Muscle Function in Orthodontics / Orthodontic Courses by Indian Dental Academy

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INTRODUCTION
CLASSIFICATION OF OROFACIAL
MUSCLES
NORMAL MUSCLE FUNCTIONS
METHOD TO STUDY MUSCLE FUNCTION
MUSCLE MALFUNCTIONS AND
MALOCCLUSION
CLINICAL APPLICATIONS
CONCLUSION
REFERENCES
INTRODUCTION
According To functional matrix theory
origin growth and maintenance of
skeletal unit depends exclusively on soft
tissue matrix
As muscle is an important part of the
soft tissue matrix ,it changes the
morphology of bone which is plastic in
nature.

Musculoskeletal system is governed by
muscles, a sort of rubber bands that on
stretching ,keep our skeletal architecture
together. It is roughly like a present day
architectural cable structure . Each relationship
between bone is controlled by muscles and
restricted by the shape of the joints and
ligaments.
So mandibular movement can be perceived as
that of a free body manipulated in an intricate
web with the teeth and joints acting as stops
and guides.
CLASSIFICATATION OF
OROFACIAL MUSCLES
Depending upon site they can be classified
as
Facial muscles
Jaw muscles
Portal group of muscles
FACIAL MUSCLES
Derived from second branchial arch
Innervated by facial nerve
Main muscles in this group are
Frontalis
Zygomaticus major and minor
Buccinator
Mentalis
Orbicularis oris
FUNCTIONS

Expression of emotions
To maintain posture of facial structures
Assists swallowing in infants
Maintains integrity of dental arch

INFANTILE SWALLOWING
Moyers characteristics
Jaw are apart with tongue between gum pads
Mandible is primarily stabilized by contraction of
muscles of seventh cranial nerve
Guided mainly by sensory exchange between
lips and tongue
BUCCINATOR MECHANISM
It is a continuous muscle band that
encircles the dentition and is anchored at
the pharyngeal tubercle.
Components;--
Orbicularis oris
Buccinator
Pterygomandibular raphae
Superior constrictor of pharynx
BUCCINATOR MECHANISM
JAW MUSCLES
Designated as elevators depressors protractors
and retractors
Mainly derived from first branchial arch and are
supplied by fifth cranial nerve
Muscle in this group are
Muscles of mastication
Hyoid group of muscles
FUNCTION
Maintenance of the balance of the head
on the vertebral column
Opening and closing movements of the
mandible
Study by Motoyosi M etal (Eur J Orthod Aug
2002) the biomechanical influence of the head
posture on the cervical column and the
craniofacial complex during masticatory
simulation were quantified using 3-d finite
element analysis. 3 types of FEM were designed
to examine the relationship between the head
posture and the malocclusion.. model a with
standardized cervical column curve and b and c
with forward and backward head posture
respectively .during masticatory simulation
model b moved forward and model c moved
backward. The stress distribution on the
cervical column for model a ,b, and c showed
difference .

Stress converged at the atlas in model a.
High level of stress was observed at the
spinous level of c6 and c7 in model c.
Stress converged at the anterior edge of
the vertebral body of c4 in the model b.
However stress distribution on the occlusal
plane and the maxillofacial structure did
not show absolute differences among
three models .
PORTAL GROUP OF MUSCLES
The term portal area was coined by
Bosma to denote the upper alimentary
and respiratory tract.
Mainly derived from third and fourth
branchial arch and are supplied by third
and fourth cranial nerve.
COMPONENTS

Muscle of tongue
Soft palate
Pharyngeal pillars
Pharynx proper
Larynx

FUNCTION
Postural maintenance
Respiration
Deglutination in adults

Mainly controlled by complex neural
reflexes eg retching and coughing reflex
in foreign body aspiration .
FOR ORTHODONTIC POINT OF
VIEW TWO PORTAL REFEXES
ARE OF GREAT IMPORTANCE
Mature swallowing
Pharyngeal air way maintenance
MATURE SWALLOWING
According to Moyers:--
Teeth together
Mandible supported by muscles supplied
by fifth cranial nerve
Tongue tip is held above and behind the
upper incisors against the palate
Minimum contraction of lips
STAGES OF DEGLUTITION
ORAL STAGE
PHARYNGEAL STAGE
OESOPHAGEAL STAGE
RESPIRATION
Respiration like mastication and swallowing is an
inherent reflex activity
The orofacial growth is significantly influenced
by the development of respiratory spaces and
maintenance of the airway eg. as we can see
collapse of pharynx and poor orofacial growth in
tracheotomised infant.
METHOD OF STUDY MUSCLE
FUNCTION
ANATOMIC
FUNCTIONAL
BEHAVIORAL
ANATOMIC
Dissection-oldest method . the shape size
origin and insertion provide insight into
possible force vectors of the mandible .
Disadvantage-limited value in predicting the
real muscle force because muscle are never
fully contractile during function
Histological-based on concentration of
oxidative enzymes and/or ATPase in muscle
fiber , and are classified as type one and two.
Muscle fiber
Type I
Small , low
tension ,slowly
contracting
motor units.
Very resistant to
fatigue
Richly supplied
by capillaries
TYPE II
;Large, high tension, rapidly
contracting muscle fibers
A B
Fatigue
resistant
Good capillary
circulation
Fatigue
sensitive
Poor capillary
circulation
A study was done by( Gedrange T etal J Appl
Gnet 46 ,2005)to determine the myosine heavy
chain proteins (MyHC) and MyHC mRNA in
masseter muscles of patients with different
mandibular positions. 10 patients were selected
with distal and mesial malocclusion.and amount
of MyHC and its different isoforms was
determined by western blot essay .and PCR..
The ant. part of masseter muscle showed more
type i and 2x myhc in distal occlusion than in the
mesial occlusion.
One of the study done by Anthea
Rowlerson et al [Am J Orthod Dentofac
Orthop 2005] showed a link between a
vertical growth disturbance and particular
muscle fiber composition. Type one fibers
were find to be increased in open bite
cases ;type two fibers were increased in
deep bite cases, where as there were
more no of hybrid fibers and type one in
class three cases.
FUNCTIONAL-three methods
Movement-movement of facial structures are
recorded on moving film eg. cineradiograph.
Force and pressure - measures the pressure of lip
tongue and cheek against the teeth using strain
gauges
Electromyogram -Contain two type of electrodes.
Surface electrodes-to study large portion of
muscles and needle electrodes-to study few motor
units in a specific region. Measures the electrical
activity of the muscle .
.
Disadvantage-impossible to know how much
muscle activity is missed due to working of
antagonistic muscle synergistically to control
the movement or provide stabilization.
BEHAVIORAL
More applicable to human beings. Includes
disciplined observation of total muscle activity in
the natural state. Non invasive and most
practical method. any type of muscle function
which are carried out in the head and neck
region can be genetically predetermined or can
be a learned behavior. In the oral phase of
swallowing the bolus propelling component is
predetermined where as anterior tongue - lip
seal and stabilization components are learned.
which can be altered by the muscle training. eg.
myofunctional appliances. but a predetermined
muscle activity is less likely to change by the
orthodontic appliances.
RECENT ADVANCES
Scoliosometer
Stabilometric board
Electronic axiograph
Mechanical axiograph
Kinesiograph
Computer tomography
Scoliosometer: an
instrument for
optical evaluation
of posture allowing
to monitor gross
variations in
patient's posture.
Computer assisted system used to investigate
the type of plantar rest, distribution of the
barycentre and its balance system,
microvariations in patients postural behavior
and postural muscle activity.
STABILOMETRIC BOARD;
AXIOGRAPH AND KINESIOGRAPH
Dental instrument used to assess
mandibular joint function and disorders.
COMPUTER TOMOGRAPHY
Used to study muscle function in terms of
muscle cross section, muscle volume and
muscle density.
A study [Gedrange T etal Rofo. 2005
Feb;177(2):204-9 ] was done to determine
the relationship between the morphological
parameters of the masticatory muscles and the
jaw bone by computer tomography, lat.ceph.
and denture models. It showed higher densities
of medial pterygoid, masseter and genioglossus
in deep bite individuals than in the open bite
cases. Significant difference in the muscle cross
section of the masseter muscle was found in
individuals with retroclined maxillary incisors
and the individuals with open bite .
MUSCLE MALFUNCTION
RELATED TO MALOCCLUSION
Malocclusion is a final outcome due to
interaction among various factors.
According to Dockrell:--
CAUSE (ACT AT) TIMES ON TISSUE PRODUCING
RESULTS

EQUILIBRIUM THEORY
States that an object subjected to unequal force will
be accelerated and thereby will move to different
position in space. It follows that if any object is
subjected to a set of force but remains in the same
position those forces must be in a balance or
equilibrium . from this perspective the dentition is
obviously in equilibrium since the teeth are subjected
to variety of forces but dont move to a new location
under usual circumstances
The duration of force is more important than its
magnitude, due to its biological effect.
DIAGRAMMATIC REPRESENTATION OF
INTERDEPENDENCE OF ETIOLOGICAL FACTORS IN
MALOCCLUSION
GENETIC

CONGENITAL FUNCTIONAL
DEVELOPMENTAL
ENVIRONMENTAL
Malocclusion represents nature attempt to
establish a balance between all
morphogenic functional and environmental
components
Muscle function causes malocclusion or its
function changes as compensatory
mechanism
So malocclusion is a dynamic balance at
that particular time.
Muscle Function Causing
Malocclusion Or Malocclusion
Produced By Active Muscle
Function Participation Are
TONGUE THRUST
SWALLOWING
MOUTH BREATHING
LIP BITING
THUMB SUCKING
TORTICOLIS
CEREBRAL PALSY
MUSCULAR WEAKNESS
SYNDROME
TONGUE THRUST
SWALLOWING
Defined as placement of tongue tip
forward between the incisors during
swallowingProffit.
Tongue Thrust
Simple
tongue
thrust
Complex
tongue
thrust
Normal
infantile
swallow
Retained
infantile
swallowing
Muscle pathophysiology associated
with abnormal deglutition
Heavy mentalis activity.
Heavy labi superioris and inferioris activity.
Moderate post temporal muscle activity
Moderate posterior masseter muscle
activity.
Moderate supra and infrahyoid activity
Moderate medial pterrygoid activity.
A case report by Valiathan A. AND Sameer H
Shaikh. (J Ind Ortho Soc 1998;31:53-57)
showed the effect of an abnormally large
tongue in producing the spaces similar in
appearance to primate spaces. A 28 year male
patient of south Indian origin was presented
with a chief complain of proclination of upper
anterior teeth along with spacing between the
same. His face was fairly symmetrical with
convex facial profile, prominent nose, acute
nasolabial angle and incompetence of lip.
.An additional lateral ceph was taken following
the administration of radio- opaque contrast
medium to highlight the dorsum of tongue and
related soft tissue. Based on detailed
examination of the tongue dimension, tongue
volume, electromyographic activity and force
exerted by the tongue, it was concluded that
excessively large volume tongue and
dimension produce excessive force which
possibly causes the malocclusion.
CLINICAL APPLICATION
SIMPLE TONGUE THRUST
COMPLEX TONGUE
THRUST
CONSCIOUS LEARNING OF
NEW REFLEX.
MOYERS
TRANSFORMING TO
SUBCONSCIOUS LEVEL
MUSCLE
EXERCISE
MYOFUNCTIONAL
APPLIIANCES
REINFORCEMENT OF
NEW REFLEX
MECHANICAL
RESTRAINTS
FIXED
ORTHODONTIC
THERAPY
MUSCLE
TRAINING
MOUTH BREATHING
Moyersone who breathes orally even in
relaxed and restful situations
MOUTH BREATHING
Characterized by
Lowering of mandible
Positioning of tongue downward
Tipping back of head
Upset oral equilibrium
Unrestricted buccinator activity
Study done by Vig ps et al (ajo
77;258;268 1980) showed changes in
posture as change of about 5 degree in
the craniovertebral angle which leads to
elevation of maxilla and depression of
mandible in the study group individuals.
When the nasal obstruction was removed
the original posture immediately returned.
Mouth breathing can be effectively treated
by oral screen,
It is inserted at night, before going to bed
and worn throughout the night
Precaution should not be given to
obstructive mouth breathers
Thumb sucking---placement of thumb
or one or more finger in varying depth
into the mouth
The effect on dental arch and
supporting system depends upon the
duration frequency and intensity of the
habit
THUMB SUCKING
MUSCLE PATHOPHYSIOLOGY
Contraction of cheek muscles.
Hypotonic upper lip
Hyperactive mentalis
Tongue is displaced inferiorly in to the
floor of the mouth and laterally between
the posterior teeth

DIAGNOSIS
Proclination of upper incisors
Retroclination of lower incisors
Anterior open bite
Tongue thrusting
Posterior bilateral cross bite
High lip line due to hypotonocity of upper
lip
Presence of callus on fingers
DEPENDING UPON THE AGE OF THE PATIENT
PSYCHOLOGICAL
METHODS
INTRA ORAL
HABIT
CORRECTING
APPLIANCES
REMOVABLE
CRIB
RAKES
ORAL
SCREEEN
FIXED
QUAD
HELIX
PALATAL
CRIB
LIP SUCKING
Can be defined as forceful wedging of the
lip between upper and lower teeth. Lip
sucking involves puling the entire lip,
including the vermillion border into the
mouth
MUSCLE PATHOPHYSIOLOGY
Hyper active mentalis
Non functional upper lip
Tongue to lower lip seal during swallowing
A study done by Jung MH et al (Am J Orthod
Dentofacial 2003 Jan) to evaluate the influence
of force of orbicularis muscle on the incisor
position and craniofacial morphology where
average and maximum upper lip force was
determined by a device y meter. The skeletal
structure and the incisal angulation were
recorded by lateral cephalogram. The result
showed that the upper incisor proclination was
significantly related to the magnitude of the
orbicularis oris force. So the disuse atrophy of
orbicularis might be an significant factor in the
development of malocclusion.
DIAGNOSIS
Diagnosed as a deleterious, compulsive,
functional, muscular habit, either primary
or secondary to the increased overjet that
results in the collapse of the lower
anterior alveolus.
REDUCTION OF
EXCESSIVE OVER JET
ORTHODONTICALLY IN
CASE IF IT IS THE
PRIMARY CAUSE
INTRA ORAL APPLIANCE
TO KEEP THE LOWER LIP
AWAY FROM WEDGING
BETWEEN THE TEETH
eg. ORAL SCREEN , LIP
BUMPER
LIP EXERCISES
A case report by Vaishali and Utreja ( JCO feb
2005)a 4 year female child was reported with
chief complain of protrusive upper anterior teeth
and crowding in the lower anteriors and had a
history of abnormal speech.. Clinical examination
revealed a lower lip sucking habit , a non-
functional upper lip and hyperactive lower lip. An
oral screen was fabricated and was instructed to
wear the appliance full time removing it only for
eating and brushing ; exercise were also
prescribed to improve the lip competence by
pulling on the holding ring and closing the lip
against the pressure.
The lip sucking habit was remarkably
reduced after 15 days and completely
eliminated after three months of
appliance wear. There has been no
recurrence of the lip sucking habit and
the lower alveolus and dentition have
remained stable during three years of
follow up observation
MUSCULAR WEAKNESS
SYNDROME
Causes mandible to drop down away from
the facial skeleton
Distortion of facial proportions, increased
facial height
Excessive eruption of posterior teeth,
narrowing of maxillary arch and anterior
open bite.

TORTICOLIS
Struggle between muscle and bone, where
bone yields. There is foreshortening of
sternocleidomastoid muscle which leads to
profound change in the bony morphology of
cranium and face, clinically seen as bizarre
facial asymmetries with severe malocclusion.
CEREBRAL PALSY
Lack of motor control which leads to abnormal
muscle function.
Uncontrolled and aberrant activities upset the
muscle balance that is necessary for the
establishment and maintenance of normal
occlusion
TYPES
SPASTIC
ATHETOSIS
ATAXIA
MIXED
TREMORS
RIGIDITY
ASSOCIATED MALOCCLUSION
Malocclusion occurs twice as often than in
average population
Protrusion of max. Ant teeth
Excessive overjet open bite and unilateral
cross bites
In spastic type class I div II and in
athetoid group class II div I malocclusion
is seen along with high and narrow palatal
vault
A study by (Ghafari J, Clark RE et al AJO- DO
Feb 1988) 79children having neuromuscular
disorder were examined for occlusal and dental
characteristics.56 children suffered from primary
muscle disorders, 19 suffered from neuropathies
and remaining 4 having disorder of
neuromuscular junction ..Results showed that
post. cross bite occurred more in primary
myopathies(57%) as compared to neurogenic
disorders(14%).
In primary myopathy group the patient
suffering from Duchene muscular dystrophy
exhibited statistically significant delay in the
dental emergence(1.06y) unlike the others
myopathies(.31y) and neurogenic
disorders(.03y). The studies emphasizes the
influence of muscular environment on dental
development in general. The dentition may be
more affected in the primary myopathies than in
the neuropathies.
COMPENSATORY MUSCLE CHANGES
ASSOCIATED WITH GENETICALLY
DETERMINED CLASS II AND CLASS III
MALOCCLUSION.
CLASS TWO DIV ONE
MALOCCLUSSION

Muscle pathophysiology-hyperactive
mentalis activity. Hypotonic upper lip.
Increased buccinator activity.
Treatment-correction of muscle
imbalance using MYOFUNCTIONAL
appliances in the growth period.
CLASS TWO DIV TWO
MALOCCLUSION
Mainly hereditary. Muscle changes take place
as a compensatory mechanism for existing
malocclusion. Dominant activity of post. Fibers
of both temporalis and masseter from initial
contact position to the position of final
occlusion take place
Treatment-elimination of posterior fiber
dominance by properly guided orthodontic
therapy which restores VDO that is in
harmony with postural vertical dimension.
CLASS THREE MALOCCLUSION
MUSCLE PATHOPHYSIOLOGY-SHORT UPPER
LIP.INCREASED ACTIVITY OF UPPER LIP DURING
SWALLOWING.TONGUE LIE LOWER IN THE
FLOOR OF THE MOUTH.GRETER MOBILITY OF
HYOID BONE DURING DEGLUTITION DUE TO
GRETER ACTIVITY OF SUPRA AND INFRA HYOID
MUSCLES.THE LOWER LIP IS RELATIVELY
PASSIVE ,HYPERTROPHIC,REDUNDANT

CONCLUSION
The effect of muscle force is three dimensional.
Whenever there is struggle between bone and muscle,
bone yields. Muscle function can be adaptive to
morphogenetic pattern or a change in the muscle
function itself can initiate morphological variation in the
normal configuration of the teeth and the supporting
bone or it can enhance the already existing
malocclusion. Sometimes the structural abnormality is
increased by compensatory muscle activity to the extent
that a balance is reached between pattern, environment
and physiology and so at times it is impossible to assign
a specific cause and effect role to any one factor. So for
an orthodontist it is necessary to conduct orthodontic
treatment in such a manner that the finished result
reflects a balance between the structural changes
obtained and functional forces acting on the teeth and
investing tissue at that time.
REFERENCES;------
Handbook Of Orthodontics 4
th
EditionROBERT E.MOYERS
CONTEMPORARY ORTHODONTICS,3
rd
Edition.WILLIAM R.
PROFFIT, HENRY W.FIELDS.JR
ORTHODONTICS PRINCIPLES AND PRACTICE [THIRD EDITION]--
-T.M.GRABER
Dentofacial Orthopedics with Functional Appliance Second Edition
Thomas M.Graber, Thomas Rakosi, Alexandre G.Petrovic

Malfunction of the tongue, part III [WALTER J.STRAUB
Am.J.Orthodontics,vol-48,no-7 July 1962

The three Ms: Muscles, malformation, and malocclusion
[T.M.GRABER Am. J. Orthodontics vol-49 number- 6 June 1963]
Muscle activity in normal and post normal occlusion [Johan G.A,
Ahlgren.Am.J.Orthodontics,vol-64,no-5,November1973]

Resistance to nasal airflow related to changes in head
posture. [Z.J. Weber, C. B. Preston, et al. vol -80, No-
5, Am .J. Orthodontics November 1981]
Dental and occlusal characteristics of children with
neuromascular disease.[Ghafari J,Clark RE
etal,Am.J.Orthod.Dentofac.Orthop,126-32 ,Feb 1988]
The dimensions of the tongue in relation to its motility:
[Kazuhiko Tamari, et al .Vol- 99 ,No -2, Am. J.Orthod.
Dentofac. Orthop. Feb 1991]

Nasal airway impairment: The oral response in cleft
palate patients [Donald W. Warren, et al Vol- 99 ,No -4
Am. J .Orthod .Dentofac .Orthop April 1991]


Malocclusion and the tongue :[Ashima Valiathan,Sameer H
Shaikh.31:53-57,J Ind Orthod Soc,1988]
Biomechanical influence of head posture on occlusion:an
experimental study using finite element analysis.[Motoyoshi
M,Shimazaki T etal.Eur.J.Orthod.24(4):319-26,Aug 2002]
Effect of upper lip closing force on craniofacial structures.[Jung
MH,Yang WS etal.123,58-63,Am.J.Orthod.Dentofacial.Orthop Jan
2003]
Fiber type differences in masseter muscle associated with different
facial morphologies (Rowlerson A ,Raoul G et al Am .J
.Orthod.Dentofacial.Orthop.Vol-127;37 -46 Jan 2005)
Myosine heavy chain protein and gene expression in the masseter
muscle of adult patients with distal or mesial malocclusion.
[Gedrange T ,Buttner C,J.Apply.Genet,46,227-36.2005]
Computed tomographic examination of muscle volume ,cross section
and density in patients with dysgnathia. [Gedrange T
etal,177(2),204-9,Rofo Feb 2005]

An oral screen for early intervention in lower- lip -sucking habits [Vaishali Nandini
Prasad ,A . K. Utreja,Vol XXXIX, NO.297100,Feb 2005JCO]


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