1. 6/18/12 InnerSmile Pro © Zerobase Dynamic sEMG InnerSmile Pro Single Track Muscle Scanner ©

2. 6/18/12 InnerSmile Pro © ATTENTION! There are no teeth in this lecture! There are no specific appliances in this lecture. There is no TMJ cure in this lecture. So what is the purpose of this lecture? Simply said: Dynamic EMG...... NEXT

3. 6/18/12 InnerSmile Pro © Simply said: Dynamic EMG is a tool, not a treatment! 1. Muscles help form and stabilize teeth. 2. Balanced muscles stabilize the occlusal plane. 3. You can evaluate muscle balance for any appliance, any crown placement, or any surgery. 4. You can also assess some swallowing problems. 5. You can also assess muscle aspects of TMJ/TMD.

4. 6/18/12 InnerSmile Pro © And You can do it while a patient is in the chair. It takes 3 or 5 minutes. You have a Report immediately. You can do it again as many times as needed. Appliances Crowns Surgeries

5. 6/18/12 InnerSmile Pro © sEMG SINGLE CHANNEL HAND SCANNER Simple Muscle Evaluation for Awareness Training Single Channel sEMG Unit Zerobase Dynamic sEMG InnerSmile Pro ©

6. 6/18/12 InnerSmile Pro © This devise can be used alone. Or as a screening devise for... NEXT

7. 6/18/12 InnerSmile Pro © Zerobase Dynamic sEMG Complete Muscle Evaluation and Awareness Training sEMG 4 CHANNEL It allows you to do a physiological evaluation of muscle activity and symmetry as well as oral muscle training. 4 Channel sEMG Unit InnerSmile Pro ©

8. Click to edit the outline text format Second Outline Level  Third Outline Level Fourth Outline Level  Fifth Outline Level  Sixth Outline Level  Seventh Outline Level  Eighth Outline Level Ninth Outline LevelClick to edit Master text styles – Second level Third level – Fourth level » Fifth level Click to edit the outline text format Second Outline Level  Third Outline Level Fourth Outline Level  Fifth Outline Level  Sixth Outline Level  Seventh Outline Level  Eighth Outline Level Ninth Outline LevelClick to edit Master text styles – Second level Third level – Fourth level » Fifth level 6/18/12 InnerSmile Pro © Zerobase Dynamic sEMG Before Training After Training InnerSmile Pro © Example: 4 Channel sEMG Unit ZeroBase 4-Channel sEMG Hookup Cory-san

9. Click to edit the outline text format Second Outline Level  Third Outline Level Fourth Outline Level  Fifth Outline Level  Sixth Outline Level  Seventh Outline Level  Eighth Outline Level Ninth Outline LevelClick to edit Master text styles – Second level Third level – Fourth level » Fifth level Click to edit the outline text format Second Outline Level  Third Outline Level Fourth Outline Level  Fifth Outline Level  Sixth Outline Level  Seventh Outline Level  Eighth Outline Level Ninth Outline LevelClick to edit Master text styles – Second level Third level – Fourth level » Fifth level 6/18/12 InnerSmile Pro © PRACTICAL BACKGROUND “I am afraid of making a fool of myself.”

10. 6/18/12 InnerSmile Pro © What is the biggest problem in communicating with your patient? How much time do you have to communicate with your patient? What kind of evidence do you present? InnerSmile Pro ©

11. 6/18/12 InnerSmile Pro © Structural evidence is objective. - X-rays, casts, models, tomograms Functional evidence is usually ignored, or referred out. - sEMG, TMJ Bite Muscle Analysis, Etc InnerSmile Pro ©

12. 6/18/12 InnerSmile Pro © STRUCTURAL EVIDENCE: - This is the Outer Smile FUNCTIONAL EVIDENCE: - This is the Inner Smile. InnerSmile Pro ©

13. 6/18/12 InnerSmile Pro © * If the Matrix is Neutral, you will see balanced clench and swallow. ‘OUTER SMILES’ are static, teeth-based smiles. They may be genuine smiles or superficial smiles or spontaneous or posed smiles. ‘INNER SMILES’ are much different. They are really Gugino’s Functional Matrix. InnerSmile Pro ©

14. 6/18/12 InnerSmile Pro © KEY POINTS: 1. FUNCTIONAL ESTHETICS & Inner Smile To neutralize the functional matrix, enhance esthetics 2. CORRECTIVE ORTHO & Inner Smile To neutralize (train) Breathing/Swallowing To neutralize (train)Muscle To neutralize (train)Posture  How can you neutralize what you can't evaluate? INNER SMILE >ZeroBase Evaluation InnerSmile Pro ©

15. 6/18/12 InnerSmile Pro © INNER SMILE> ZeroBase Evaluation KEY POINTS: 3. PREVENTATIVE ORTHO & Inner Smile Dynamic sEMG shoud be done on every patient. A new Dynamic sEMG should be taken for every re- evaluation Why? The Functional Matrix is also Dynamic. InnerSmile Pro ©

16. Click to edit the outline text format Second Outline Level  Third Outline Level Fourth Outline Level  Fifth Outline Level  Sixth Outline Level  Seventh Outline Level  Eighth Outline Level Ninth Outline LevelClick to edit Master text styles – Second level Third level – Fourth level » Fifth level Changing Function changes Form FUNCTIONAL MATRIX

17. Click to edit the outline text format Second Outline Level  Third Outline Level Fourth Outline Level  Fifth Outline Level  Sixth Outline Level  Seventh Outline Level  Eighth Outline Level Ninth Outline LevelClick to edit Master text styles – Second level Third level – Fourth level » Fifth level 1. Breathing / Swallowing 2. Muscles 3. Posture 4. Elimination of Habits FUNCTIONAL MATRIX Neutral Zone InnerSmile Pro ©

18. 6/18/12 InnerSmile Pro © * However if your patient's inner smile [Functional Matrix] is not within the neutral zone, how do you communicate this to the patient? The purpose of this talk is to show how to use the sEMG scanner to communicate whether the inner smile is in the neutral zone. You can communicate a good outer smile to a patient. InnerSmile Pro ©

19. 6/18/12 InnerSmile Pro © sEMG BACKGROUND “What is it and why should I care?”

20. 6/18/12 InnerSmile Pro © History of Oral Muscle Assessment BEFORE COMPUTERS - PALPATION Done by touch alone. Interpretation is subjective You cannot communicate visually. No objective comparison in possible. WITH COMPUTERS TODAY- DYNAMIC MUSCLE ASSESSMENT Rest-Squeeze-Rest – objective report. [Our current talk] InnerSmile Pro © Where? How? Time per muscle? Make Report? Time per muscle? Make Report?

21. 6/18/12 InnerSmile Pro © Commercial dynamic muscle evaluation devices: Are big. Cost a lot of money. Require at least 30 minutes. Are done by a tech with specialized training. Rarely does more than assess simple muscle timing. *Usually restricted to TMJ.- Evolution of Dynamic sEMG Assessment InnerSmile Pro ©

22. 6/18/12 InnerSmile Pro © Zerobase Dynamic sEMG Scanner is for the masses: Is small. Is cheap. You could fill an auditorium for the price of a big unit. Takes 3 minutes start to finish. Can be done in the chair by the ortho at the first visit. Provides Graphic Reports for ALL muscle-related measures. * Not restricted to TMJ.- Detects malocclusions, bite, etc Evolution of Dynamic sEMG Assessment InnerSmile Pro ©

23. 6/18/12 InnerSmile Pro © Plug the unit into the USB port on your computer and hold it on the muscle group you want to evaluate. No messy gel on the electrodes Use alcohol to moisten the contacts and to clean the area on the face to be scanned. USE ON EVERY PATIENT InnerSmile Pro ©

24. 6/18/12 InnerSmile Pro © 3 minute scan: Quick Masseter-Digastric sEMG Evaluation 5 minute scan: Full Head - Neck sEMG Evaluation TWO LEVELS OF PROCEDURES InnerSmile Pro ©

25. 6/18/12 InnerSmile Pro © Let’s look at the 3 minute Scan. We will start with: The Masseter pair Digrastric contractions... next InnerSmile Pro ©

26. 6/18/12 InnerSmile Pro © 3 minute: Masseter-Digastric sEMG Evaluation Left Masseter Right Masseter Digastic Results look like this… NEXT

27. 6/18/12 InnerSmile Pro © RESULTS ! “Finally!”

28. 6/18/12 InnerSmile Pro © Left Masseter Right Masseter Digastric  Amplitude is in microvolts 3 minute: Masseter-Digastric sEMG Evaluation Clench SwallowClench

29. 6/18/12 InnerSmile Pro © INTERPRETATION InnerSmile Pro © “I thought we'd talk about results first!”

30. 6/18/12 InnerSmile Pro © MUSCLE PATTERNS ◦ So, how do you evaluate this basic sEMG muscle pattern? There are 5 elements to the sEMG muscle pattern : NEXT…

31. 6/18/12 InnerSmile Pro © The five elements in dynamic muscle evaluation are : 1. Resting Muscle Pattern 2. Initial Contraction Pattern 3. Sustained Contraction Pattern 4. Release Pattern 5. Post-Contraction Pattern MUSCLE PATTERNS InnerSmile Pro ©

32. 6/18/12 InnerSmile Pro © HEALTHY PATTERN RECOVERY: RETURNS to BASELINE BASELINE CLENCH MAINTAIN CLENCH RELAX KEY POINTS: AMPLITUDE LARGE RECOVERY FAST MUSCLE PATTERNS InnerSmile Pro ©

33. 6/18/12 InnerSmile Pro © BRACING AND GUARDING indicates the muscle is damaged. How is this determined? NEXT… BRACING & GUARDING

34. 6/18/12 InnerSmile Pro © BASELIN E CLENCH MAINTAIN CLENCH RELAX LATENCY TO RECOVER Look here UNHEALTHY MUSCLES SHOW #1 - “POOR RELEASE” RECOVERY: RETURNS to BASELINE BASELINE CLENCH MAINTAIN CLENCH RELAX MUSCLE PATTERNS InnerSmile Pro ©

35. 6/18/12 InnerSmile Pro © BASELINE CLENCH MAINTAIN CLENCH RELAX DESCENT NOTCH This is what we refer to as a DESCENT NOTCH in the release or latency to return. Release is slowed. This is due to bracing or guarding. Difficult to return to baseline UNHEALTHY MUSCLES SHOW #2 - “POOR RELEASE” MUSCLE PATTERNS InnerSmile Pro ©

36. 6/18/12 InnerSmile Pro © sEMG patterns are revealed by movement. Clench reveals the strength of muscle activity. Recovery reveals bracing and guarding. BRACING AND GUARDING indicates the muscle may be damaged. NEXT… KEY POINTS ABOUT MUSCLES

37. 6/18/12 InnerSmile Pro © MUSCLE BALANCE - CLENCH Ideally both sides contract equally during a CLENCH. So how would this look? NEXT SLIDE… Left MasseterRight Masseter MASSETER PATTERNS

38. 6/18/12 InnerSmile Pro © HEALTHY MUSCLE PATTERNS Balanced Clench and Release Pattern Left Masseter Right Masseter In Balance

39. 6/18/12 InnerSmile Pro © MUSCLE ASSYMETRIES - CLENCH An ideal clench shows balanced masseters. Unhealthy patterns are not balanced during a clench. So how would this look? NEXT SLIDE… MASSETER PATTERNS

40. 6/18/12 InnerSmile Pro © MASSETER PATTERNS Asymmetrical Clench and Release Pattern 1 Left MasseterRight Masseter Left Dominant UNHEALTHY MUSCLE PATTERNS

41. 6/18/12 InnerSmile Pro © Left MasseterRight Masseter Right Dominant MASSETER PATTERNS Asymmetrical Clench and Release Pattern 2 UNHEALTHY MUSCLE PATTERNS

42. 6/18/12 InnerSmile Pro © An ideal clench shows strong masseters. Unhealthy patterns also show little masseter activity during a clench. So how would this look? NEXT SLIDE… MUSCLE WEAKNESS - CLENCH MASSETER PATTERNS

43. 6/18/12 InnerSmile Pro © MASSETER PATTERNS Weak Clench and Release Pattern Left MasseterRight Masseter Weak Contact UNHEALTHY MUSCLE PATTERNS

44. 6/18/12 InnerSmile Pro © “I get it. Masseters control the bite. So we don't need to worry about other muscles, eh?” Well, sometimes a little knowledge is a dangerous thing. Let's at least include the Anterior Temporalis. OK? NEXT...

45. 6/18/12 InnerSmile Pro © MUSCLE INTERACTIONS - CLENCH ANT. TEMP. PATTERNS What about the antiorior temporalis contraction pattern? An ideal clench shows balanced masseters and temporales. So how would this look? NEXT SLIDE…

46. 6/18/12 InnerSmile Pro © BITE PATTERNS Ideal Clench and Release Pattern HEALTHY INTERACTION PATTERNS Left MasseterRight Masseter Balanced Masseter Clench Balanced Temporalis Clench Left Ant. Temp. Right Ant. Temp.

47. 6/18/12 InnerSmile Pro © MUSCLE INTERACTIONS - CLENCH BITE PATTERNS What does this say about contact points? When the anterior temporales are dominant, posterior bite problems dominate. Teeth contact posteriorally. When the masseters are dominant, masseter bite problems dominate. Teeth contact anteriorally. So how would this look? NEXT SLIDE…

48. 6/18/12 InnerSmile Pro © Left Masseter Right Masseter Masseter Dominant Ant. Temp. Submissive Left Ant. Temp.Right Ant. Temp. BITE PATTERNS Anterior vs Posterior Clench and Release Pattern MALOCCLUSION INTERACTION PATTERNS

49. 6/18/12 InnerSmile Pro © Left MasseterRight Masseter Masseter Submissive Ant. Temp. Dominant Left Ant. Temp. Right Ant. Temp. BITE PATTERNS Anterior vs Posterior Clench and Release Pattern MALOCCLUSION INTERACTION PATTERNS

50. 6/18/12 InnerSmile Pro © MORE RESULTS 'It's about time … again!”

51. 6/18/12 InnerSmile Pro © NOW REORGANIZED AS.... 12 3 4 1234

52. 6/18/12 InnerSmile Pro © Clench

53. 6/18/12 InnerSmile Pro © Clench Anterior Temporalis Right Side > Left Side

54. 6/18/12 InnerSmile Pro © Clench Masseters Right Side > Left Side

55. 6/18/12 InnerSmile Pro © Anterior Temporalis Right Side > Left Side Masseters Right Side > Left Side

56. 6/18/12 InnerSmile Pro © Instant Replay: InnerSmile Pro © “Muscle Asymmetry is shown by comparing muscle pairs.”

57. 6/18/12 InnerSmile Pro © “OK. But is it IMPORTANT?” Yes, it sets practical functional treatment plans. But … If you can't communicate it, don't do it. Ask another question: “Are asymmetries always the same?” Humm. Take a look at the next slide.

58. 6/18/12 InnerSmile Pro © Masseter M. Right Side > Left Side Left Side > Right Side Anterior Temporalis Right Side >Left Side Masseters Left Side> Right Side

59. 6/18/12 InnerSmile Pro © Next…. WHAT ABOUT THIS PATTERN? InnerSmile Pro ©

60. 6/18/12 InnerSmile Pro © Right Temporalis Muscle Remains active at rest Very little amplitude during clench. Digastric m. also low, until swallow ->

61. 6/18/12 InnerSmile Pro © A simple 3 or 5 minute exam provides objective information about stability of the jaw in action. A simple clench-release test tells you about soft-tissues: 1.Does a clench favor one side over the other during a clench? 2.Does a clench show dominance of the anterior temporales? 3. or do the masseters dominate? 4.Is the clench stable? NEXT … SUMMARYOF BITE ANALYSIS MUSCLE INTERACTIONS - CLENCH

62. 6/18/12 InnerSmile Pro © “That's hard to swallow!” TONGUE SCAN EVALUATIONS InnerSmile Pro ©

63. 6/18/12 InnerSmile Pro © REMEMBER: The task is a clench and a swallow. So how would this look? NEXT SLIDE.. SWALLOW CLENCH DIGASTRIC MUSCLE SCANS

64. 6/18/12 InnerSmile Pro © Ideal Digastric Muscle Scans SWALLO W CLENCH DIGASTRIC MUSCLE SCANS

65. 6/18/12 InnerSmile Pro © CLENCH Contracts during clench [bad] Contracts during the swallow [good]. Unhealthy Digastric Activity SWALLOW

66. 6/18/12 InnerSmile Pro © “So what. I don't understand!” That's because no one looked at digastrics in this manner. People who contract the digastric muscle while clenching the masseters need a full swallowing analysis. Usually they have an undiagnosed breathing-swallowing problem.

67. 6/18/12 InnerSmile Pro © The 5 Minute Scan adds the CPS muscle pairs. The 7 Minute scan that will adds CPS and SCM muscle pairs. Use this before those big 'TMJ' machines costing. InnerSmile Pro ©

68. 6/18/12 InnerSmile Pro © 5 minute: Head-Neck sEMG Evaluation Left Masseter Right Masseter Left Ant. Temp. Right Ant. Temp. Left CPSRight CPS Digastic Results look like this… NEXT

69. 6/18/12 InnerSmile Pro © 5 minute: Head -Neck sEMG Evaluation

70. 6/18/12 InnerSmile Pro © PART 2-Beyond sEMG Amplitude With today’s computers, you can see more than the amplitude of a muscle. NEXT… InnerSmile Pro ©

71. 6/18/12 InnerSmile Pro © Subjective Pain or Discomfort ◦ Detects and recorded pain spots Muscle Fatigue Signal: Mean-Median sEMG in Frequency [Hz] ◦ Detects local muscle fatigue Microbreaks in Responses/min ◦ Index of muscle health at rest Other sEMG Signals : InnerSmile Pro ©

72. 6/18/12 InnerSmile Pro © PAIN GRAPH Patients rate their pain level (from 0-10) in the areas that are scanned. THE PAIN LINK InnerSmile Pro ©

73. 6/18/12 InnerSmile Pro © The Mean and Median Frequency [Hz] is dynamic. - An inversion of frequencies = Local Muscle Fatigue But what does that mean? MUSCLE FATIGUE InnerSmile Pro ©

74. 6/18/12 InnerSmile Pro © EXAMPLE OF INVERSION Inversion or Local Fatigue Spectral Mean-Median wave colors INVERT at fatigue point. InnerSmile Pro ©

75. 6/18/12 InnerSmile Pro © MICRO BREAKS Hold in full tension Technical : Microbreaks are related to Muscle Spindle looping – like an auto-reset on the computer to keep it clear under load. Healthy Muscles show ‘microbreaks ’ – Split second gaps in contraction that allow blood flow, and sustained endurance. MICROBREAK

76. 6/18/12 InnerSmile Pro © MICRO BREAKS : Micro breaks in Responses/min This allows you to see if muscles are healthy, if they have split second gaps in contraction that allow blood flow, and sustained endurance. MICRO BREAKS Hold in full tension MICROBREAK InnerSmile Pro ©

77. 6/18/12 InnerSmile Pro © FULL SCAN PROFILE InnerSmile Pro ©

78. 6/18/12 InnerSmile Pro © Dynamic Oral Muscle Assessment WITH COMPUTERS TODAY- DYNAMIC MUSCLE ASSESSMENT YOU CAN COMMUNICATE VISUALLY BEFORE AND AFTER TRAINING - VISUAL REPORT SEE THAT YOUR TRAINING GOALS ARE MET InnerSmile Pro ©

79. 6/18/12 InnerSmile Pro © In Summary, Dynamic Muscle Scanning provides rapid, objective detection of soft-tissue issues and can help you bring out your patient's true inner smile. InnerSmile Pro ©

80. 6/18/12 InnerSmile Pro © Bring out their InnerSmile InnerSmile Pro © fin