Role of masticatory and

facial muscles in
Orthodontics

Madhuvanthi Gopalakrishnan
Ist year PG
Contents
• Introduction • Muscle function and bone
development
• Development of muscles
• Form and function of muscle
• Classification of muscles • Muscle malfunction and
• Events in skeletal muscle contraction malocclusion
• Oral habits
• Motor unit
• Significance of muscle in
• Orofacial muscles orthodontics
• Facial muscle • Role of muscle in functional jaw
• Masticatory muscle orthopaedics
• Muscles of tongue • Electromyography in orthodontics
• Suprahyoid muscle • Conclusion
• Portal muscles • References
 Introduction

• Muscle as a whole, helps to orient the basic structure of the body.

• Strong inter dependence occurs between the bone and the muscle

• Although the bone is the hardest tissue in the body it is also one of
the most responsive tissue to changes whenever there is an alteration
in their balance
 DEVELOPMENT OF MUSCLES
• Striped muscle differentiation begins in the 7th week.

• Typical muscle fibers 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.

• The muscles of mastication at first develop in relation to the Meckel’s cartilage but are
independent of insertion and are attached to forming mandible.

• Between the 4th fetal month to birth muscular system increases by 50 fold.

• Birth to middle of the 3rd decade of post natal life increases by 40 fold.
 Classification of muscles
• Depending upon presence or absence of striations-
1.Striated muscles
2.Non striated muscles

• Depending upon the control

1.Voluntary muscle
2.Involuntary muscle

• Depending upon the location

1.Skeletal
2.Cardiac
3.Smooth
Events in skeletal muscle contraction
 Motor unit
• Number of muscle fibre innervated by one motor neuron

• Fewer the muscle fibres per motor neuron precise is the movement

• Eg : Inferior lateral pterygoid has relatively low muscle fibre to motor

neuron ratio capable of finer adjustment in length
needed to adapt to horizontal changes in mandibular position.

• Masseter has greater number of motor fibres per motor neuron

gross function in providing force for mastication .

Type of muscle fibre
• Patient with deep bite and maximal occlusion have more type II fibres

• Patients with open bite and poor occlusion have type I fibre

• Hunter et al – there is a relative increase in type II fibre in short face

patients and relative decrease in type II fibres in long face patients

• Patient with mandibular asymmetry were shown to have type I fibre

but the area of type II fibre were seen more in deviated side than non
deviated side .
Orofacial muscle

DEPENDING UPON THE SITE THEY CAN BE CLASSIFIED AS

• FACIAL MUSCLES

• JAW MUSCLES

• PORTAL GROUP OF MUSCLES

Muscles of facial expression
• Developed from the 2nd branchial arch
• Innervated by the Facial Nerve
• 42 muscles out of which 20 are skeletal
• Includes the
• Buccinator
• Orbicularis oris
• The lower group contains the depressor anguli oris, depressor labii
inferioris and the mentalis.
• The upper group contains the risorius, zygomaticus major,
zygomaticus minor, levator labii superioris, levator labii superioris
alaeque nasi and levator anguli oris.
Functions
• Elevating and everting the upper lip: levator labii superioris, levator
labii superioris alaeque nasi, risorius, levator anguli oris , zygomaticus
major and zygomaticus minor.

• Depressing and everting the lower lip: depressor labii

inferiorus, depressor anguli oris and mentalis .

• Closing the lips: orbicularis oris.

• Compressing the cheek: buccinator.

Buccinator
Origin Superior part: Alveolar process of
maxilla
Inferior part: Alveolar part of mandible
Posterior part: Pterygomandibular
raphe, buccinator crest of mandible
Insertion Modiolus, blends with muscles of upper
lip
Function Compresses cheek against molar teeth
 Buccinator mechanism

• Refers to a phenomenon in which

a continuous band of muscles
that encircle the dentition and is
firmly anchored at the
pharyngeal tubercle of the
occipital bone.
• These muscles with elasticity and contractility acts like a rubber band
tightly encircling the bone system, the mandible.

• The tongue acts opposite to the buccinator mechanism exerting an

outward force.
Clinical significance

• Any imbalance in buccinators mechanism leads to malocclusion

• pernicious oral habits like thumb sucking and tongue thrusting, the
equilibrium between buccinator mechanism and tongue is lost.

• This causes various changes in dentition like constricted maxillary

arch, increased proclination and open bite.
Buccinator mechanism in
maintaining the arch form and
tooth position
• The integrity of dental arches and the relationship of teeth to each
other within each arch and with opposing members are result of
morphogenic pattern as modified by stabilizing and active function of
muscles of tongue on one side and lip and cheek on another
Cancrum oris

Importance of pressure from

lips and cheeks can be derived
from this example
In unrepaired cleft lip there
is proclintaion of incisors
although in buccal
segments where cheek are
normal the teeth are in
normal relation .
Mentalis

Origin Incisive fossa of mandible

Insertion Skin of chin (Mentolabial sulcus)

Action Elevates, everts and protrudes lower

lip, wrinkles skin of chin
• Hyperactivity of the mentalis muscle is most commonly found in patients with an
incompetent lip or patients with upper incisor protrusion.

• This hyper function arises from the muscle compensating for the skeletal discrepancy to
make an anterior oral seal for normal oral function.

• Class II division 1 patients present higher mentalis activity than Class I patients
especially when swallowing .

• Hyper active mentalis activity results in narrower symphysis width and increased
symphysis height .

• The management of a hyperactive mentalis muscle during the mandibular growth spurt
may help in preventing an undesirable narrow symphysis morphology.
Masticatory muscles

• Includes the
• Muscles of mastication

• Hyoid group of muscle

Muscles of mastication

• Developed from the 1st branchial arch

• Innervated by the Mandibular Nerve

• Includes the
• Masseter
• Medial pterygoids
• Lateral pterygoids
• Temporalis
Masseter
Origin:
A) Superficial layer (largest) : from anterior two
third of lower border of the zygomatic arch
and adjoining zygomatic process of the maxilla.
B) Deep layer : from the deep surface of
zygomatic arch
C) Middle layer : from the lower border of
posterior one third of zygomatic arch
• Insertion:
A) Superficial layer : lower part of lateral surface
of ramus of the mandible.
B) Deep layer : into the rest of the ramus.
C) Middle layer : central part of the ramus.
Examination
• Patient is asked to clench the teeth and simultaneously palpated on
both sides extra orally
Masseteric hypertrophy and its
implication
• Vertical corrections achieved during active treatment have to be
considered in patient with hypermassetric activity and brachyfacial
pattern
• This is due to the strong musculature which tends to depress the
extrusion of posterior tooth.
• The primary objective in such cases would be to improve the facial
aesthetics and to decrease the biting forces witch tend to depress the
posteriors
Temporalis
• Origin:
A)Temporal fossa excluding the
zygomatic bone
B) Temporal fascia

• Insertion:
A)Margin and deep surface of
coronoid process
B) Anterior border of ramus of the
mandible
Examination
• The muscle is divided into 3 functional areas- Anterior, Middle and
Posterior
• Anterior-above the zygomatic arch and anterior to TMJ
• Middle-directly above the TMJ and superior to zygomatic arch
• Posterior – above and behind the ear
Lateral pterygoid
• Origin:
A) Upper head (small): from infra
temporal surface and crest of
greater wing of sphenoid
B) Lower head (larger): from the lateral
surface of lateral pterygoid plate.

• Insertion:
A) Pterygoid fovea
B) Anterior margin of the articular disc
and capsule of TMJ.
Examination
• Place the forefinger over the buccal area of the maxillary 3rd molar
region applying pressure in a posterior superior and medial direction
to maxillary tuberosity
 Medial pterygoid
• Origin:
A)Superficial head(small): from
maxillary tuberosity and adjoining
bone.
B) Deep head (large): from medial
surface of lateral pterygoid plate
and adjoining process of palatine
bone.

• Insertion:
• Medial surface of angle and
adjoining ramus of mandible.
Examination
• Anterior part of insertion can be palpated by placing the finger 45
degree in the floor of the mouth near the base of relaxed tongue
• The opposite hand can be used to palpate the posterior and inferior
portions of insertion
• From outside the mouth: Curl your palpating fingers around to the
inside surface of the angle of the mandible.
Movements
• Depression:lateral pterygoid [mainly]
Digastric,geniohyoid,mylohyoid [helps to open wide or against resistance]

• Elevation:masseter,anterior vertical and middle oblique fibres of temporalis and medial

pterygoid muscle of both sides.

• Protrusion:lateral pterygoid, medial pterygoid and superficial oblique fibres of masseter.

• Retraction:posterior horizontal fibres of temporalis and deep vertical fibres of masseter.

• Lateral /side to side: example-in case of left side movement-right lateral pterygoid, right
medial pterygoid, left temporalis, left masseter.
 Reflexes in masticatory system
1. Myotatic reflex: also called liddell-sherrington reflex, muscular reflex, and
stretch reflex. It is the tonic contraction of the muscles in response to a
stretching force, due to stimulation of muscle proprioceptors.

2. Clasp knife reflex: also called autogenic inhibitor ,inverse myotatic reflex.
This is produced by stretching an extensor muscle against increased
extensor muscle tone. Results in relaxation of the muscle being stretched.
That is the muscle now lengthens easily after initial resistance.

3. Jaw closing reflex: or the nociceptive reflex also called jaw jerk reflex. Most
basic reflex in the facial and oropharyngeal area.

4. Jaw –opening reflex: also called linguo-mandibular reflex. First reflex

movement in orofacial region at about 8.5weeks.
Myotatic reflex

The myotatic reflex protects the

masticatory system from sudden
stretching of a muscle and
maintains the stability of the
musculoskeletal system with
muscle tonicity.
Nociceptive reflex

The nociceptive reflex

protects the teeth and
supportive structures
from potential damage
due to sudden and
unusually heavy
functional forces
 Muscles of neck (Suprahyoid)
• The digastric and stylohyoid elevate
the hyoid during swallowing and help
keep the mouth open.
• The geniohyoid moves the hyoid
forward and supports the opening and
lateral movement of the mandible.
• Mylohyoid form the oral diaphragm
and elevate the floor of the mouth, it
can also assist in jaw
opening and chewing movements.
• Due to their contribution during
mastication, the suprahyoid muscles
are also referred to as accessory
muscles of mastication.
 Muscles Origin Insertion Nerve supply Action
Digastric
Posterior belly Mastoid process of Intermediate Facial nerve Depresses
temporal bone tendon is held to mandible /elevates
Suprahyoid muscles

hyoid by facial hyoid bone

Body of mandible sling Nerve to
Anterior belly mylohyoid

Stylohyoid Styloid process Body of hyoid Facial nerve Elevates hyoid

bone bone
Mylohyoid Mylohyoid line of Body of hyoid Inferior alveolar Elevates floor of
body of mandible bone and fibrous nerve mouth and hyoid
raphae bone or depresses
mandible

Geniohyoid Inferior mental Body of hyoid First cervical nerve Elevates hyoid
spine of mandible bone bone or depresses
mandible
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

For orthodontic point of view two portal reflexes are of great importance:
• Mature swallowing
• Pharyngeal air way maintenance
 Superior longitudinal
Muscles of tongue muscle
Mucosa of
tongue

Vertical
muscle
• It is divided into Transverse muscle

• Intrinsic
Palatoglossus
• Extrinsic
Inferior longitudinal
muscle

Styloglossus

Genioglossus Hyoglossus
 Genioglossus muscle Origin: Superior mental spine of mandible
Insertion: Entire length of dorsum of tongue, lingual aponeurosis, body of hyoid
bone
Function: Depresses and protrudes tongue (bilateral contraction); deviates
tongue contra laterally (unilateral contraction)
Extrinsic group of muscle
Neurovascular supply: Lingual and facial arteries, hypoglossal nerve (CN XII)

Hyoglossus muscle Origin: Body and greater horn of hyoid bone

Insertion: Inferior/ventral parts of lateral tongue
Action: Depresses and retracts tongue
Neurovascular supply: Lingual and facial arteries, hypoglossal nerve (CN XII)

Styloglossus muscle Origin: Anterolateral aspect of styloid process (of temporal bone),
stylomandibular ligament
Insertion: Blends with inferior longitudinal muscle (longitudinal part); blends with
Hyoglossus muscle (oblique part)
Action: Retracts and elevates lateral aspects of tongue
Neurovascular supply: Lingual artery, hypoglossal nerve (CN XII)

Palatoglossus muscle Origin: Palatine aponeurosis of soft palate

Insertion: Lateral margins of tongue, blends with intrinsic muscles of tongue
Action: Elevates root of tongue, constricts isthmus of throat
Neurovascular supply: Ascending pharyngeal arteries and facial arteries, vagus
nerve (CN X) (via branches of pharyngeal plexus)
Mature swallow
• Swallowing is a complex neuromuscular activity involving rapid coordination of
structures in the oral cavity, pharynx, larynx, and oesophagus
• These structures must also support the physiologies of respiration, phonation, and
articulation, in addition to deglutition.
• In normal adults, respiration ceases during the process of deglutition since the food
bolus crosses the pathway that air takes on its way to the lungs.

• According to Moyers mature swallow

• Teeth together
• Mandible supported by muscles supplied by the fifth cranial nerve
• Tongue tip is held above and behind the upper incisors against the palate
• Minimum contraction of lips
Mature vs immature swallow
Respiration

• Respiration is a reflex activity

• The growth of orofacial area is significantly influenced by the

development of respiratory spaces and maintenance of airway
Muscle function and bone
development
• Muscle function begins in prenatal life .

• Muscle function influences the internal arrangement of bones and

also induces the changes on the surface of the bones.

• Osteogenesis proceeds in the opposite direction to muscular stresses.

• Between 6-10 years of age, there is steady rate of muscle

development.

• Development of muscles is rapid during the replacement of deciduous

teeth by permanent teeth.
• Child acquires coordinated activity of the voluntary muscles gradually.

• Balance of voluntary muscles is easily upset by habits. Muscles of

facial expression and mimetic and vocal muscles are easily influenced
by muscles.

• Masseter and temporalis show strong developmental increase in size.

• Because of muscle function, maxillary tuberosity become well

developed, mandible shows everted border and bigonial width
increases.
Form and function of muscle

• Bones of maxillofacial region are membranous bones and more

susceptible to the environmental factors such as influence of muscles
and extra functional force.

• Skeletal growth is influenced by muscular growth to which muscles

attach.[Ex:coronoid process]

• But the muscle might not act by inducing growth at the area of
muscle attachment. Eg gonial angle
Wolff’s law
• Julius Wolff in the year 1870 stated that” Every change in the form and function of bone or
of their function alone is followed by certain definite changes in their internal architecture
and equally definite alteration in their external conformation, in accordance with
mathematical laws.”
• The stimulating influence of muscle or extra-functional force produced demonstrable
changes in bone
• Ie., Increase in function leads to increase in density of bone
• Lack of function leads to decrease in trabecular pattern
• Functional matrix theory of Melvin Moss explained the mechanism by which
the soft tissue envelope could direct/divert the skeletal growth.

• Sassouni (1969) –

• The vertical alignment (and subsequent force) of jaw-closing muscles direct

skeletal growth toward a shallow mandibular plane angle, an acute gonial angle,
and deep bite,

• Obliquely aligned jaw-closing muscles (with subsequent diminished force)

permit a steep mandibular plane, an obtuse gonial angle

• He classified the skeletal facial types into short face syndrome and
long face syndrome.
Factors leading to increased horizontal growth of the facial skeleton
Factors leading to increased vertical growth of facial skeleton
Muscle malfunction and
malocclusion
• Malocclusion represents the nature’s attempt to establish a balance
between all morphogenic , functional and environmental components

• Muscle function causes malocclusion or its function changes as means

of compensatory mechanism
Equilibrium theory (Weinstein. S et
al 1963)
• Object subjected to unequal force will be accelerated and thereby will
move to different position in space.

• According to Profitt(1978) there are four main factors that can be

seen in relation to dental equilibrium

• Intrinsic forces by tongue and lips.

• Extrinsic factors including pressure habits and orthodontic appliances.

• Forces from dental occlusion.

• Forces from periodontal membrane, eruptive forces.

Oral habits – Tongue thrust

• Placement of tongue tip forward between the incisors during

swallowing

• Classified as
• Simple tongue thrust

• Complex tongue thrust

Simple tongue thrust
• Teeth together swallow

• characterized by a normal tooth contact during swallowing act

• Presence of open bite

• Tongue thrust forward during swallowing to help establish an anterior lip seal

• Exhibit good intercuspation of teeth

• Abnormal mentalis muscle activity is seen

Complex tongue thrust
• Defined as teeth apart swallow

• Normal tooth contact is not present during swallowing

• Absence of temporal muscle constriction during swallowing

• Strong circumoral muscle contraction

• Occlusion of the teeth is poor.

Retained infantile swallow
• This is the persistence of the infantile even after the arrival of the
permanent teeth.

• Very few people have this type of swallow.

• Tongue thrusts between the teeth.

• Mastication occurs between tongue and palate.

• Teeth occlude on only one molar in each quadrant.

• Violent contractions of 7th cranial nerve musculature during
swallowing

• Tongue is markedly protruded between all teeth during initial stages

of swallow.

• The patients will have an expression less face since facial muscles are
used for stabilizing the mandible

• Excessive anterior facial height is present producing severe frontal

open bite
Tongue size
• Tongue size is an important consideration.
• Microglossia or aglossia results in collapse of the arches with
crowding.
• Macroglossia leads to spacing, bimaxillary protrusion and
open bite.
Thumb sucking
●Digit sucking is defined as placement of thumb or one or more fingers
in varying depths into the mouth

●Normal :3-4 years

●Pressure during finger sucking causes direct pressure to the teeth and

equilibrium
Fr H
also alter the cheek and lip pressure thereby affecting the normal

eq a
ue Durati Intens
●Trident of habit
b
on ity

nc
Muscle pathophysiology

• Contraction of cheek muscle

• Hypotonic upper lip

• Hyperactive mentalis

• Tongue is displaced inferiorly in to the floor of mouth between the

posterior teeth
Clinical features
• Proclination of upper incisors

• Retroclination of lower incisors

• Anterior open bite

• Tongue thrust

• Posterior bilateral cross bite

• High lip line due to hypotonicity of upper lip

• Presence of callus on fingers

 Mouth breathing
• Moyers “ONE WHO BREATHES ORALLY EVEN IN RELAXED AND
RESTFUL SITUATIONS”

• Lowering of mandible

• Positioning of tongue downward

• Tipping back of head

• Upset oral equilibrium

• Unrestricted buccinator activity

• Angle believed that the raised negative air pressure difference between the oral and
nasal passages in mouth breathers led to development of a deep palatal vault.

• The mouth breather was believed to position the tongue in a more downward and
forward manner in the oral cavity, a position in which it could not exert adequate
buccal pressure to counteract the inward forces from the lips and cheeks upon the
maxilla (Harvold, Linder-Aaronson et al). This theory called the compression theory
exists in current literature.
Significance of muscle in
Orthodontics
Muscle dysfunction :The facial muscles can affect jaw growth in two ways.
1. The formation of bone at the point of muscle attachments
depends on the activity of the muscle.
2. Loss of part of the musculature can occur from unknown causes which
results in underdevelopment of that part of the face, with deficiency of
both hard and soft tissues.
 Torticollis
• Excessive muscle contraction can restrict growth in much
the same way as scarring after an injury.

• This effect is seen most clearly in torticollis

• It is the foreshortening of SCM resulting in facial asymmetry

with severe malocclusion due to growth restriction on the
affected side.
Muscular weakness syndrome
• Decrease in tonic muscle activity as in muscular dystrophy, some forms of
cerebral palsy etc.
• The mandible drops downward away from the rest of the facial skeleton.
• Leads to
• increased anterior face height,
• distortion of facial proportions and mandibular form
• excessive eruption of the posterior teeth
• narrowing of the maxillary arch and
• Anterior open bite
Cerebral palsy
• Lack of motor control leads to abnormal muscle function
• Predominantly class 2 molar relation
• Open bite
• Excessive overjet
• Decreased lower third height
• Spastic type class I type II and athetoid class II div I along with high
and narrow palatal vault.
Role of muscle in functional jaw
orthopaedics
●Functional appliances envelopes an assortment of removable appliances designed
to influence the function and position of the mandible by amending the
arrangement of various muscle groups so as to redirect forces to the dentition and
the basal bone.

●Therefore, by altering the mandibular position sagitally and vertically, muscular

forces are engendered resulting in orthodontic and/or orthopedic changes.
CLASSIFICATION OF FUNCTIONAL APPLIANCES
Grabers classification:
Group 1: transmits the muscle force directly to the tooth
Eg., Inclined plane and oral screen

Group 2: transmits the force to the teeth as well as other structures

Eg., Activator

Group 3: operates from vestibule

Eg., Frankel

Based on the way muscle is used

• Myotonic appliances- relies on muscle mass for action
Eg., Activator. Bionator

• Myodynamic appliances: relies on muscle movements

Eg., Bimler
 Electromyography in orthodontics
• The best way to visualize the innervation of the muscle is by the use of an electromyogram.

• Einthoven discovered in 1918 that a muscle during contraction gives idiomuscular current.
Referred to as action current.

• The current generated is so small that it must be amplified many thousands times to be
recorded.

• Two types of electrodes are used: surface and needle electrode.

• Surface electrode recorded from larger population of muscle fibers than do needle
electrodes.

• Both electrodes record the membrane action potential from several fibers in a single motor
Needle electrode Surface electrode
• Ferrario et al. -in a study in which 30 healthy subjects with Angle class I
and overbite and overjet ranging from 2 to 5 mm were examined,
observed larger standardized potentials in MVC in the temporalis
anterior muscle (91.1 μV/μV%) than in the masseter muscle (85.45
μV/μV%).

• Lodetti et al. in a study of 29 healthy patients aged 20–35 years,

observed higher values of MPF in the masseter, temporalis anterior, and
trapezius muscles recorded during maximal clenching of the teeth in
the intercuspal position, than during clenching the teeth with controls
(cotton rolls)
• Mc Namara –suggested that 2 heads of lateral pterygoid muscle are
functionally distinct and anatomically distinct .
• He suggested that the inferior head acts with the suprahyoid muscle
in jaw opening and anterior and lateral movements but does not
appear to function during swallowing
• In contrast superior head is active in closing movements(mastication)
and in movements such as swallowing . This produces a well
circumscribed burst of electrical activity which is characteristic of
swallow
• Yousefzadeh et al.-EMG recordings of the temporalis, masseter,
orbicularis oris, and digastric muscles were performed in patients
aged 10.1–13.2 years with an anterior open bite. The patients with
malocclusions exhibited lower activity in the muscles during clenching
and higher activity in the muscles of the balancing side during
chewing compared with healthy subjects.

• Ciccone de Faria et al.- paid attention to the different activities of the

muscles in patients with either a skeletal or dento-alveolar
malocclusion. Healthy patients presented the highest electrical
activity in the temporalis and masseter muscles during MVC (85.27%).
Significantly lower activity was detected in subjects with a dento-
alveolar anterior open bite (61.52%), and the lowest in patients with a
skeletal open bite (42.13%).
• Moreno et al. - to determine the influence of sagittal malocclusion on
the electrical activity of the masticatory muscles. The results obtained
indicated that patients with Angle class II showed higher activity than
other classes for the temporalis muscles in deglutition and chewing;
subjects with class III achieved the highest activity for the temporalis
and masseter muscles during MVC. The values of temporalis activity in
MVC for patients with I, II, and III Angle classes were significantly
different

• Moreno et al.- observed that the posterior cross bite resulted in a large
decrease of ipsilateral masseter activity during a maximum effort test.
Conclusion
• The jaw muscles control the position and motion of the mandible and
create forces at the teeth and temporomandibular joints.
• The consequences of their action are pertinent to, for instance, prosthetic
changes of dental occlusion, orthodontic treatment of malocclusions, and
surgical craniofacial corrections.
• Their special functional anatomy makes jaw muscles the most complex
and most powerful in the human body
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Dong-Seok Nahm, DDS, MSD, PhD
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