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The effect of musculoskeletal facial pain on registration of maxillomandibular

relationships and treatment planning: A synthesis of the literature
Ales Obrez, DMD, PhD,a and Jens C. Trp, DDS, Dr Med Dentb
College of Dentistry, University of Illinois at Chicago, Chicago, Ill., and
School of Dentistry, University of Michigan, Ann Arbor, Mich.
Statement of problem. A significant number of patients exist who are in need of prosthodontic
rehabilitation and who at the same time report musculoskeletal pain in the facial area.

Purpose. This article, which is based on an assessment of both the past and the most recent basic science
and clinical literature, evaluates the effect of musculoskeletal facial pain on two static (physiologic rest
position and centric relation) and two dynamic (protrusive border and lateral border movements)
maxillomandibular relationships.
Material and methods. To find the relevant studies addressing the association between musculoskeletal
facial pain and maxillomandibular relationships, a MEDLINE search was conducted, which was complemented by a hand search in selected journals.
Results and Conclusions. Musculoskeletal facial pain seems to variably affect the aforementioned
positions and movements. Hence, the validity of maxillomandibular registrations in patients with existing
facial pain is questioned. In those patients with facial pain who simultaneously are in need of a
prosthodontic rehabilitation, clinicians should be cautious with regard to the timing of the restorative
procedures. (J Prosthet Dent 1998;79:439-45.)

CLINICAL IMPLICATIONS
When prosthodontic rehabilitation is required in a patient who is having musculoskeletal facial pain, the first obligation of the clinician is to differentially diagnose the
pain. Clinicians should take a cautious approach to the timing of restorative treatment in patients who are experiencing musculoskeletal pain. The validity of the
maxillomandibular registration is questionable.

rosthodontic rehabilitation is intended to improve masticatory function, esthetics, and phonetics due
to missing, decayed, and/or fractured teeth.1 Depending on the extent of the restoration, cer tain
maxillomandibular registrations are routinely used. These
are (1) vertical dimension of occlusion (in situations of
loss of vertical support), (2) centric relation (in situations of loss of horizontal maxillomandibular relationship), (3) maximum intercuspation, and (4) lateral and
protrusive mandibular border movement records (in situations of extensive oral rehabilitation).
On first sight, prosthodontic and facial pain patients
seem to be two somewhat heterogeneous groups of patients. The typical patient with musculoskeletal (temporomandibular) pain is a woman within the childbearing age. 2 Conversely, patients who are in need of
prosthodontic care are more or less equally distributed
between the genders and belong predominantly to the
a

Assistant Professor, Department of Restorative Dentistry, College of

Dentistry, University of Illinois at Chicago.
b
Visiting Assistant Professor, Department of Biologic and Materials
Sciences, School of Dentistry, University of Michigan.
APRIL 1998

middle and older age groups.3 On the other hand, a significant number of patients diagnosed with temporomandibular joint (TMJ) arthropathies are in their fifties
and older.4 In addition, there are several general medical conditions that may produce pain in the facial region, and these may also appear in younger populations,
for example, neuropathies. Therefore a significant possibility exists for an overlap between patients who are in
need of prosthodontic rehabilitation and, at the same
time, report orofacial pain,5 though the exact demographic overlap of the two groups has not been reported
in the literature. These patients can be classified into
several groups according to the temporal relationship
between pain and prosthodontic treatment. This article
focuses only on those clinical situations where a patient
has both musculoskeletal facial pain and concurrent need
for prosthodontic treatment, with prosthodontic rehabilitation primarily intended to restore the dentition and
function. The few articles that have been published so
far regarding this topic focused primarily on clinical decision-making processes.5-9
The intent of this article is to evaluate the effect of
musculoskeletal facial pain on maxillomandibular relaTHE JOURNAL OF PROSTHETIC DENTISTRY

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tionships based on an assessment of the clinical and basic science literature and to discuss how it might affect
the timing and sequencing of prosthodontic procedures.

METHODS
To find relevant articles, a MEDLINE literature search
was conducted for the period from 1966 to April 1997.
The key word pain was combined with the following
key words (and combinations thereof): temporomandibular joint, mandible, occlusion, centric relation,
movement, mandibular, prosthodontics, treatment, temporomandibular joint dysfunction syndrome, and temporomandibular joint disorders. The computer-based
literature search was further supplemented with a hand
search of articles and book chapters. Whenever possible,
reference was given to those articles that represented
original research rather than to those that described a
clinical case or an opinion.

PAIN AND REGISTRATION OF

MAXILLOMANDIBULAR RELATIONSHIPS
Vertical dimension of occlusion/vertical dimension of rest
Vertical dimension of occlusion (VDO) has been defined as the vertical separation of the jaws that exists
when teeth are in occlusal contact.10 When occlusal contacts between the maxillary and mandibular teeth are
inadequate or unstable, VDO must be determined by
the clinician. Various methods have been developed for
this purpose using different approaches that include the
use of preextraction records or, in their absence, old
photographs11 and lateral cephalometric radiographs,12
and the use of facial13,14 and intraoral measurements.15
VDO has also been related to the maximal bite force,16
the mandibular position during swallowing,17 the closest speaking space before loss of the remaining natural
teeth,18,19 the patients own judgment of ideal VDO,20
and the vertical dimension of rest.21 Unfortunately, there
is little compelling evidence to argue the merit of one
method over the other.22 In addition, there is lack of a
significant advantage of one method over the other with
respect to the final outcome desired, namely, a reasonable VDO. The factors that play the most important
role in selecting a method are its cost and the time involved in its application. Among the methods previously
mentioned, use of vertical dimension of rest has become
one of the most often used clinical methods for determining the VDO.
Vertical dimension of rest, also known as physiologic
rest position or mandibular rest position, is referred to
as the mandibular position assumed when the head is in
an upright position and the involved muscles, particularly the elevator and depressor groups, are in equilibrium with respect to their tonic contraction, while the
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condyles are in a neutral, unstrained position. 23 The

method of using vertical dimension of rest and
interocclusal space to determine VDO was initially supported by Thompson and Brodie24 and Thompson,25 who
later modified his view regarding the positional stability
of the hinge axis during the movement from rest to centric occlusion position. The clinical use of this method
was subsequently recommended by several clinicians.21
However, the assumption of stability of vertical dimension throughout life was challenged in several studies.2631
For example, changes in vertical dimension of rest
were demonstrated not only to be associated with age,
but also with loss of teeth,27,29,32 changes in head position,33-35 the presence or absence of dentures in edentulous patients,36 and emotional stress.37
One of the methods to determine vertical dimension of rest has been electromyography (EMG).38 Several studies that used surface electrode EMG reported
that the electrical activity of masticatory muscles was
at its minimum or absent while the mandible was at its
clinically established vertical dimension of rest.39-41
These results suggested that this mandibular position
was a fairly repeatable position of the mandible in space
and that it could be assessed and verified with the EMG
procedure. However, the clinical applicability of this
procedure was first questioned by an investigation that
demonstrated a range of mandibular rest positions (as
opposed to a specific position) associated with minimal electrical activity of masticatory muscles.42 Furthermore, other studies demonstrated that spontaneous
electrical activity could be present in the clinically determined vertical dimension of rest.43-45 Finally, a study
by Rugh and Johnson46 demonstrated an average of 6
mm discrepancy in mandibular opening between the
clinically determined vertical dimension of rest and the
mandibular position of minimal muscle activity. According to Rugh and Johnson,46 the EMG rest position of
the mandible with minimal muscle activity exists beyond the clinically determined vertical position of rest
at a position where masticatory muscles exhibit tonic
contraction. These studies therefore support the theory
of Mller,47 who emphasized the role of a servocontrol
mechanism48 in maintaining the determined vertical
dimension of rest with muscle tonic activity. Fusimotorinitiated contraction of intrafusal fibers leads to sensory output through afferent nerve fibers from the
muscle spindles to a servomotor system that activates
the motor innervation and causes contraction of the
muscles extrafusal fibers (stretch reflex).49 The studies
also support the theory proposed by Yemm50,51 suggesting the primary role of viscoelastic elements and
gravity in maintaining vertical dimension of the mandible with minimal or no muscle activity found beyond
the vertical dimension of rest.
It has been suggested that the neuromuscular activity
of the masticatory muscles recorded at vertical dimenVOLUME 79 NUMBER 4

OBREZ AND TRP

sion of rest occurs as a result of a stretch reflex that counteracts gravitational forces acting on the masticatory
system.52 The stretch reflex, and with it the neuromuscular activity of the elevator muscles, can be further influenced by neural activity originating in other afferent
peripheral pathways, for example, the mechanoreceptors of the TMJ,53 mucosa, and periodontal ligament.
They can also be affected by neural activity of the descending pathways from the central nervous system, for
example, reticular formation, limbic system, basal ganglia, cerebellum, and cerebral cortex. Therefore it has
generally been assumed that masticatory muscle pain may
affect the stretch reflex by increasing the activity of the
trigeminal alpha motor neurons through the gamma
loop, resulting in a decrease of the interocclusal space.
However, the intracellular recordings of neurons in the
subnucleus-caudalis of a decerebrated, paralyzed rabbit
did not show an increase of neural activity in the
fusimotor neurons after the injection of a painful substance (hypertonic saline) into the masticatory muscles
while they were at rest.54 The effect of pain was evident
only later when mastication was induced. It was found
that frequency, amplitude, and velocity of masticatory
cycles decreased. These results are supported by clinical
observations in human beings.55-58 Furthermore, subsequent clinical experiments that used hypertonic saline
as a stimulant for provoking masticatory muscle pain in
otherwise healthy volunteers revealed that there was no
difference in EMG activity of the painful and nonpainful
muscles while at rest.59-61 These findings questioned the
vicious cycle theory of musculoskeletal pain.62 Instead,
the authors59 proposed a pain-adaptation model to explain the EMG activity of painful masticatory muscles
while acting as agonists (decreased activity) or as antagonists (increased activity). Contrary to the initial hypothesis that pain would cause the interocclusal space
to decrease, the hypothesis based on the pain-adaptation model suggests that inhibition of the gamma system would lead to an increase of the interocclusal space.
Unfortunately, there is a lack of well-controlled clinical
studies that would support either of the two hypotheses. Such studies are needed, however, because vertical
dimension at rest is already highly variable in subjects
without pain and, as shown by Tallgren,32 patients tend
to accept the interocclusal space at different VDO.
Because pain is also one of the symptoms reported by
patients diagnosed with intracapsular TMJ disorder
(namely, TMJ disk interference disorders, arthropathies),
similar observations are expected in this group of patients. In addition to the effect of pain, structural incongruities within the TMJ may mechanically interfere
with the normal mandibular opening pattern,63 or cause
anomalous motor neuron activity through arthrokinetic
reflex pathways.64 In patients where a significant restriction of the mandibular opening exists, registration of a
valid record of the physiologic position of rest and deAPRIL 1998

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termination of the VDO becomes difficult, if not impossible.

Centric relation
In an attempt to establish a reproducible
maxillomandibular position in patients without posterior support or a stable interocclusal relationship, the
concept of mandibular centric relation (CR) was introduced. Centric relation refers to a condylar reference
position within the TMJ, and thus indirectly to a
maxillomandibular position, independent of tooth contact.10,65 The clinical significance of the mandibular CR
has been somewhat diluted over the years because of
changes in its definition. The first edition of the Glossary of Prosthodontic Terms (GPT-1) defined centric relation as the most retruded relation of the mandible to
the maxilla with its condyles in the most posterior unrestrained position in the glenoid fossae from which lateral mandibular movements could be made. The definition currently in use23 defines mandibular centric relation as the maxillomandibular relationship in which
the condyles articulate with the thinnest avascular portion of their respective disks in an anterior-superior position against the posterior slope of the articular eminences. According to the definition, this position is clinically established when the mandible is related superiorly
and anteriorly relative to the base of the cranium.23
Different clinical methods have been proposed to
guide the dentate or edentulous mandible into its CR
position.66-68 Some authors recommend bilateral manipulation of the mandible,69 while others prefer a one-handed
technique.70 Another group of clinicians relies predominantly on the patients own retrusive movements of the
mandible.71 A mechanical system for recording the
maxillomandibular relationship is the intraoral graphic
recording technique (Gothic arch tracing, central bearing tracing). The central bearing point, as part of the
maxillary assembly, traces the movements of the patients
mandible during protrusion, retrusion, and laterotrusion
in one plane, which is represented by a metal plate attached to the lower part of the recording assembly. It is
agreed that the apex of the Gothic arch tracing indicates
the mandibular position in its CR.71,72
Despite the fact that CR is described as a reference
mandibular position, it is not fixed in space. Instead, its
position may change over the course of time.73-77 In addition, the results of a recent experimental study suggest that masticatory muscle pain may also influence the
intraindividual position of CR.78 By using a validated
delivery system,79 5% hypertonic saline solution was injected into the central portion of the superficial part of
the masseter muscle of five healthy volunteers.78 Experimental tonic muscle pain was thus maintained while the
mandibular border movements were recorded with the
Gothic arch tracing technique. The most posterior jaw
position from which lateral border movement could be
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made was compared intraindividually among baseline,

painful, and sham-pain stages of the experiment. The
position of the apex of the Gothic arch tracing significantly changed in the presence of pain. The change observed was on average 0.22 mm (range of 0.2 to
0.6 mm) anteriorly, and varied in a transverse direction
irrespective of the side of injection when compared with
the baseline. The positional change of the apex of the
Gothic arch was thus beyond the observed normal variability range in pain-free subjects and well within the
detected range of tactile perception in dentulous and
edentulous subjects.80-82 If the change in mandibular
position had been present in an anterior direction only,
one could argue that the occlusal concept of long centric would enable the clinician to compensate for the
mandibular shift.
Because of the low sample size and the current lack of
an independent validation, the results of the study by
Obrez and Stohler78 should be regarded as preliminary
at this stage. If verified, however, they may explain why
persons with masticatory muscle pain frequently complain that their teeth do not fit anymore. Also, they
may suggest a strong argument for caution regarding
the timing of initiation of the prosthodontic rehabilitation in patients with masticatory muscle pain. Because
of the considerable interindividual variation in the extent of CR when subjects are in pain, it is impossible to
predict the CR position of the mandible when the subjects become free of pain, or when their pain intensity
reduces significantly.
Mandibular border movements
Mandibular border movements are primarily used to
record at least two points on their respective trajectories
to set articular parameters on the articulator. Specifically, the protrusive mandibular border movement is used
to set the inclination of the articular eminence, whereas
the lateral border movement determines the contralateral transverse orientation of the medial wall of the
articulators condylar fossa (Bennetts angle). Though
the paths of the condylar assembly of the articulator
during these movements do not exactly correspond to
the paths of mandibular condyles, they do represent an
adequate approximation.
Mandibular border movements are influenced by the
skeletal anatomy of the TMJs, the occlusal structure of
the teeth, and physiologic constraints of the ligaments
of the TMJ.
Mandibular protrusive border movement
There are two methods to register the inclination of
the articular eminence, the dynamic recording using a
pantograph and the positional recording with a static
registration. Both register the mandibular protrusive
movement relative to the maxilla, while some of the
maxillary and mandibular anterior teeth maintain their
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OBREZ AND TRP

occlusal contact. The movement of the condylar head

from the position assumed at CR to the point of protrusive registration is predominantly translatory and
curvilinear in shape when projected onto the sagittal
plane.83 While a pantograph records this condylar path
precisely in its whole length, the static method registers at least one mandibular position on the trajectory
of the mandibular protrusive movement. When this
condylar position and the position of the condylar head
in CR are projected onto the sagittal plane, they form
a line. The angle formed between this line and the horizontal reference line is then used as an approximation
of the inclination of the articular eminence on the articulator.
Because of its curved structure, the degree of steepness of the articular eminence, as seen in a sagittal plane,
changes continuously. Therefore it becomes evident that
the measured angle of inclination, as determined during
static registration of the protrusive record, depends on
the condylar position in centric relation as well as on the
extent of the condyles anterior position assumed during this registration. In theory, if the protrusive excursion of the mandible during the recording procedure is
too short or too long (namely, the condylar head positioned on the preglenoid plane), the registration of the
inclination of the eminence underestimates its anatomic
angle. As a consequence, the occlusal contacts of the
posterior teeth, fabricated on the articulator that is set
according to the registered angle, separate during the
patients protrusive movement. The result may have no
clinical effect in prosthodontic rehabilitation of dentate
patients with planned anterior distoclusion during protrusive movement. However, in edentulous patients,
complete dentures set in posterior and bilaterally balanced articulation on the articulator may exhibit posterior bilateral disocclusion (Christensens phenomenon)
during the patients protrusive movement and a loss of
occlusal contact on the balancing side during lateral
mandibular movement.
Obrez and Stohler78 showed that experimentally induced pain in the masseter muscle decreased the length
of the protrusive mandibular border movement. The
change in its length, though not statistically significant,
was demonstrated despite the fact that the painful substance was injected unilaterally only into one of the masticatory muscles. Because only five subjects were used
and the interindividual variability in their responses to
pain was high, it is difficult to predict the amount of
change in length of the protrusive border movement as
a result of masticatory muscle pain, based on the results
of this study. These observations are supported by clinical studies comparing patients with temporomandibular pain and control subjects.56,57
Regardless of the amount of change, the decrease of
the protrusive mandibular border movement with simultaneous change in position of the centric relation posiVOLUME 79 NUMBER 4

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tion of the mandible in patients with experimentally induced masticatory muscle pain (as discussed previously)
question the validity of their protrusive record. For example, underestimation of the anatomic condylar guidance registered in patients with masticatory muscle pain
may significantly affect the articulation of the posterior
teeth in patients with posterior bilateral balance (such
as patients with complete dentures) after their pain subsides. The occurrence of Christensens phenomenon is
a likely clinical finding.
In patients with TMJ disk interference disorders or
arthropathies, patients may exhibit significant limitations
of the mandibular protrusive movements due to structural incongruities within the TMJ complex and/or pain
that accompanies it.56 The extent of functional limitation during registration may subsequently affect the validity of the protrusive maxillomandibular registration.
Mandibular lateral border movement
The lateral border movement of the mandible rarely
occurs during function. However, the recording of this
mandibular movement is important to set the orientation of the medial wall of the articulators fossa relative to the midline (Bennetts angle). Similar to the
registration of the protrusive record, the lateral border
movement registration can be obtained by a pantograph
or a static record. When the latter method is used, at
least one mandibular position should be registered on
the trajectory of the mandibular lateral border movement from CR. The orientation of the resultant line
toward the midline is then used to adjust the transverse orientation of the medial wall of the articulators
condylar fossa. Because the path of the balancing side
condyle-disk complex is three-dimensional, both the
setting of inclination of the condylar eminence and the
orientation of the medial wall of the articulators condylar fossa influence the lateral condylar movement on
the articulator. While the inclination of the articular
eminence influences the vertical component of the balancing side contact pattern between the posterior teeth,
the orientation of the medial wall has an effect on the
horizontal (antero-posterior and lateral) component of
the lateral mandibular movement. The clinical effect
of underestimating the anatomic inclination of the articular eminence on the lateral mandibular movement,
as a consequence of a faulty registration of the protrusive record that may have occurred in patients with
masticatory muscle pain, is similar to the clinical effect
of such pain on the protrusive mandibular movement,
as described earlier in this article. Namely, clinical observation may reveal disocclusion of the patients posterior prosthodontic restorations during lateral mandibular movements after pain subsides. This effect may
have no clinical significance in the prosthodontic rehabilitation of dentate patients. In edentulous patients,
however, the posterior teeth of the dentures set in biAPRIL 1998

THE JOURNAL OF PROSTHETIC DENTISTRY

lateral balanced occlusion may disocclude on the balancing side during the patients lateral mandibular
movement while not in pain. As a consequence, bilateral cross arch balance, indicated for some of the full
denture patients, is lost.
Obrez and Stohler 78 reported that experimentally
induced masticatory muscle pain affects lateral border movements with respect to both the length and
their orientation relative to the midline. Bennetts
angle changed significantly in the presence of masticatory muscle pain, more so on the contralateral side
with respect to the side where pain was induced. Because of the limitations of this study already mentioned, it is difficult to predict the extent and direction of change in mandibular lateral border movements in any patient who experiences masticatory
muscle pain. However, this study indicated that
changes in mandibular border movements occur in
the presence of pain. Similar findings were observed
in the clinical studies.56,57 Therefore it is expected that
a patient receiving prosthodontic restorations, fabricated on an articulator that is set according to the
occlusal registrations made while the patient was in
pain, may subsequently exhibit working side interferences during lateral mandibular movements when the
masticatory muscle pain subsides. This clinical finding can be expected in patients receiving fixed and/
or removable prosthodontic restorations.
Patients diagnosed with intracapsular TMJ disorders
(TMJ disk interference disorders or arthropathies) often report limitations of mandibular border movements.56 In addition to the effect of pain, structural incongruities within the TMJ complex may therefore significantly affect the registration of maxillomandibular
relationships, including lateral mandibular border movement. Depending on the goals of the treatment provided (or not) to this group of patients with respect to
their pain condition, the extent and direction of change
of the mandibular movement determine the amount of
occlusal discrepancy that may be expected after the pain
condition subsides or changes with time.

CONCLUSIONS
For most of the prosthodontic rehabilitation, certain maxillomandibular registrations are needed. Pain
seems to variably affect them (Table I), raising questions about the validity of maxillomandibular registrations taken in patients with existing musculoskeletal
facial pain. In addition, because pain often changes its
intensity, it is expected that static and dynamic positional relationships between the maxilla and the mandible will vary with changes in pain level.78 Patients
with facial pain who are in need of more extensive
prosthodontic rehabilitation should therefore be approached cautiously with respect to its initiation and
the treatment planning. Definitive prosthodontic treat443

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Table I. Summary of clinical findings from MEDLINE literature

search
Maxillomandibular relationship

Effect of musculoskeletal pain

Vertical dimension of rest

Change in interocclusal distance,

which may or may not be clinically
significant56,78
Anteriorly and asymmetrically
positioned mandible78
No change56,57 or reduction in its
length78
Decrease in its length and right-left
asymmetry56,57,78

Centric relation
Maximum mandibular
protrusive movement
Mandibular lateral border
movement

ment should be deferred until a definite diagnosis of

the pain condition can be established, and until factors
responsible for the obser ved change in the
maxillomandibular relationship have been revealed and
the facial pain itself has been properly managed. 6,85
Prosthodontic criteria for successful oral rehabilitation
in these patients cannot always be satisfied, so some
degree of compromise may be required. In addition, it
is important that both the clinician and the patient understand that prosthodontic treatment per se may not
prevent recurrence of musculoskeletal facial pain.84
We thank Charles S. Greene and Robert S. Scapino, University of
Illinois at Chicago, for making helpful suggestions on earlier versions
of the manuscript.

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Reprint requests to:
DR. A. OBREZ
DEPARTMENT OF RESTORATIVE DENTISTRY (M/C 555)
COLLEGE OF DENTISTRY
UNIVERSITY OF ILLINOIS AT CHICAGO
801 S. PAULINA ST.
CHICAGO, IL 60612-7212
Copyright 1998 by The Editorial Council of The Journal of Prosthetic Dentistry.
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