GOOD MORNING

PRESENTED BY:
DR.MURALI P.S
DEPARTMENT OF ORTHODONTICS AND
DENTOFACIAL ORTHOPAEDICS

MUSCLES OF
MASTICATION

CONTENT

Introduction
Development of muscle of mastication
Anatomy of Muscles of mastication
Physiology of muscles of mastication
Characteristic of muscles of jaw
Palpation of muscles of mastication
Significance in relation to orthodontics
Masticatory muscle disorder
pathological diseases of muscles of mastiction
Conclusion

INTRODUCTION
Orthodontist aim is to achieve

FUNCTIONAL EFFICIENCY
STRUCTURAL BALANCE
ESTHETIC HARMONY
to achieve this balance not only our concepts regarding
occlusion has to be clear,,,,,,,,,,,
It is also important that we realize and study the action of
various muscle of expression, mastication, deglutition,
speech and breathing.

INTRODUCTION
Orthodontist aim is to achieve

FUNCTIONAL EFFICIENCY
STRUCTURAL BALANCE
ESTHETIC HARMONY
to achieve this balance not only our concepts regarding
occlusion has to be clear,,,,,,,,,,,
It is also important that we realize and study the action of
various muscle of expression, mastication, deglutition,
speech and breathing

DEVELOPMENT
Muscles of mastication develops from the

mesoderm of the first brachial arch that is also

called mandibular arch.
Muscles begins differentiation in seventh week
of intra uterine life. Although the muscle of
mastication develop at first in close relationship
to meckels cartilage and the cranial base
cartilages, they are independent and only later
attach to the bony skeleton.

Temporalis :
Begins lateral development in the 8th week ,

occupying the space anterior to the otic capsule .

As the temporal bone begins ossify in the 13th
week, the muscle attaches to it.

Masseter:
Begins attachment to the zygomatic arch as it
undergoes lateral growth, providing space for
muscle development.

Pterygoid muscle:
Differentiate in the 7th week.
It is related to the cartilage of the cranial

base and the condyle initially.

Later as the bony skull appears and
increases in width and length, the muscle
expands rapidly.

ANATOMY
ORIGIN
INSERTION
BLOOD AND NERVE SUPPLY
ACTION

MASETTER
This

is

quadrilateral

muscle.
which covers the lateral
surface of the ramus of
mandible
Its fibres has 3 layers
Superficial
Middle
Deep layers

Origin:
superficial

layer

Originates from anterior

2/3rd of the lower border of
zygomatic arch and from
zygomatic process of the
maxilla
Middle layer
--From
anterior 2/3rd of deep surface
and posterior 1/3rd of lower
border of zygomatic arch
Deep layer -from the deep
surface of the zygomatic
arch

INSERTION:

Fibres of the superficial layer pass

downwards and backwards to insert

into the angle and lateral surface of the
mandibular ramus.
Fibres of the middle layer insert into
the central part of the mandiblular
ramus
Fibres of the deep layer insert into
upper part of the mandibular ramus
and into it's coronoid process.

RELATIONS:
Superficial relations:
Skin, Platysma Risorious, Zygomaticus Major and
Parotid Gland.
Muscle is crossed by the parotid duct, branches of
facial nerve and transverse facial vessels.
Deep relations :
Temporalis and mandibular ramus.
A mass of fat separates it in front of the buccinator and
the buccal nerve.
Masseteric nerve and artery reach the deep surface of
the muscle.

Nerve supply:
Supplied by masseteric nerve a
branch of anterior division of
mandibular nerve
Blood supply:
Supplied by masseteric artery
branch of maxillary artery and
venous
supply
through
masseteric vein

Action:
Elevation(bilateral):masseter elevates the

mandible to occlude the teeth in mastication.

Ipsilateral excursion(unilateral): as the origin of
the masseter muscle is slightly lateral to its
insertion , a single masseter muscle can move the
mandible to the same side.
Retrusion: (bilateral): when the mandible is in a
protruded position the deep fibers are in a position
to retrude the mandible.

TEMPORALIS MUSCLE
Large, fan shaped
muscle.
The muscle is
covered by a strong
membranous sheet of
fascia, which attaches
superiorly to superior
temporal line.

Origin:
originates from the temporal fossa and

lateral surface of skull.

Insertion:
It's

fibers converge and descend into a

tendon which passes through the gap
between zygomatic arch and side of
skull and attaches to the medial surface,
apex, anterior and posterior borders of
the coronoid process and the anterior
border of ramus of the mandible.

It can be divided into 3

distinct areas according

to fiber direction and
function.
The Anterior fibers are
directed almost
vertically- elevation of
mandible
The middle fibers run
obliquely forward as
they pass downward
-elevate and retrude the
mandible.
The posterior fibers are

Relations:
Superficial :
Skin, temporal fascia, superficial temporal vessels,
auriculotemporal nerve, zygomatico temporal
nerve zygomatic arch and Masseter muscle.
Deep Relation :
Temporal fossa lateral pterygoid, superficial head
of the medial pterygoid and maxillary artery.
Nerve Supply :
Deep temporal branches of the anterior trunk of
the mandibular nerve.

ACTIONS :
i.Elevation(bilateral): Temporalis elevates the
mandible to close mouth and approximate the
teeth, this movement requires the both the upward
pull of the anterior fibres and backward pull of the
posterior fibres.
Retrusion(bilateral): the posterior fibers of
temporalis lie in an almost horizontal plane and
therefore are in a good position to pull the
protruded mandible to a centric position.

Ipsilateral excursion: The insertion of

temporalis is medial to the origins and

therefore temporalis muscle is capable of
pulling the mandible to the same side.

MEDIAL PTERIGOID
Deep head:
Origin: Medial surface
of the Lateral plate of
Pterygoid process and
Pyramidal process of
Palatine bone.

Insertion : Medial

surface of the ramus

of Mandible near the
angle.

Superficial head:

Orgin:Tuberosity of the

maxilla and pyramidal

process of palatine bone
Insertion : it joins deep
head to insert on the
Mandible

Nerve supply : Nerve

to Medial Pterygoid from

the Mandibular Nerve.
Blood Supply :
Pterygoid branches from
Maxillary artery

Action :
Elevation (bilateral) : the medial pterygoid

acting along with the masseter muscle are

powerful elevators of the mandible.
Protrusion( bilateral): the insertion of the
muscle is posterior to its origin and
therefore it helps in protrusion of mandible.
Contralateral excursion: the medial and
lateral pterygoid muscle of two sides
contract alternately to produce Side-toSide movement of Mandible.

Lateral pterygoid
Upper head:
Origin : It arises from

the infratemporal
surface and crest of the
grater wing of the
sphenoid bone.
Insertion: The upper
head passes posteriorly
and lateraly to insert
into the articular
capsule and the
articular disc.

Lower head:
Origin :It arises from the

lateral pterygoid plate of

sphenoid bone.
Insertion : The inferior head
passes back ward , upward
and slight laterally to insert
into the pterygoid fossa of
condylar neck.
Nerve supply : Nerve to

Lateral Pterygoid from the

Mandibular Nerve.

Blood Supply : Pterygoid

vessels from Maxillary

artery

Action :
Action of inferior head:
Depression(bilateral): depresses the mandible along with
suprahyoid and infrahyoid muscles to open the mouth
Protrusion(bilateral): the lateral pterygoid acting
together are the prime protractors of the mandible.
Contralateral excursion(unilateral): the medial and
lateral pterygoid muscle of the two sides contact
alternately to produce side to side movement of the
mandible(as in chewing).

Action of superior head:

They are active during the power stroke.

Power stroke refers to movement that involves

closure of the mandible against resistent such as in

chewing or clenching the teeth together.

RELATIONS:

Superficial :
Ramus of mandible, maxillary artery and the
tendon of temporalis

Deep :
Upper part of the medial pterygoid,
sphenomandibular ligament, middle meningeal artery
and mandibular nerve.
Upper border : It is related to the temporal and
Masseteric branch of mandibular nerve.
Lower border : It is related to the lingual and inferior
alveolar nerve.
The buccal nerve and maxillary artery pass
between two heads.

Accessory muscles of mastication

Accessory muscles are :
Digastric(anterior and posterior)
Stylohyoid
Mylohyoid
Buccinator

Digastric
Posterior belly:
Ori : Mastoid process

of Temporal bone
Anterior belly:
Ori : Body of Mandible
Ins : Intermediate

Tendon is held to hyoid

bone by fascial sling

Nerve supply :
Facial Nerve (post belly)
nerve to mylohyoid (ant belly)
Action :
Depresses Mandible or elevates Hyoid
bone

Stylohyoid:
Ori : Styloid process
Ins : Body of Hyoid

bone
Nerve supply : Facial
nerve
Action : Elevates
hyoid bone

Mylohyoid:
Ori : Myloid line of

body of Mandible
Ins : Body of Hyoid
bone and fibrous raphe
Nerve supply : Inferior
Alveolar nerve
Action : Elevates floor
of mouth and hyoid
bone or depresses
mandible

Buccinator
Is thin quadrilateral muscle,
occupying the interval between
the maxilla and the mandible
.

Ori : Posterior part of

Maxilla , Mandible and

Pterygomandibular
raphe
Ins : Lip, blending with
fibres of Orbicularis
Oris

Nerve supply: - supplied by the lower

buccal branch of the facial nerve

Action: It compresses the cheek against the teeth so

helps in mastication as the food is passed

between them.
It helps in blowing, hence the name
buccinator.

Role of masticatory muscle in

mandibular movement
Mandibular movements during normal
function and during Para function involve
complex neuromuscular patterns originating
in the brain stem and modified by influences
from higher centers namely

cerebral cortex

basal ganglia

peripheral influences
(e.g. peridontium, muscles )

Mandibular Closing :
Mandible is elevated slowly without
occlusal contact, is brought about by the
contraction of the masseter and medial
pterygoid muscle.
Mandible is elevated against resistance, it
is brought about by the contraction of the
temporalis, masseter and medial pterygoid
muscles.

MANDIBULAR OPENING :

During opening movements, the lateral

pterygoid muscles show initial and
sustained activity
In forced depression the digastic
muscle is activated along with the
lateral pterygoid muscle.

PROTUSION :
The lateral and medial
pterygoid muscles contract
together, in conjunction with
controlled stabilizing
relaxation of opening muscle

RETRUSION :
Voluntary mandibular retrusion
with occlusion is brought about by
contraction of the posterior fibers of
the Temporalis muscle and by the
suprahyoid and infrahyoid muscles.
Retraction of the mandible from
protrusion and without occlusal
contact is effected by the
contraction of the posterior and
middle fibers of the Temporalis
muscles.

PHYSIOLOGY OF MUSCLES OF
MASTICATION
It is skeletal muscle.
Types of muscle fiber:
Slow muscles fibers (type I)
Fast muscles fibers (type II)

Lateral movement:
Lateral movement of the mandible to the
right side without occlusal contact is
achieved by ipsilateral contraction of
primarily the posterior fibers of the
Temporalis muscle.
Movement to the left side without
occlusal contact is brought about by the
contralateral contraction of the medial
pterygoid and masseter muscles.
Movement to the right side with
occlusal contact is achieved by ipsilateral
contraction of the Temporalis muscle.
Movement to the left with occlusal
contact is brought about by contralateral
contraction of the medial pterygoid and
masseter muscles.

Slow muscle fibers:-[Tonic muscles]:

These are the muscles which are redder in
colour because of some pigment protein
myoglobin.
These are also called as the type I fibers.
E.g. Temporalis, the masseter, the anterior
medial pterygoid and the lateral pterygoid
are 75 % composed of type I fibers.
[Eriksson]

45

Fast muscles fibers:

They are paler in colour
They are also considered as the type II muscle

fibers
Acc. To burke et .al 1973 type can be subdivided
into fibers which fatigue easily [type IIB] and the
other one which are resistant to fatigue [type II A].
Type IIA is found in 30 % only in digastric
muscle.
Type IIB is found in 45 % in the superior
temporalis, posterior medial pterygoid, and
anterior digastric muscle. [Acc to Eriksson]

Reflexes of the muscles:Reflex: A reflex action is the response

resulting from a stimulus that passes as an
impulse along an afferent neuron to the
posterior nerve root or its cranial
equivalent, where it is then transmitted to
an efferent neuron leading back to skeletal
muscle.
Most imporatant

Myotactic reflex

Nociceptive (flexor) reflex.

47

Myotactic (stretch) reflex:

They are monosynaptic jaw reflex.
When skeletal muscle is quickly stretched this protective

reflex is elicited and bring about a contraction of the

muscles.
myotactic reflex is activated by sudden application of
downward force to the chin
Results in sudden stretching of the muscle spindle increases

afferent out put from the spindle

These afferent impulse pass into the brain stem to the

trigeminal motor nucleus (where afferent cell body are

present) by way of trigeminal mesencephalic nucleus.
In trigeminal motor nucleus the afferent fibers synapse

with alfa efferent motor neurons that lead directly back to

the extrafusal fibers of the elevator muscle.
The reflex information sent to the extrafusal fiber is to

contract.

Prevent further stretching and often causes an elevation of

the mandible into occlusion

Myotactic reflex

50

This

reflex is used in myofunctional

appliances like activator.
The appliance is trimmed loosely and the
patient is conditioned to bite into the
appliance to keep it in position.
When the mandible moves mesially to engage
the appliance, the elevator muscles are
stretched.
Thus the myotatic reflex is activated, the
muscles contract and the forces elicited help
in causing skeletal and dento-alveolar
changes.
51

Nociceptive (flexor) reflex:It is a polysynaptic reflex to noxious stimuli

and is thus considered protective reflex

The afferent neuron stimulates one or more
interneuron's in the CNS which in turn
stimulate the efferent fibers.
The nociceptive reflex is activated by
unexpectedly biting on a hard object.

52

The Afferent fibers stimulate

inhibitory interneuron's which
have their effect on the jaw
elevating muscles and cause them
to relax.

The afferent fibers stimulate

excitatory interneuron that
innervate the jaw depressing
muscle to cause contraction.
53

Characteristics of the jaw muscles: The mandible being maintained against the

gravity by the stretch reflex of the elevators.

EMG studies have shown of [postural position]
that the inframandibular groups of muscles are
more active than the levator.
The head posture also affects the posture of

the mandible for e.g. when there is extension

of the head there is increase in the freeway
space and when there is flexion there is
decrease in the freeway space.

 Changes in the head posture also results

changes in the anteroposterior positioning of

the posture of the mandible.
One of the most important factors is the
posture of the mandible affecting the
development of the jaws.
E.g. during the mouth breathing there is
effect on the growth of both maxilla as well
as the mandible due to alteration in position
of the mandible, hyoid and the tongue.

Palpation of muscles: The muscles of mastication are palpated for

tenderness or pain during the screening

examination.
It is accomplished mainly by the palmar
surface of the middle finger, with the index
finger and the forefinger testing the
adjacent areas.
Soft but firm pressure is applied to the
designated muscles, the fingers compresses
the adjacent tissues in a small circular
motion.

56

 The temporalis: It has three functional areas and each is

independently palpated.
Anterior region: - Palpated above the zygomatic
arch and anterior to the TMJ.
Middle region: - Directly above TMJ and superior

to the zygomatic arch

Posterior region: - Palpated above and behind the

ear.
Otherwise, the patient is asked to clench the teeth so
that the temporalis contracts and this is felt with
hands.

The masseter muscles :Are palpated bilaterally at

their superior and inferior attachments.

The fingers are placed on the zygomatic arches
and then dropped down slightly just anterior to the
tmj for palpating superior part.
Secondly, the fingers are placed on the inferior
border of the rami to palpate inferior attachment.

Medial pterygoid: Finger tips are placed on

the inferior border of the
mandible at the angles
and are rolled medially
and superiorly.
Ask the patient to clench
the teeth if it is difficult to
locate the muscle.

The lateral pterygoid :

Palpation is difficult.
It is accomplished by placing the

forefinger or little finger behind

the maxillary tuberosity, right
above the occlusal plane, with the
palmar surface of the finger
directed medially toward the
pterygoid hamulus.
If there is tenderness in the
superior head of the lateral
pterygoid muscle than it indicates
abnormal functional loading of
the joint.

 The finding are classified into four categories.-

1. Zero: - no tenderness or pain is reported by the

patient,
2. One: - patients response is recorded. Here the
palpations cause discomfort.
3. Two:-there is definite discomfort or pain.
4. Three: - patient shows evasive action or
verbally expresses desire not to palpate.

Functional manipulation
Three
muscles that are basic to jaw movements
.
but impossible or nearly impossible to palpate are
(1) the inferior lateral pterygoid,
(2) superior lateral pterygoid,
(3) medial pterygoid.

Functional manipulation of the inferior lateral

pterygoid:
Contraction.:
When the inferior lateral pterygoid contracts, the mandible is
protruded, the mouth is opened, or both. Functional manipulation is
best accomplished by having the patient make a protrusive
movement, because this muscle is the primary protruding muscle
Therefore the most effective manipulation is to have the patient
protrude against resistance provided by the examiner If the inferior
lateral pterygoid is the source of pain, this activity will increase the
pain

Stretching:
The inferior lateral pterygoid stretches
when the teeth are in maximum
intercuspation. Therefore if it is the
source of pain when the teeth are
clenched, the pain will increase.
When a tongue blade is placed
between the posterior teeth, the
intercuspal position (ICP) cannot be
reached; therefore the inferior lateral
pterygoid
does
not
stretch.
Consequently, biting on a separator
does not increase the pain but may
even decrease or eliminate it.

Functional manipulation of the superior

lateral pterygoid
Contraction.:
The superior lateral pterygoid contracts with the
elevatormuscles
i.e.,temporalis,
masseter,medialpterygoid), especially during a power
stroke (i.e., clenching). Therefore if it is the source of
pain, clenching will increase the pain. If a tongue
blade is placed between the posterior teeth bilaterally
and the patient clenches on the separator, pain again
increases with contraction of the superior

lateral pterygoid.
These observations are exactly the same as for the elevator muscles.
Stretching is needed to enable superior lateral pterygoid pain to be
distinguished from elevator pain.

Stretching:
-As

with the inferior lateral pterygoid,

stretching
of
the
superior
lateral
pterygoid
occurs
at
maximum
intercuspation. Therefore stretching and
contracting of this muscle occur during
the same activity: clenching. If the
superior lateral pterygoid is the source of
pain, clenching will increase it. Superior
lateral
pterygoid
pain
can
be
differentiated from elevator pain by
having the patient open widely. This will
stretch the elevator muscles but not the
superior lateral pterygoid. If opening

Functional
pterygoid

manipulation

of

the

medial

Contraction: The medial pterygoid is an

elevator muscle and therefore contracts as
the teeth are coming together. If it is the
source of pain, clenching the teeth together
will increase the pain. When a tongue blade is
placed between the posterior teeth and the
patient clenches against it, the pain is still
increased because the elevators are still
contracti

Stretching.:

The

medial

pterygoid

also

Role of masticatory
muscle in orthodontics

Muscle as the etiology of malocclusion

Muscle dysfunction:-

The facial muscles can affect the growth

of the jaws in two ways:1. The formation of the bone at the point of
muscle attachment depends on the activity
of the muscles
2. The musculature is important part of the
total soft tissue matrix, whose growth
normally carries the jaws downward and
forward.

70

 Facial asymmetry in a eleven yr old boy whose masseter

muscle was missing on left side. So the muscle is an

important part of total soft tissue matrix,in its absence
growth of the mandible is affected.
71

If there is decrease in tonic

muscles activity that occurs

in muscular dystrophy, this
allows the mandible to drop
downward away from the
rest of the facial skeleton.
This results in increase of the anterior facial
height, distortion of facial proportions ,
mandibular form, excessive eruption of the
posterior teeth, narrowing of the maxillary arch
and anterior open bite. Ex: in cerebral palsy
72

Patterns of muscular activity in patients with

class III malocclusions
Dominant bone dysplasia,

with adaptive muscle

function

Strong heredity pattern

Here the anterior and the

posterior temporal muscle
are found to be more active
than that of masseter muscle
in the interocclusal position.

73

THE RELATIONSHIP BETWEEN CRANIOFACIAL

The mandibular muscles and their importance in orthodontics: A contemporary review

(AJO 2005,128:774-80)

MORPHOLOGY AND THE MANDIBULAR

MUSCLES :

Bite-force and facial morhology:

In dolichofacial subjects, significantly smaller max

imum molar bite forces have been found during maxi

mum effort than in mesofacial and brachyfacial sub
jects.

This implies a correlation between bite force and

facial morphology, and these findings have been

used to support the theory that the form of the face
partly depends on the strength of the mandibular
muscles.
Ingervall and Helkimo found that adults
with weak muscles have a greater variation in
facial morphology than those with strong muscles,

The efficiency with which a muscle

generates a force at a particular point is

defined as the ratio of the moment arm of
the muscle to the moment arm of the load.
Throckmorton et al attempted to explain
that the significantly smaller bite force of
dolichofacial subjects is due to the reduced
mechanical advantage of the mandibular
muscles.

 . According

to Kiliaridis, strong muscles

produce faces with similar morphologic
features, whereas weak muscles cannot
influence the morphology to such an extent.
Those with weak mandibular muscles can
belong to either the mesofacial or the
dolichofacial group.

Cross-sectional area of the mandibular

muscles and facial morphology:
Many authors have described the
relationship between the cross-sectional area
of the mandibular muscles and facial
morphology.
A common finding has been that the
masseter and medial pterygoid muscles have
large cross-sections in people with short
anterior face heights and small gonial angles.

Also the maximum force that can be

produced by a muscle is dependent on its

cross-sectional area.
Hannam and Wood found a statistically
significant correlation between masseter and
medial pterygoid cross-sectional areas and
molar bite force

Position, orientation and mechanical

advantage of the mandibular muscles:
According to Takada et al, a short posterior
face height with steep mandibular plane and
large gonial angles is often associated with
an anteriorly inclined superficial masseter
to the occlusal plane and a superior
positioning of its insertion on the mandible.

Haskell et al reported that the superficial masseter

was angled considerably more anteriorly with a

much more acute angle to the occlusal plane in a
dolichofacial pt when compared with a
brachyfacial pt
whether masseter angulation is constant relative
to the occlusal plane is controversial.
Although Proctor and DeVincenzo noted a
constant angular relationship (about 69) between
the superficial masseters and the occlusal planes.

Cause and effect relationship between muscle function and

craniofacial morphology:

In animal studies, it has been shown that

interference with the development of the jaw and

facial muscles can lead to major changes in the
shapes of jaw bones.
It has also been shown that human subjects with
strong bite forces tend to have brachyfacial
patterns, in contrast to those with weak bite forces,
who tend to have dolichofacial patterns. This
difference in bite force has led to much speculation
about the etiology of vertical facial patterns.

According to Proffit and Fields, it is possible that

the lower bite force in dolichofacial people might

allow greater eruption of the posterior teeth than
might otherwise occur, and so are directly related
to the excessive tooth eruption and backward
rotation of the mandible.
Ingervall and Helkimo suggested that the
interindividual form of the face is smaller in
persons with strong muscles than in those with
weak muscles. This would support the hypothesis
that the muscles do actually contribute to the final
shape of the face.

The ingervall and bitsanis, who showed that

training the jaw muscles in dolichofacial

children strengthened these muscles and
induced a favorable anterior mandibular
growth rotation.

CONSIDERATION OF THE MANDIBULAR

MUSCLES AND VERTICAL FACIAL PATTERN
DURING ORTHODONTIC TREATMENT:

Forward-rotating brach facial subjects tend to

have deep overbites, whereas backward-rotating

dolichofacial subjects tend to have open bit.
In general, most brachyfacial patients require
bite-opening mechanics during orthodontic
treatment, in what is often a powerful muscular
environment.
dolichofacial patients usually require some
limiting of vertical development during treatment
to avoid extrusion of the posterior teeth.

 Brachyfacial

subject , with deep overbite

tends to resist extrusive forces during
orthodontic treatment.
If molar extrusion does occur during
treatment in brachyfacial patients, there is
likely to be a strong tendency toward
reintrusion through the influence of the strong
muscles during swallowing and chewing. Thus,
it might be difficult to cause permanent
extrusion of the molars and backward rotation
of the mandible in such patients, even though
this is a main aim of treatment.

In dolichofacial pt ,inter maxillary elastics or

headgears (extrusive force) should be avoided

during treatment, to prevent any undesirable
backward rotation of the mandible.
In such patients, it is crucial to really control the
vertical dimension if stability, facial balance, and
harmony are the ultimate goals of treatment.

Post surgical stability and muscles

Three principles that influence post surgical stability

1.Stability is greatest when soft tissues are relaxed
during surgery & least when they are streched .
Maxilla up---relaxes the tissue
Moving mandible forward ----streches
Rotating up at gonial
angle and down at chin -----Strech

88

2.Neuro muscular adaptation is essential for stability

Most procedures
good nm adaptation
Any procedure streching pterygomandibular sling nm

adaptation doesnot occur

Syndromic pts cannot adapt to changes.
3.Nm adaptation affects muscular length, not muscular
orientation
If orientation of a muscle group such as the mandibular
elevators is changed adaptation cannot be expected
Successful mandibular advancement requires keeping
ramus in upright position,rather than letting it inclined
forward as mandibular body is brought forward
89

Masticatory muscle disorder

There are five types of masticatory muscle disorder.
1.PROTECTIVE CO-CONTRACTION (MUSCLE
SPLINTING)
2. LOCAL MUSCLE SORENESS (NONINFLAMMATORY
MYALGIA)
3. MYOSPASMS (TONIC CONTRACTION MYALGIA)
4.MYOFASCIAL PAIN (TRIGGER POINT MYALGIA)
5.CENTRALLY MEDIATED MYALGIA (CHRONIC
MYOSITIS)

PROTECTIVE CO-CONTRACTION (MUSCLE

SPLINTING):

Protective co-contraction is the initial response of a

muscle to altered sensory or proprioceptive input or

injury (or threat of injury). This response has been
called protective muscle splinting or coactivation.
CAUSE
Altered sensory or proprioceptive input

The presence of constant deep pain input

Increased emotional stress

CLINICAL CHARACTERISTICS
Structural dysfunction: decreased range of

movement, but the patient can achieve a relatively

normal range when requested to do so
Minimal pain at rest
Increased pain with function
A feeling of muscle weakness

DEFINITIVE TREATMENT;
Treatment should be directed toward the reason for the
co- contraction. When co- contraction results from
trauma, definitive treatment is not indicated because the
cause is no longer present.
When co-contraction results from the introduction of a
poorly fitting restoration, definitive treatment consists of
altering the restoration to harmonize with the existing
occlusion. Altering the occlusal condition to eliminate cocontraction is directed only at the offending restoration
and not the entire dentition. Once the offending
restoration has been eliminated, the occlusal condition is
returned to its preexisting state, which resolves the
symptoms.

SUPPORTIVE THERAPY:
It begins with instructing the patient to restrict use

of the mandible to within painless limits.

A soft diet may be recommended until the pain
subsides.
Short-term pain medication (nonsteroidal anti
inflammatory drugs [NSAIDs]) may be indicated.

LOCAL MUSCLE SORENESS (NON INFLAMMATORY

MYALGIA) :
Local muscle soreness is a primary, non inflammatory,
myogenous pain disorder. Local muscle soreness represents
a change in the local environment of the muscle tissues
CAUSE:
Protracted protective co-contraction secondary to a

recent alteration in local structures or a continued

source of constant deep pain
Local tissue trauma or unaccustomed use of the muscle
Increased levels of emotional stress

CLINICAL CHARACTERISTICS
Structural dysfunction: marked decrease in the
velocity and range of mandibular movement (full
range of movement cannot be achieved by patient)
Minimum pain at rest
Pain increased with function
Actual muscle weakness present
Local tenderness when the involved muscles are
palpated

DEFINITIVE TREATMENT

Eliminate any ongoing altered sensory or proprioceptive input.

Eliminate any ongoing source of deep pain' input (whether dental

or other).

Provide patient education and information on self-management

(PSR).
SUPPORTIVE THERAPY
Supportive therapy for local muscle soreness is directed toward reducing pain
and restoring normal muscle function.
However, if pain continues, it can usually be controlled with a mild analgesic
such as aspirin, acetaminophen, or an NSAID (e.g., ibupro-fen).
Manual physical therapy techniques such as passive muscle stretching and
gentle massage may also be helpful. Relaxation therapy may also be helpful if
increased emotional stress is suspected.
Local muscle soreness should respond to therapy in 1 to 3 weeks.

MYOSPASMS (TONIC CONTRACTION MYALGIA)

Myospasm is an involuntary, CNS-induced, tonic

muscle contraction often associated with local

metabolic conditions within the muscle tissues.
CAUSE:
Continued deep pain input

Local metabolic factors within the muscle tissues

associated with fatigue or overuse

Idiopathic myospasm.

CLINICAL CHARACTERISTICS
Structural dysfunction: marked restriction in

range of mandibular movement according to the

muscles involved; acute malocclusion common
Pain at rest
Pain increased with function
Affected muscle is firm and painful when
palpated.
Generalized feeling of significant muscle tightness

DEFINITIVE TREATMENT:

Myospasms are best treated by reducing the pain and then

passively lengthening or stretching the involved muscle.

Reduction of the pain can be achieved by manual
massage, vapor-coolant spray, ice, or even an injection of
local anesthetic into the muscle in spasm.
When obvious causes are present (i.e., deep pain input),
attempts should be directed toward elimination of these
factors so as to lessen the likelihood of recurrent
myospasms.
SUPPORTIVE THERAPY:

Often physical therapy techniques are the key to managing

myospasms. Soft tissue mobilization such as deep massage

and passive stretching .

MYOFASCIAL PAIN (TRIGGER POINT

MYALGIA)
Myofascial pain is a regional myogenous pain con

dition characterized by local areas of firm, hyper

sensitive bands of muscle tissue known as trigger
points .This condition is also called myofascial
trigger point pain.
CAUSE:
Continued source of deep pain input

Increased levels of emotional stress

Presence of sleep disturbances
Local factors such as habits, posture, muscle

strains, or even chilling

CLINICAL CHARACTERISTICS
Structural dysfunction:
The heterotopic pain is felt even at rest.
Pain may increase with function.
When provoked,the trigger points increase the heterotopic pain.

DEFINITIVE TREATMENT
Eliminate any source of ongoing deep pain input in an
appropriate manner according to the cause.
Reduce the local and systemic factors that contribute to
myofascial pain.
If a sleep disorder is suspected, low dosages of a tricyclic
antidepressant, such as 10 to 20 mg of amitriptyline
before bedtime, can be helpful

One of the most important considerations in the

management of myofascial pain is the treatment

and elimination of the trigger points. Its done by
Sprai/ and Stretch
Pressure and Massage
Ultrasound and Electrogalvanic Stimulation
injection and Stretch
SUPPORTIVE THERAPY

Various physical therapy modalities and manual

techniques are used to treat myofascial pain.

CENTRALLY MEDIATED MYALGIA (CHRONIC MYOSITIS):

Centrally mediated myalgia is a chronic, continuous muscle pain

disorder originating predominantly from CNS effects that are felt

peripherally in the muscle tissues. This disorder clinically presents
with symptoms similar to an inflammatory condition of the
muscle tissue and therefore is sometimes referred to as myositis.

Clinical charecteristic:
structural dysfunction.
Significant pain at rest
Pain increased with function
Generalized feeling of muscle tightness
Significant pain to muscle palpation
As chronic centrally mediated myalgia becomes protracted, it

may induce muscle atrophy and/or myostatic or myofibrotic

contracture.

DEFINITIVE TREATMENT

chronic centrally mediated myalgia ,the outcome of

therapy will not be as immediate as with treating

local muscle soreness
NSAID such as ibuprofen is a good choice and
should be given to relive pain.
SUPPORTIVE THERAPY

Early in the treatment of chronic centrally mediated

myalgia, physical therapy modalities should be used

cautiously because any manipulation can increase
the pain. Sometimes moist heat can be helpful.

Congenital and developmental muscle

disdorder:
Common congenial muscle and

developmental muscle dissoder can be

divided into 3 categories
1. Hypertrophy
2.Hypotrophy(lack of development)
3.Neoplasia

Masseter muscle hypertrophy:

There is over development of the muscle.
Hypertrophic changes may be secondary to

increased use such as bruxism.

They rarely show any symptoms
Hypertrophy may observer as a large masseter
muscle.
Treatment:
When hypertrophy is present secondary to
bruxism, a muscle relaxation appliance is given.

Pathological diseases of muscles

of mastication

MYASTHENIA GRAVIS
It is a chronic disease with progressive weakness of

skeletal muscles
Caused by destruction of acetyl choline receptors at
neuromuscular junction
This is autoimmune condition
Muscles of mastication are involved before any other
muscle group
Difficulty in mastication ,deglutition and dropping of
jaw is seen
Treatment
Drug of choice is physostigmine and anticholinisterase
administered intramuscularly(im) ,which improves the
strength of muscles in minutes

TRISMUS
There is stiffness of muscles of mastication

Etiology
Local infection pericoronitis,dentoalveolar abscess
Direct trauma to muscles of mastication
Cns tetanus, rabies
Local infection
Pressure is on med.Pterygoid and masseter leading
to irritation and consequent spasm
Tetany
Infection is caused by clostridium tetanus which
releases powerful exotoxin thus destroying the
spinal inhibition causing uncontrolled muscle spasm
In muscles of mastication it causes lock jaw

MYOFACIAL PAIN DYSFUNCTION

SYNDROME:
Spasm of muscles of mastication occures due to overuse,

trauma ,stress and strain plays an important role

Signs and symtoms

Unilateral dull pain in ear
Tenderness of one or more muscles of mastication on palpation
Limitation or deviation of mandibular opening
Clicking or popping at tmj
Treatment
Local anaesthetic inj at trigger points thus breaking the spasm
Soft diet is recommended
Aspirin or nsaid prescribed
Tens (transcutaneous electric nerve stimulation)

Conclusion:
It is crucial responsibility of orthodontist to

recognize each persons muscular environment and

be aware of the problems related with excessive or
deficient use of muscle and their bearing to the
dentition. Final result can be stable until
environmental harmony can be achieved.

REFERENCES

Grays anatomy willams,bannister,colin-38 th edition

Cunninnghams manual of practical anatomy head neck & brain
Inderbig singhs text book of anatomy head & neck vol 3
Text book of oral pathology shafers,hine,--4th edition
Oral medicine diagnosis and treatment burket -10 th editin
Proffit contamporary orthodontics
Graber and neumann removable orthodontic appliance
Graber --orthodontics 3rd edition

Thank you