ATT00183
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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
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
439
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.
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
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
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
Centric relation
Maximum mandibular
protrusive movement
Mandibular lateral border
movement
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