneration via TRPV4 activation. Oral Dis. 2023 Apr 27. doi: 10.1111/odi.14595. Online ahead of print.PMID: 37103670</ref> experimentally demonstrated that the effect of mechanical overload on TMJ discs in an in vivo rat occlusal interference model, inhibition of transient mechanoinductive receptor vanilloid potential 4 (TRPV4) alleviated TMJ disc degeneration in the rat occlusal interference model.
-Si-Yi Mo et al.<ref>Mo SY, Xue Y, Li Y, Zhang YJ, Xu XX, Fu KY, Sessle BJ, Xie QF, Cao Y. Descending serotonergic modulation from rostral ventromedial medulla to spinal trigeminal nucleus is involved in experimental occlusal interference-induced chronic orofacial hyperalgesia. J Headache Pain. 2023 May 10;24(1):50. doi: 10.1186/s10194-023-01584-3.PMID: 37165344 </ref> rafforza la correlazione neuro-occlusale di cui sopra dimostrando che il percorso discendente dai neuroni serotoninergici (5-HT) al midollo ventromediale rostrale (RVM) ai recettori 5-HT3 nel nucleo del trigemino spinale (Sp5), gioca un ruolo importante nel facilitare il mantenimento dell'iperalgesia orofacciale dopo la rimozione ritardata dell'interferenza occlusale sperimentale (REOI).
+In conclusion, as we hope to share, the question is much more complex than what clinicians think and they hurry to eliminate the interferences, for example, mediotrusive because if the load induced on the joint, perhaps by a neuromotor hyperexcitability (see chapter Spasm Eimasticatorio and Cavernosa Pineale) the mediotrusive excursion could be a protective element perhaps to the detriment of the tooth itself.
-Fin qui abbiamo una visione più vasta sull'argomento interferenza confermata dalla correlazione neuro-occlusale ma il fenomeno si evince anche localmente proprio nel disco articolare. Uno altro studio di Cui SJ et al. <ref>Cui SJ, Yang FJ, Wang XD, Mao ZB, Gu Y. Mechanical overload induces TMJ disc degeneration via TRPV4 activation. Oral Dis. 2023 Apr 27. doi: 10.1111/odi.14595. Online ahead of print.PMID: 37103670</ref>ha dimostrato sperimentalmente che  l'effetto del sovraccarico meccanico sui dischi dell'ATM in un modello di interferenza occlusale di ratto in vivo, l'inibizione del potenziale vanilloide 4 del recettore transitorio meccanoinduttivo (TRPV4) ha alleviato la degenerazione del disco dell'ATM nel modello di interferenza occlusale del ratto.
+For this reason, the term 'Mediotrusive Interference' should be re-evaluated
-In conclusione, come si spera di condividere, la questione è molto più complessa di quanto i clinici pensano e si affrettano ad eliminare le interferenze, per esempio, mediotrusive perchè se il carico indotto sull'articolazione, magari da una ipereccitabilità neuormotoria ( vedi capitolo Spasmo Emimasticatorio e Cavernosa Pineale) l'escursione mediotrusiva potrebbe essere un elemento protettivo magari a discapito del dente stesso.
+In figure 9c and 9d the mediotrusive path highlighted with the articulation paper was constructed by calculating the angle determined by the unilateral Root-MEPs which displaces the mandible by about 1/2mm on each side. By programming the Denar joint (figure 10) it was possible to construct an excursion with different angles between the TMJ, molar and canine. This procedure generates a natural path in which the canine guides together with the mediotrusion to protect the TMJ from the masticatory load that exists beyond bruxism.
-Per questo motivo bisognerebbe rivalutare il termine 'Interferenza mediotrusiva'
-In figura 9c e 9d il percorso mediotrusivo evidenziato con la carta di articolazione è stato costruito attraverso il calcolo dell'angolo determinato dalla Root-MEPs monolaterale che sposta la mandibola di circa 1/2mm su ciascun lato. Attraverso la programmazione dell'articolare Denar ( figura 10) si è potuto costruire una escursione con angoli diversi tra la ATM, molare e canino. Questo procedura genera un percorso naturale in cui il canino guida insieme alla mediotrusuone per proteggere la ATM dal carico masticatorio che esiste comunque al di là del bruxismo.
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