1

MUSCLE
PHYSIOLOGY
ORTHODONTICS

AND

MUSCLE

SIGNIFICANCE

IN

INTRODUCTION
Development of muscle and muscle changes during growth
Muscle physiology and methods of studying muscle activity
ORO facial muscles
Facial muscle
Jaw muscle
Portal muscles
- -Basic concepts of neuromuscular system
-- -Role of muscle in functional jaw orthopedics
Role of muscle in temporo mandibular dysfunctions
Role of muscle in malocclusion:
1.
Functional slides into occlusion due to occlusal interferences
2.
Detrimental sucking habits
3.
Abnormal patterns
4.
Incompetent normal reflexes (lip posture)
5.
Abnormal muscle contractions
Role of muscle in orthognathic surgery
Role of muscle in retention and relapse
In Orthodontics it is necessary to view the orofacial musculature in a different context to
understand its effects on growth of the face and the effects of malfunction of jaws and
facial structure on muscle activity.
DEVELOPMENT OF MUSCLE AND MUSCLE CHANGES DURING GROWTH
Prenatal muscles grow by increase in size and amount of fibrous tissue surrounding the
muscle bundles as well as by cell division. Striped muscle differentiation begins in the
7th week of intrauterine life and typical muscle fibers are seen in the 22nd week. Normal
muscular activity begins at the end of the 7th month and is not complete in the
extremities until after birth. Muscles of mastication at first develop in relation to
Meckels cartilage but are independent of the insertions and are attached only to the
forming mandible. Increase in bulk of a muscle is due to activity. Atrophy results from
disease. During infancy and childhood, gain in muscle tissue is essentially the result of
hypertrophy. Between the 4th fetal month and birth the muscular system increases by 50
fold. It increases 40 fold between birth and middle of the 3rd decade of post natal life.
POST NATAL GROWTH: Muscle growth is rapid in infancy and childhood, slower and
regular in the middle of childhood and again more rapid preceding and during
adolescence. The muscles of the head show the smallest relative increment of growth.
The weight of the facial musculature increases 4 fold between birth and age 20 years,
which that of the mandible alone increases almost 7-fold by age 20 years.

2
MUSCLE CHANGES DURING GROWTH
Friel (1926) has shown correlation between the growth of the muscles of mastication and
development of the dentition. The muscles develop most rapidly after puberty when the
deciduous teeth are replaced by permanent dentition. A general correlation exists
between growth of the muscles of mastication, development of the dentition and strength
of the mandible. Growing bone is susceptible to deformation resulting from muscle
forces acting upon it provided these forces are strong and continuous enough to
overcome its inherent growth vector. Abnormal force during growth period can produce
abnormal form.
Since deformity can be produced by pressure, removal or paralysis of
muscles. Deformities are the result of change in direction of growth of the developing
skulls.
Continued adjustments in muscle attachments occur during skeletal growth. Muscles
can be divided into two groups with respect to their attachments.
1.
2.

Periosteal the fibrous layer of the periosteum

Tendinous a tendon which cannot be removed from the bones without some
destruction of the surface of the bone.

The first group can shift its attachments by growth changes of the periosteum. Different
rates of lengthening at different regions allow the periosteum to shift relative to the bone,
carrying the muscle attachments with it thus maintaining the constant spatial relationship
of the muscles.
In the second type of muscle attachments a mechanism exists to break down or alter the
attachment so that the muscles may shift. In muscles attached by tendons the change is
made by bone resorption and apposition, which carries the tendinous attachments with it.
The insertion of the suprahyoid and external Pterygoid muscles into the mandible belong
to the second group and to certain extent also the internal Pterygoid and temporal muscles
since their insertions or partly tendinous.
Where bone resorption is found in relations to the tendinous attachment of a muscle,
resorption frees the muscle from the bone. Muscles can become temporarily periosteal in
attachment and can shift relative to bone growth maintaining their normal position. This
is particularly true of muscles attached at the growing ends of the mandible. When bone
resorption causes, the muscles may become reattached directly to the bone by tendinous
fibers.
Growth at the anterior end of each half of the mandible until the symphyseal suture is
obliterated in the latter part of the 1st year. Gradually tends to separate the anterior belly
of the diagnostic and the geriohyoid muscles.
The tendinous insertion of the temporal muscle is gradually fixed from the bone of the
anterior border of the ramus of the mandible which is resorbed to make room for
permanent molar eruption and the development of the alveolar process around these
teeth.
The attachment of internal Pterygoid shifts during the growth of the mandible and
expands as the ramus increases in size by bone deposition along its posterior border.

3
MICROSCOPIC ANATOMY OF SKELETAL MUSCLE
Microscopic examination of a typical skeletal muscle reveals hundreds or thousands of
very long cylindrical cells called muscle fibers or myofibers. The muscle fibers lie
parallel to one another and range from 10 to 100 m in diameter. The plasma membrane
of a muscle cell is termed the sarcolemma and it surrounds the muscle fibers cytoplasm
which is called sarcoplasm. The nuclei are at the periphery of the cell next to the
sarcolemma conveniently out of the way of contractive elements. The mitochondria lie in
rows throughout the muscle fiber strategically close to muscle proteins that use ATP
during contraction. At high magnification the sarcoplasm appears stuffed with little
threads. These small structures are the myofibrils. Although the myofibrils extend
lengthwise within the muscle fiber their prominent alternating light and dark bands make
the whole muscle cell look striated or striped. The bands are called cross striations.
MYOFIBRILS
Myofibrils are the contractive elements of skeletal muscle. They are 1 2 um in
diameter and contain three types of small structures called filaments. The filaments are
thick filament (16 mm), thin filament (8 mm) and elastic filament. Depending or whether
the muscle is contracting or relaxing the thick and thin filaments overlap one another to a
greater extent.
The filaments inside a myofibril do not extend the entire length of the muscle fiber. They
are arranged in compartments called Sarcomeres which are the basic functional units of
striated muscle fiber. Narrow plate shaped regions of dense material called Z discs
separate one Sarcomere from the next. Within each Sarcomere is a darker area called the
A band. It consists mostly of thick filaments and includes portions of the thin filaments
where they overlap the thick filaments. A lighter, less dense area called the I bands
contains the rest of thin filaments but no thick filaments .The Z disc passess through the
center of each I band. The alternatively darker A bands and lighter I bands give the
muscle fiber its striated appearance. A narrow H zone in the center of the A band
contains thick but not thin filament. Dividing the H zone is the M line formed by a
protein molecule that connect adjacent thick filaments.
(Z I + A + I) (H = Mid A (thick region)
(M = line in mid of H zone)
The two contractive proteins in muscle are myosin and actin. About 200 molecules of the
protein myosin form a single thick filament. Each myosin molecule is shaped like two
golf clubs twisted together. The myosin tails point towards the M line in the center of the
Sarcomere. The projections called myosin heads or cross bridges extend out towards the
thin filaments. Tails of neighboring myosin molecules lie parallel to one another forming
the shaft of the thick filament. The heads project from all around the shaft in a spiraling
fashion.
The filaments extend from anchoring points within the Z discs. Their main component is
actin. Also present in the think filament are smaller amounts of two regulatory proteins
Tropomyosin and troponin. Individual actin molecules have an irregular shape. They join
to form an action filament that is twisted into a helix. On each actin molecule is a myosin
binding site, a location where a myosin head (cross bridge) can attach. In relaxed muscle
Tropomyosin causes the myosin binding sites on actin and thus blocks attachment of
myosin heads to actin.
The elastic filament, component of Sarcomere is composed of the protein titin
(connectin) the third most plentiful protein in skeletal muscle (after actin and myosin)

4
Titin anchors thick filaments to Z discs and thereby helps stabilize the position of thick
filaments. It may also play a role in recovery of the resting Sarcomere length when a
muscle is stretched or during relaxation.
SARCOPLASMIC RETICULUM AND TRANSVERSE TUBULES
A fluid filled system of cisterns called the sarcoplasmic reticulum encircles each
myofibril. In a relaxed muscle fiber the sarcoplasmic reticulum stores ca++. Release of
ca++ from the sarcoplasmic reticulum into the sarcoplasm around the thick and thin
filaments triggers muscle contraction. The calcium ions leave the sarcoplasmic reticulum
through channels in its membrane called ca++ release channels.
The transverse tubules (T tubules) are tunnel like infoldings of the sarcolemma.. They
penetrate towards the center of the muscle fiber at right angles to the myofilaments.
There are two transverse tubules in each Sarcomere. One at each A-I band junction T
tubules are open to the outside of the fiber and are filled with extra cellular fluid .On both
sides of a transverse tubule are dilated end sacs of the sarcoplasmic reticulum called
terminal cisterns. The tern triad refers to a transverse tubule and the terminal cisterns on
either side of it.
CONTRACTION OF THE MUSCLE
In the mid 1950s Jean Hauson and High Huxley had a revolutionary insight into
the mechanism of muscle contraction. Previously scientists had imagined that muscle
contraction must be a folding process, some what like closing an accordion. Hauson and
Huxley proposed, however that skeletal muscle shortens during contraction because the
thick and thin filaments slide past one another. Their model is known as sliding filament
mechanism of muscle contractions.
SLIDING FIMALENT MECHANISM
During muscle contraction, myosin heads pulls in the thin filaments, causing them to
slide increased the H zone at the center of Sarcomere. The myosin cross bridges may
even pull the thin filaments of each Sarcomere so far inward that their ends overlap in the
centre of the Sarcomere. As the thin filament slide inward, the Z discs come toward each
other, and the Sarcomere shortens but the lengths of thick and thin filaments do not
change. The sliding of the filaments and shortening of the Sarcomeres cause shortening
of the whole muscle fiber and ultimately the entire muscle.
ROLE OF CA++ AND REGULAR PROTEIN
The sliding filament model explains the mechanism of contraction, but what starts and
stops sliding of the filaments? As increase in ca++ concentration in the sarcoplasm starts
filament sliding while a decrease turn off the sliding process.
When a muscle fiber is relaxed, the concentration of Ca++ in its sarcoplasm is low. This
is because the SR membrane contains ca++ active transport pumps that move ca++ from
the sarcoplasm into the SR. ca++ is stored inside the SR. As the muscle action potential
travels along the sarcolemma and into the transverse tubule system, however ca++ release
channels open in the SR membrane. As a result ca++ floods into the sarcoplasm around
thick and thin filaments. The ca++ released from the SR combine with troponin, causing
it to change shape. This shape moves the troponin and Tropomyosin complex away from
myosin binding sites on action.
THE POWER STROKE AND ROLE OF ATP
As we have seen, muscle contraction requires ca++. It also requires energy, in the form of
ATP.

5
1. While the muscle is relaxed, ATP attaches to ATP binding sites on the myosin
cross bridges (heads) A portion of each myosin head acts as on ATPASE,
enzyme that splits the ATP into ADP (phosphate group) through a hydrolysis
reaction. This reaction transfers energy from ATP to the myosin head, even
before contraction begins. The myosin cross bridges are thus in an activated
(energized state)
2. When the SR release CA++ and CA++ level rises in the sarcoplasm,
Tropomyosin moves away from its blocking position.
3. The activated myosin heads spontaneously bind to the myosin binding sites on
action.
4. The shape change that occurs as myosin heads binds to action produces the
power stroke of contraction. During the power stroke the myosin heads
swivel toward the centre of the Sarcomere, like the Oars of a boat during
rowing. This action draws the thin filament past the thick filaments towards
the H zone as the myosin heads swivel, they release ADP.
5. Once the power stroke is complete, ATP again combines with the ATP
binding sites on the myosin heads. As ATP binds the myosin head detaches
from actin
6. Again the myosin ATPASE splits ATP, transferring its energy to the myosin
head, which returns to its original upright position.
7. The myosin head is then ready to combine with another myosin binding site
further along the thin filaments.
The cycle of steps 3 through 7 repeats over and over as long as ATP is available
and the ca++ level near the thin filaments is high. The myosin heads keep rotating
back and forth with each power stroke, pulling the thin filaments towards the H zone.
At any one instant about of the myosin heads are bound to actin and are swiveling.
The other half are detached and preparing to swivel again. Contraction is analogues to
running on a non motorized tread mill. One foot (myosin head) strikes the belt (thin
filament) and pushes it backward outward the H zone. Then the other foot comes
down and imparts a second push. The belt soon moves smoothly while the runner
(thick filament) remains stationary. And like the legs of a runner, the myosin heads
need a constant supply of energy to keep going!
This continual movement of myosin head applied the force that draws the Z discs
towards each other, and the Sarcomere shortens. The myofibrils thus contract, and
the whole muscle fiber, shortens. During a maxillary muscle contraction the distance
between Z discs can decrease to the resting length. But the power stroke does not
always result in shortening of the muscle fibers and the whole muscle. Contraction
without shortening is called on isometric contraction. For example, trying to lift a
heavy object the myosin heads (cross bridges) swivel and generate force, but the thin
filaments do not slide inward.
FACIAL MUSCLES
Primary function of facial muscles is expression of emotions. The capacity for
expressing effective states is highest developed in the human.

6
COLEMAN contents the human is capable of 7000 possible facial expressions. In
addition to expression of emotions, these muscles are important in maintenance of
posture of facial muscles. According to Proffit the lip and buccinator muscles opposed
by the tongue contribute to a postural equilibrium of the teeth. The facial muscles also
contribute to stabilization of the mandible during infantile swallowing and in chewing
and swallowing in the edentulous and occlusally compromised adult. It is quite possible
that postural alternations in the facial muscles may contribute to structural changes in the
jaws.
Frankel has speculated that the buccinator muscles exert a constraining force on the
maxillary alveolar process as well as the teeth. Form also dictates function: patients with
short upper lips or excessively proclined maxillary incisors compensate by elevation of
the lower lip through action of the mentalis muscle, to establish an anterior seal during
swallowing. Facial muscles also play an important role in both visual and spoken
communication. Lips and cheeks are essential as well for bolus control in mastication.
JAW MUSCLES
Jaw muscles are often designated as elevators and depressors or protractors and
retractors but this classification of muscles acting as synergist or antagonists can be
handicap to a better understanding of their roles in posture and jaw muscle synergies.
The simplest concept of neural control of mandibular posture is of the mandible
maintained against gravity by the stretch reflex in mandibular elevators. EMG studies of
postural position have shown that inframandibular group of muscles are more active than
the elevator muscles.
While the mandible is capable of a pure rotational movement early in opening and late in
closure, studies have shown that normal opening and closing are never pure rotational.
The actual rotational centers are closer to the mandibular ramus and shift during opening
and closing. This means that the changes the environment of both the mandible and
maxilla and alters the way they grow. The long face syndrome which Linder arson
associates with mouth breathing is a good example.
PORTAL MUSCLES
The term portal muscles were coined by BOSMA to denote the upper alimentary and
respiratory tracks. The muscles of portal area serve the multiple functions of posture,
respiration and feeding. Postal muscles include the muscles of tongue, soft palate; the
pharyngeal pillars the pharynx proper and larynx. It is the crossing of these tracts in the
pharynx that requires special reflex controls for maintenance and protraction. The two
portal reflexes of greatest significance to orthodontics are pharyngeal airway
maintenance and swallowing.
Basic concepts of orofacial neuromuscular physiology
Active and Passive tension
When a muscle is stretched the tension in that muscle increases. This increase in
tension may be the result of reflex contraction of the muscle. If the muscle contains
sensory organs called muscle spindles the elongation of the spindle excites the spindle
afferents, which synapse on molar neurons innervating the gross muscle resulting in their
contraction. This is the classic stretch reflex. The spindle afferents can be segregated
into at least two types

7
(nuclear bag or primary and nuclear chain or secondary endings) which are preferentially
sensitive to a sudden stretch or a prolonged stretch. Since all the mandibular elevator
muscles possess spindles this mechanism can occur opening and closing of the mandible
can no longer be conceived as largely an interplay between elevators and depressors.
Mandibular movement is more accurately perceived as that of free body manipulated in
an intrinsic muscular web with the teeth and joints acting as stops and guides. If it were
not this way, patients with bilateral condylectomies can never chew.
In this interactive web muscles serve various functions movements for the two heads of
lateral Pterygoid muscle at rest and open positions completed about the instantaneous
centers of rotations of the mandible. At postural position the superior head has a closing
movement while the inferior head has an opening moment. At the open position both
heads have opening normal.
The tension resulting from contraction of muscle tissue is called active tension. Since
the facial muscles possess no spindles stretching of facial muscle will not elicit a stretch
reflex. Nevertheless the tension in these muscles will increase with elongation because
of the elastic properties of muscle and its investing tissues. Tension which result from
the physical properties of the tissue is called passive tension.
In many muscles elongation will result in an increase in both active and passive tension.
The sum of both tensions is appropriately called total tension. Below a specific level all
the tensions of the muscle are zero. As the muscle is stretched the active tension
increases. In a muscle containing spindles this has been attributed to the stretch reflex.
Initially there is no passive tension so that total tension is equal to active tension. As the
stretching increases the muscle begins to behave elastically. Passive tension now adds to
total tension. As the muscle is elongated further active tension is inhibited while passive
tension continues to increase. On further stretching active tension is suppressed or
passive tension rises exponentially. At this length total tension is the same as passive
tension
The active tension may be due in part to extent to which the actin and myosin filaments
overlap. The generation of active tension falls off if the overlap is excessive or
inadequate. The decline in active tension with increasing muscle length is due to initiate
inhibitory reflexes suppressing the contraction brought about by excitation of spindle
afferents.
Many procedures result in elongation of jaw and facial muscles. Expansion of dental
arches stretches the cheeks or lips and increases tension in the buccinator and orbicularis
oris muscle. Increasing the vertical dimension is closed bite malocclusions will stretch
in the elevator muscles. Appliances such as bite planes and activators which increase
vertical dimension and / or advance the mandibles increase tension in both elevator and
retractor muscles. Habits such as mouth breathing which increase the postural vertical
dimension increase tension in elevator muscle.
The contribution of active tension to total tension in facial muscles would be different
from that in jaw muscles since facial muscles contain no spindles. Characterization of
the active and passive tension curves in lips and cheeks might be indicative of the extent
to which expansion could be used in treatment.
Role of the muscle in functional jaw orthopedics:

8
Ever since Andersen and Haupl introduced Functional Jaw Orthopedics (activator) in
1936, diverse views have been presented regarding the neuromuscular responses brought
about with activator treatment.
Andersen and Haupl claimed that the activator, which stimulates the
protractor muscles and inhibits the retractor muscle of the mandible, produces myotactic
reflexes leading to isometric contractions from the activities of the jaw closing muscles.
Petrovic in his study of the condylar cartilage came to similar conclusion that functional
requirement for condylar growth stimulation is activation of lateral Pterygoid muscle
(LPMs)
Eschler supported Andersen and Haupl, but claimed that the retractor muscles are
stimulated, not inhibited by the activator. He attributed the muscle contraction to
proprioceptive stretch reflexes and observed the occurrence of both isotonic and isometric
contraction with use of the activator. He described the cycle as at insertion of the appliance
the mandible is elevated by isotonic muscle contractions the mandible assumes a mucostatic
position in contact with appliance, isometric contractions arise.
According to Woodside, a stretch of the soft tissues primarily requires dislocating the
mandible anteriorly or opening beyond the postural rest vertical dimensions.
Between two extremes exemplified by Andersen and Haupl versus Selmer Olsen, Witts
supported a combination of isometric muscle contractions and viscoelastic properties being
responsible for the forces delivered by the activator.
Ahlgrens electromyography research (1970) shows that activator function as interference in
producing new contraction patterns in jaw muscles. The innervations pattern can be
adjusted after a while and the mandible repositioned forward. He reported that during day
time wear of an activator, there was an increased postural activity in Masseter and
suprahyoid muscles but not in the temporalis
Role of LPM
Lateral Pterygoid traction regulates the growth of the mandibular condyle. Lateral Pterygoid
traction on the head of condyle seems to produce increased & proliferation in the pre
chondroblastic layer of condylar cartilage. Petrovic suggested repeated modulation of
condylar growth by lateral Pterygoid activity constitutes on important element in a feed back
mechanism that serves to maintain a stable occlusion in the face of varying rates of
maxillary growth.
Temporal Muscle activity
EMG Recording shows temporal muscle activity in the rest position constant
during 1st year of activator treatment. So, in Maximal bite (in inter Cuspal position), the
temporal muscle activity is decreased with large protrusions in the construction bite. The
decrease was considered to be an effect of occlusal instability brought about by the activator
treatment. There is no evidence of decrease in postural (rest) activity of the posterior
temporal muscle during treatment, although such decrease has been described as a sign of
forward displacement of the mandible.
McNamara noted decreased postural activity of the posterior temporal muscle but increased
activity of the lateral Pterygoid muscle. This is so called Pterygoid response was thought
to lead to a forward repositioning of the mandible.

9
Role of Lateral Pterygoid muscle and Meinsco Temperomandibular Frenum:
Study in young rat of J.J.Stuzmann and A.G. Petrovic, shows the role of LPM, TMF control
the growth rate, growth direction and growth amount of cartilage. Four line of evidence,
that the lateral Pterygoid muscle (LPM) plays a role in this physiologic control of the
condylar cartilage growth rate.
1.
After surgical resection of LPM, relative decrease in the growth of the condylar
cartilage seen either in treated or untreated growing rate with functional appliance.
2.
EMG record of LPM in monkey treated with a functional appearance shows
increased electrical activity.
3.
Micro electronic stimulation of LPM in young rats produces an increased rate of
condylar cartilage growth.
After treatment with hyperpropulsor, significant increase in proportion of fast non fatigable
fibers in young rats LPM is seen and a significant decrease in the number of serial
sarcomeres in the same muscle.
Harvold (1974) and wood side (1973) do not accept the theory that myotactic reflex activity
with isometric muscle contraction induces skeletal adaptation. According to their views, the
viscoelastic properties of muscle and stretching of soft tissues are decisive for activator
action.
During each application of force, secondary forces are in the tissues, introducing bio elastic
process, thus not only the muscle contractions but also the viscoelastic properties of the soft
tissues are important in stimulating the skeletal adaptations.
According to him, eliciting a stretch of soft tissues primarily requires dislocating the
mandible anteriorly or opening beyond the postural rest vertical dimensions

10
MECHANISM OF CLASP KNIFE REFLEX ON AUTOGENIC INHIBITION: Muscle
first resists, then relaxes. This resembles that of a spring loaded folding knife blade this
phenomenon is called the clasp knife reaction. The excessive or rapid stretch of the
muscle brings in to play some inference that annuls the stretch reflex and allows the muscle
to be lengthened with little or no tonic resistance. Thus the stimulus necessary to elicit the
clasp knife reflex is excessive stretch and when elicited it inhibits muscular contraction, thus
causing the muscle to relax. The receptors for the clasp knife reflex are the Golgi tendon
organs located in the tendon of the muscle. The impulses are conducted by group 1B
sensory nerve fibers the impulses act on the motor neuron of alpha efferent supplying the
stretched muscle. However it is a disynaptic reflex arc because an interneuron is interposed
between the sensory neuron and the motor neuron. It follows during the muscle stretch; the
motor neurons supplying the stretched muscles are bombarded by impulses delivered over
two competing pathways one facilitating and other inhibiting muscle contraction.
The
output of the motor neuron poll depends upon the balance between the two antagonists
inputs. The functional significance of the clasp knife reflex is to protect the over load by
preventing damaging contraction against strong stretching forces. The proponent of this
concept content that these of myotactic reflex along with attempts to increase the frequency
of biting and swallowing should be largely ignored, letting passive tension (viscoelastic
properties) in the stretched labial and oral musculature deliver the primary force of the
appliance thus, the power to produce alveolar remodeling is obtained from the inherent
elasticity of muscle, tendinous tissues and skin without motor stimulation muscle spindles
have not been clearly demonstrated in the labial muscles and therefore there seems to be no
mechanism for turning off reflex muscle activity through a modification of the myotactic
reflex. Thus, more these muscle are stretched, greater is the force delivered to the activator.
The forces generated by this extreme bite registration (10-15 mm) represent combination of
forces generated by swallowing, biting, activation of the myotactic reflex in the stretched
muscles of mastication and the power delivered through the viscoelastic properties of
stretched muscles, tendon tissue, Skin and musculature.
The reason that the bite registered for 3mm to 4 mm distal to the most protruded position is
to avoid the possibility of initiating Golgi tendon organ activity and thus eliminate any
undesirable myotactic reflex.
Twin block
The clinical responses are observed after fitting twin blocks, is closely analogous to the
changes observed and reported in animal experiments using fixed inclined planes by
McNamara.
With in few days of fitting the appliances, immediate change in the neuromuscular
proprioceptive response is seen provided that all phasic and tonic muscle activity is affected.
This results in position of muscle balance, which is altered, so that it becomes painful for the
patient to retract the mandible. This has been described as the Pterygoid response by
McNamara or the formation of a tension zone distal to condyle by Harvold. This kind of
response is rare in other functional appliances that are not worn full time. The rapid clinical
response confirms the adaptive response in functional protrusion experiments with fixed
inclined planes by McNamara.

11
Structural alterations are more gradual and are measured in months, whereby dento
alveolar skeletal structures adapt to restore a functional equilibrium to support the altered
position of muscle balance.
Role of Lateral Pterygoid muscle
The position of the mandible did not change significantly after fatiguing the protrusive
muscle. Authors agreed that change in muscle activity diminished shortly after appliance
insertion and before correction of the jaw relationship was achieved. Morphologic change in
jaw relationship appeared that the lateral Pterygoid muscle might not be responsible for the
new position of the mandible after treatment with twin block appliance. The
Temperomandibular joint adapted to displacement of the mandible by condylar growth and
surface apposition in the fossa
Growth Relativity hypothesis
Growth relativity refers to, growth that is relative to the displaced condyle from actively
relocating fossae. Viscoelasticity is conventionally applied to elastic tissue primarily
muscles i.e. non calcified tissues, specifically addresses to the viscosity and flow of the
synovial fluids, the elasticity of the retrodiskal tissues, the fibrous capsule and other
nonmuscular tissues including LPM perimysium, TMJ tendons and ligaments, other soft
tissues and bodily fluids.
Wolffs law states that bone architecture is influenced by neuro musculature. This law may
now be extended for orthopedically displaced condyle. With orthopedic advancement of the
mandible, the law of growth relativity states that bone architecture is influenced by the
neuromusculature and the contiguous, nonmuscular, viscoelastic tissues anchored to the
glenoid fossa and the altered dynamics of the fluids enveloping bone.
Electromyogram activity
Insertion of the twin block appliance in the mouth cause a change in the EMG pattern
of both the Masseter and anterior temporalis during 6 months observation period
EMG Shows increase in postural and maximum clenching in Masseter, whereas during the
act of swallowing there was no change in EMG activity. The increased postural activity of
the Masseter is explained as a balancing contraction as a result of the protrusion of the
mandible imposed by the Twin block. These findings are in confirmation with the anatomic
function of the Masseter, which plays a dominant role in elevation when the mandible is
protracted.
Muscle activity during maximal voluntary clenching immediately on insertion of the Twin
block appliance in the mouth was lower in both anterior temporalis and Masseter than
without the appliance. This can be accounted for by the fact that when the muscle is
lengthened and isometrically contracted, the EMG activity falls, although the tension is
greater. This is in accordance with the active muscle activity in the isometric length
tension curve.
This can also be interpreted as an effect of reciprocal innervations, temporalis muscle being
an antagonistic muscle to a protrusive movement of the mandible, which agrees with the
results of Ahlgren who reported a decrease in electrical activity during biting contractions.
From study increase in EMG activity of Masseter and numeric increase of anterior

12
temporalis deduce that active contraction plays a more important role in treatment with
Twin block than passive tension associated with viscoelastic properties of soft tissues unlike
the activator. This increase in postural EMG activity may reflect an adaptation to a new
mandibular position during active phase of treatment with twin block.
Philosophy of the Frankel appliance
A major tenet of Frankel philosophy is that dentition are heavily influenced by functional
matrix; buccinator mechanism and the orbicularis oris complex. Compared to other
removable functional appliances, the FR is largely confined to the oral vestibule, and holds
away the buccal and labial musculature from the dentition in those areas in which pressure
on the dentoalveolar structures has restricted the outward development of these structures
during the critical transitional phase of dental development.
Frankel conceives the vestibular constructions as an artificial ought to be matrix that allows
the muscles to exercise and adapt. Thus the fundamental phenomenon of physiology is
adaptation or homeostasis. Concurrent muscle adaptation to the new position through the
exercise role of the appliance enhances the stability of the result.
Mode of action of the Frankel appliance
A) FR is not a tooth-moving appliance (i.e. FR is a tissue borne appliance)
B) FR withholds muscle pressure from the developing jaws and surrounding area having its
arena of operation largely in the vestibule surrounding the alveolar bone.
C) Changes with FR in transverse dimensions is achieved by relief of force from the
neuromuscular capsule (the buccinator mechanism)
D) Changes with FR in sagittal posturing is an entirely tissue borne manner.
ANALYSIS OF TEMPEROMANDIBULAR JOINT DYSFUNCTION
Each muscle involved in mandibular movements should be routinely palpated at rest and
in isometric contractions in an attempt to reduce reflex responses to pain, often,
Unbeknownst to the patient, muscles or parts of the muscles are painful upon palpation.
The Masseter, lateral Pterygoid and temporalis are those which most frequently
demonstrate myalgia in patients with temporo mandibular dysfunctions associated with
malocclusion.
Patients with TMD symptoms can be divided into two large groups
1.
Those with general joint pathology including displacement of destruction
of the intra articular disc
2.
Those with symptoms primarily of muscle origin caused by spasm and
fatigue of the muscles that position the jaw and head.
Myo functional pain develops when muscles are over fatigued and tend to go into spasm,
it is all but impossible to overwork the jaw muscle to this extent during normal occlusal
function. To produce myo facial pain the patient must be grinding or clenching the teeth
for many hours per day presumably or a response to stress and interval joint pathology or
an occlusal discrepancy.

13

ROLE OF MUSCLE IN MALOCCLUSION

DETERMINENTAL SUCKING HABITS
All habits are learned patterns of muscle contraction of a very complex nature. Certain
habits serve as a stimuli to normal growth of the jaws for example normal lip action and
mastication. Abnormal habits which may interfere with the regular pattern of facial
growth must be differentiated from the desired normal habits that are a part of normal
oropharyngeal function and thus play an important role in the craniofacial growth and
occlusal physiology. Detorius habitual patterns of muscular behaviouring often are
associated with prevented or impeded osseous growth, tooth malpositions disturbed
breathing habits, difficulty in speech, upset balance in the facial musculature and
physiological problems. Malocclusion cannot be corrected without involvement in such
reflex activity.
It has been suggested that thumb sucking in one of the earliest examples of the
neuromuscular learning in the infant and that it follows all the laws of the learning
problems.
For us the most important question is , does digital sucking cause malocclusion? Many
children who practice digital sucking habits have no evidence of malocclusion, however
popovietch and Thompson have reported a high association of abnormal sucking habits
in the malocclusion sample. They found three distinctively different patterns of force
application during sucking, all utilizing forces sufficiently strong to displace teeth or
deform growth bone. Melsen et al found the both digital sucking and pacifier sucking
increased the tendency toward abnormal swallowing. Sucking habits were related to an
increase in severe malocclusion symptoms apart from the type of swallow presented.
Sucking habits were strongly correlated with disto occlusion and open bite and with cross
bite and maxillary over jet.
It should be remembered that the type of malocclusion that may develop in the thumb
sucker depend on a number of variables the position of the digit, associated orofacial
muscle contractions, the position of mandible during sucking, the facial skeletal
morphology, duration of sucking and so forth. An anterior open bite is the most frequent
malocclusion. Protraction of the anterior maxillary teeth will be seen, particularly if the
hand is held upward against the palate. Mandibular postural retraction may develop if the
weight of the hand or arm continually forces the mandible to assure a retruded position in
order to practice the habit. Consistently the mandibular incisors may be tipped lingually.
When the maxillary incisors have been tipped labially an open bite has developed, it
becomes necessary for the tongue to thrust forward during swallowing. During thumb
sucking buccal wall contractions produce in some sucking patterns a negative pressure
within the mouth with resultant narrowing of the maxillary arch. Within upset in the
force system in an around maxillary complex, it goes in impossible for the nasal floor to
drop vertically to its expected position during growth. Therefore thumb suckers may be
found to have a narrower nasal floor and a high palatal vault. The maxillary lip becomes
hypotonic and the mandibular lip becomes hyperactive, since it must be elevated by
contractions of the orbicularis muscle to a position between the malposed incisors during
swallowing. These abnormal muscle contractions during sucking and swallowing
stabilize the deformation.

14
ABNORMAL PATTERNS
Characteristics of infantile swallow
z Jaws apart with the tongue between the gum pads
z Mandible is stabilized by the contraction of the muscles of the 7th cranial nerve
and the interposed tongue
z The swallow is guided and to a greater extent controlled by interchange between
lips and the tongue
Characteristics of retained infantile swallow
z This is the persistence of the infantile swallowing reflex even after the arrival of
the permanent teeth
z Very few people have this type of swallow
z Teeth occlude on only one molar in each quadrant
z They demonstrate violent contractions of 7th cranial nerve musculature during
swallowing and tongue is markedly protruded between all teeth during initial
stages of swallow
z The patients will have an expression less face since facial muscles are used for
stabilizing the mandible
TONGUE THRUSTING
Tongue thrust swallow that may be etiologic to the malocclusion are of two types.
Simple tongue thrust swallow
Complex tongue thrust swallow
The child normally swallows with the teeth in occlusion the lips lightly closed and the
tongue held against the palate behind the anterior teeth. The simple tongue thrust
swallow usually in associated with a history of digit sucking even though the sucking
habit is no longer been practiced, since it is necessary for the tongue to thrust forward
into the open bite to maintain an anterior seal with the lip during swallow. Complex
tongue thrusts on the other hand are far made likely to be associated with chronic naso
respiratory distress, mouth breathing, tonsillitis or pharyngitis. When the tonsils are
inflamed the root of the tongue may encroach on the enlarged facial pillars. To avoid this
encroachment the mandible reflex drops, separating the teeth and providing more room
for the tongue to be thrust forward during swallowing to a more comfortable position.
Pain and lessening of space in throat precipitate a new forward tongue posture and
swallowing reflex while the teeth and growing alveolar processes accommodate
themselves to the attendant upset in neuromuscular forces. During chronic mouth
breathing a large freeway space is seen, since dropping the mandible and protruding the
tongue provides a more adequate airway. Because maintenance of the airway is a more
primitive and demanding reflex than the mature swallow the latter is conditioned to the
necessity for mouth breathing. The jaws are thus held apart during the swallows in order
that the tongue can remain in a protracted position.
Melsen et al in one of the studies stated that both tongue thrust swallow and teeth apart
swallow favors the development of disto occlusion, extreme maxillary over jet and open
bite. There is an increase in tongue thrust swallowing (simple tongue thrust) seen with
both pacifier sucking and digit sucking.

15
ROLE OF MUSCLE IN ORTHOGNATHIC SURGERY:
The suprahyoid musculature has repeatedly been suggested as a primary cause of relapse
after mandibular advancement surgery. Based on clinical investigations, it has been
hypothesized that when lengthened the suprahyoid musculature exerts posteriorly
directed forces on the advanced mandible as a result of active muscle contraction, recoil
of stretched elastic connective tissue elements, or both. There are numerous related
adaptations that can take place within muscle in response to an increase in muscle length.
Immediately after muscle lengthening, two specific morphologic changes take place.
First, the parallel and serial connective tissues within the muscle become stretched.
Second, once the connective tissues have reached the limit of their extensibility, the
muscle fibers themselves become stretched, resulting in an elongation of the sarcomeres
and a decrease in the overlap of actin and myosin filaments.
Effects on lip pressure and different patterns of post surgical changes
z When incisors are moved within the sphere of influence of the lips after
previously being outside of it, as when vertically prominent maxillary incisors are
elevated to a new position beneath the lip, lip pressures will increase and the
incisors will tend to move lingually post surgically;
z When soft tissues are relaxed by the surgical treatment, as when the mandible
rotates upward and forward following maxillary intrusion, lip pressures will
decrease and the incisors will move labially.
z In patients in whom the soft tissues are stretched at surgery, as in mandibular or
maxillary advancement, lip pressures will increase and the incisors will move
lingually post surgically;
Three principles that influence the post surgical stability can be proposed:
1 The suprahyoid musculature has repeatedly been suggested as a primary cause of
relapse after mandibular advancement surgery. Moving the maxilla upwards relaxes the
tissues moving the mandible forward stretches the tissues, but rotating it upward
posteriorly and downward anteriorly decreases the stretch. It is not surprising that the
least stable mandibular advancements are those that lengthen the ramus and rotate the
chin up, while the most stable advancements rotate the mandible in the opposite
direction. The least stable orthognathic surgical procedure is widening of the maxilla that
stretches the heavy, inelastic palatal mucosa.
2. Neuro muscular adaptation is an essential requirement for stability. Repositioning of
the tongue to maintain air way dimensions,(a change in tongue posture)occurs as an
adaptation to changes produced by mandibular osteotomy these adaptations of the
tongue, and adaptation in lip pressures that also occur post surgically, contribute to the
stability of tooth positions. In contrast, a neuro muscular adaptation does not occur when
the pterygomandibular sling is stretched during mandibular osteotomy as when the
mandible is rotated to close an open bite. If then neuro muscular system reacts to change
in vertical position of maxilla, adjustment in muscle length should occur when the
maxilla is moved downward just as it does when the maxilla is moved upward. Even if
the muscles adapt, however, the stretch of other soft tissues apparently can lead to the

16
instability that is observed when the maxilla is moved down ward and the mandible is
forced to rotate down ward and backward.
3. Neuromuscular adaptation affects muscular length and not muscular orientation. If the
orientation of the muscle group such as the mandibular elevators is changed, adaptation
cannot be expected. This concept is best illustrated by the effect of changing the
inclination of the mandibular ramus when the mandible is set back or advanced.
Role of muscle in retention and stability
Alfred Coleman (1865) was the first person who claimed that muscular pressure is
responsible for relapse .
According to MOYERS primary cause of relapse is specifically that abnormal seventh
nerve action as it affects the facial muscles, especially abnormal functioning of the
mentalis muscle, is one of the most frequent causes of relapse of incisor correction.
Stedman (1961,1967), in a comprehensive approach to retention, referred to an enlarged
pharyngeal space, emotionally initiated mentalis or mimetic muscle hypertension, and
anterior component of force of mandibular third molars because of insufficient growth as
factors in bringing about undesirable post treatment changes or relapse.
Strang theorized that the mandibular inter canine and inter molar arch widths are
accurate indicators of the individual's muscle balance and dictate the limits of arch
expansion during treatment. Weinstein et al and Mills stated that the lower incisors lie in
a narrow zone of stability in equilibrium between opposing muscular pressure, and that
the labio lingual position of the incisors should be accepted and not altered by
orthodontic treatment. Reitan claimed that teeth tipped either labially or lingually during
treatment are more likely to relapse.