Clinical Paper

TMJ Disorders/Facial Pain

Effects of myogenous facial
pain on muscle activity of head
and neck
A. Monaco, A. Spadaro, R. Cattaneo, M. Giannoni: Effects of myogenous facial pain
on muscle activity of head and neck. Int. J. Oral Maxillofac. Surg. 2010; 39: 767773.
#2010 International Association of Oral and Maxillofacial Surgeons. Published by
Elsevier Ltd. All rights reserved.
A. Monaco
1,a
, A. Spadaro
1,a
,
R. Cattaneo
1,a
, M. Giannoni
2,3,a
1
Department of Gnatology and Prostethic
Dentistry, School of Dentistry, University of
LAquila, Italy;
2
Department of
Odontostomatological Clinic, School of
Dentistry, University of LAquila, Italy;
3
Department of Surgical Science, School of
Dentistry, University of LAquila, Italy
Abstract. This study evaluated the effects of visual input on surface
electromyography (sEMG) of some stomathognatic and neck muscles (anterior
temporalis, masseter, anterior digastric and sternocleidomastoid muscles) in
patients experiencing myogenous facial pain compared with healthy volunteers. All
subjects kept the mandible at rest with teeth apart and underwent a 15-s sEMG
recording of anterior temporalis, masseter, digastric and sternocleidomastoid
muscles. Each recording was carried out with closed and then open eyes. The sEMG
activity of each muscle was compared between the two groups. In the study group,
anterior temporalis, masseter and sternocleidomastoid sEMG with closed eyes
showed higher values compared with controls (p < 0.05). In the study group, left
and right anterior temporalis (p < 0.003) and right digastric (p < 0.03) sEMG with
open eyes showed higher values than sEMG with closed eyes. In the control group
no signicant differences were observed between closed and open eyes. In patients
with myogenous facial pain, visual input appears to be associated with a signicant
increase in the sEMG activity of some head and neck muscles.
Key words: myogenous facial pain; muscle
activity; head; neck; facial pain.
Accepted for publication 19 March 2010
Available online 2 May 2010
Myogenous facial pain is dened as facial
pain that originates from the musculoske-
letal structures of the masticatory system.
The pain is usually exacerbated by chew-
ing or other jaw functions and is often
accompanied, singularly or in combina-
tion, by limitation of jaw movement, mus-
cular and fascial tenderness or joint
soreness
20
. It appears to be multifactorial,
potentially involving a complex interplay
of anatomic structures, biomechanical
function, environmental demands and psy-
chosocial responses, each capable of con-
tributing to clinical manifestations and
symptoms
14
.
Myogenous facial pain is a common
symptom of temporomandibular disorders
(TMD). Myogenous facial pain affects
several muscle parameters leading to
reduction in maximal voluntary bite force,
endurance time and extended recovery
time
7
.
The aetiology and pathophysiology of
myogenous facial pain are not fully under-
stood. Treatment modalities are non-spe-
cic and do not directly target the
causative factors. Surface electromyogra-
phy (sEMG) has been used to evaluate the
muscle activity of patients suffering from
myogenous facial pain. It has been sug-
gested that the mandible elevator muscles
of individuals with dental Class I pain
(Angles classication) without myogen-
ous facial pain signs or symptoms
3
with
the mandible at rest and in the absence of
exteroceptive stimuli, showed constant
sEMG values ranging from 1.4 to
2.2 mV
6,25
.
It is debatable whether patients suffer-
ing from myogenous facial pain show
higher rest sEMG values of the anterior
temporalis, masseter, sternomastoid and
Int. J. Oral Maxillofac. Surg. 2010; 39: 767773
doi:10.1016/j.ijom.2010.03.025, available online at http://www.sciencedirect.com
a
These authors contributed equally to this
work.
0901-5027/080767 +07 $36.00/0 # 2010 International Association of Oral and Maxillofacial Surgeons. Published by Elsevier Ltd. All rights reserved.
digastric muscles compared with healthy
people. A source of uncertainty could be
that previous studies did not make clear
whether individuals were recorded with
their eyes open or closed; because vision
plays an important role in the multisensory
process of postural stabilisation.
Visual input can be used by oculomotor
muscular systems and neck/trunk muscles
to follow a moving object
32
. Ocular nuclei
control the eye position in the orbit; they
send bres to the nuclei that control neck
and head movements and receive afferent
input from vestibular nuclei. It has been
observed that a modication of ocular
proprioception modies head and body
posture
1,3,27
. The role of trigeminal affer-
ences on tonic-postural regulation has
been recorded
17
.
In this complex system, adaptive mod-
ications can be induced by sensorial
dysfunction and stimulations deriving
from a discrepancy of information in con-
tiguous systems
24
. Information coming
from well-integrated peripheral receptors
may not require adaptive modications of
the system. sEMG activity could show
such adaptation. With the eyes open, a
signicant increase in rest sEMG activity
was observed in the temporal anterioris
muscles
11,19,28
. The visual input effect on
the sEMG activity of the sternocleidomas-
toid and masseter muscles at rest has also
been proved
29
.
MONACO et al.
21
found that in children
presenting with myopic defects, the sEMG
of the anterior temporalis muscle at rest
increases when the eyes are open. Another
study found positive correlations between
the amount of mandibular laterodeviation,
diottric defects, sEMG asymmetry and
increased sEMG values of the anterior
temporalis in the mandibular rest position
with the eyes open
22
.
It is possible that people suffering from
muscular pain show less muscle tolerance
and are more sensitive than normal
healthy volunteers to variation of sEMG
recording when visual input requires adap-
tive behaviour.
The purpose of this study was to deter-
mine the effects of myogenous facial pain
on the sEMG activity of the head and
masticatory muscles at rest and the effect
of visual input on the sEMG activity of
patients with myogenous facial pain at
rest. This information could be of great
interest to researchers because it could
help to clarify the physiological behaviour
of a dysfunctional stomatognathic system
compared with a healthy one.
Material and methods
The study included 40 individuals divided
into a study and a control group. The study
group included 20 patients with myogenic
craniomandibular dysfunction; 12 women
and 8 men, ranging in age from 19 to 41
years (mean 30.6, SD 8.2 years; Table 1).
The study subjects were selected from
patients with myogenous facial pain from
the TMD centre at the authors institution,
who fullled they following inclusion cri-
teria: absence of visual defects; natural
dentition and bilateral molar support;
absence of any previous orthodontic or
gnathologic treatment; recent history of
pain in or around the temporomandibular
joint (TMJ) (preauricolar area, cheek area,
parietal area, temporal area, periorbital
area) according to a research diagnostic
criteria (RDC) questionnaire
4
; presence of
spontaneous muscle pain (exacerbated by
meteorological changes, certain weather
conditions or palpation in the cervical and
masticatory muscles); self-reported teeth
clenching during the day; and if difcul-
ties were experienced when performing
functional jaw movements. Patients with
symptoms caused by trauma or surgery
were not included.
The control group included 20 healthy
volunteers; 10 female and 10 male, ran-
ging in age from 18 to 37 years (mean
27.8, SD 9.1 years). They were volunteers
selected from medical and dental
students and people referred to the dental
department for conservative or hygiene
treatment according to the following
inclusion criteria: absence of visual
defects; natural dentition and bilateral
molar support; absence of any previous
orthodontic or gnathologic treatment; no
history of pain in or around the TMJ
(according to RDC questionnaire
4
);
absence of facial pain or other chronic
pain condition (symptom free); and med-
ication free.
The study was approved by the Ethics
Committee of the University of LAquila
and signed informed consent was obtained
from all subjects.
At the rst visit, a trained dentist clini-
cally evaluated all subjects to conrm that
they complied with the inclusion criteria.
For the study subjects these were: natural
dentition and bilateral molar support;
absence of any previous orthodontic or
gnathologic treatment; recent history of
pain in or around TMJ; and presence of
spontaneous muscle pain. For the control
group they were: natural dentition and
bilateral molar support; absence of any
previous orthodontic or gnathologic treat-
ment; no history of pain in or around the
TMJ. At the second visit, a trained
ophthalmologist gave each participant a
complete ophthalmological and orthoptic
evaluation to conrmthe absence of visual
defects. At the third visit, all subjects were
investigated by sEMG.
Each individual was submitted to two
sEMG recordings in the mandibular rest
position (lips in normal soft contact, no
occlusal contact), one with closed and one
with open eyes. During the rst recording
the subjects were asked to keep their eyes
closed for 5 min in a dark room to avoid
visual information. 15 s of sEMG were
recorded for each trial. During the second
recording the subjects were asked to keep
their eyes open while looking straight
ahead. 15 s of sEMG were recorded for
768 Monaco et al.
Table 1. Age and sex of study and control group.
Study group Control group
Patients Sex Age Patients Sex Age
1 Male 27 1 Male 23
2 Male 46 2 Female 21
3 Female 18 3 Female 23
4 Male 30 4 Female 26
5 Male 37 5 Male 28
6 Male 38 6 Female 37
7 Female 21 7 Female 27
8 Female 22 8 Female 23
9 Female 27 9 Male 20
10 Male 20 10 Male 21
11 Female 27 11 Female 18
12 Female 24 12 Female 19
13 Female 19 13 Male 24
14 Female 24 14 Female 19
15 Female 21 15 Male 18
16 Male 26 16 Male 23
17 Male 41 17 Male 23
18 Female 19 18 Female 23
19 Female 24 19 Male 30
20 Female 22 20 Male 27
each trial. The mean of three consecutive
recording epochs without movement arte-
facts was chosen for statistical analysis.
The sEMG values were processed in
amplitude domain using the root mean
square (RMS) measured in microvolts.
sEMG measurement
The subjects were seated upright on a
comfortable wooden chair. The head
was positioned with the Frankfort plan
parallel to the oor. During the rst
recording the room was silent and not
illuminated; during the second recording
the room was silent and softly illuminated.
sEMG activity was recorded (K7-Myo-
tronics-Noromed, Inc., Kent, WA, USA)
using bipolar surface electrodes at single
differential with an inter-electrode dis-
tance of 2.1 cm. The surface electrodes
were afxed with adhesive tape to the
alcohol-treated skin, to reduce skin impe-
dance, over the supercial areas of the
right masseter (RMM), left masseter
(LMM), right anterior temporalis (RTA),
left anterior temporalis (LTA), right digas-
tric (RDA) left digastric (LDA), right
sternocleidomastoid (RSC) and left ster-
nocleidomastoid (LSC) muscles. The elec-
trodes were placed parallel to the muscle
bres of left and right homologous mus-
cles. Eight channel surface electromyo-
graphy equipment was used
(Myotronics-Noromed). The signals
obtained were amplied, recorded and
computed using software for the clinical
environment (K7-Myotronics-Noromed);
RMS, expressed in microvolts, was used
as amplitude indicator of the signal. Three
15 s epochs were recorded for each per-
formance.
To avoid movement artefacts or spon-
taneous activity (swallowing or blinking)
the sEMG epochs were evaluated on-line
and recorded only if they were artefact
free. The sEMG pattern of swallowing is
simple to detect
3
; sEMG epochs present-
ing swallowing were detected and deleted
on-line. Blinking did not affect sEMG
values because the sEMG signal was
pass-band (20400 Hz) ltered. Blinking
is characterized by a frequency lower than
20 Hz.
Figures 1 and 2 show the sEMG with
closed (on the left) and open (on the right)
eyes in one case of signicant change of
sEMG (Fig. 1) and in one case of unchan-
ging sEMG (Fig. 2). In Fig. 2 two episodes
of blinking can be discerned. Electrode
position, equipment, head position and
subject were not changed during the test,
so the results are probably due to visual
input. Figure 3 shows an episode of dry
spontaneous saliva swallowing. The event
is simple to detect and the operator deleted
Effects of myogenous facial pain on muscle activity of head and neck 769
Fig. 1. Closed and open eyes sEMG for a TMD patient in the study group. Note the tonic change of anterior temporalis muscles. See text for
abbreviations. The numbers on the right of the tracks represent the RMS in microvolts for each muscle.
Fig. 2. Closed and open eyes sEMGfor a healthy subject in the control group. Note the unchanged tonic EMGand that blinking does not affect the
anterior temporalis muscles values (LTA, left anterior temporalis, black; RTA, right anterior temporalis, red). See text for other abbreviations. The
numbers on the right of the tracks represent the RMS in microvolts for each muscle. (For interpretation of the references to colour in this gure legend,
the reader is referred to the web version of the article.)
the epoch on-line
2
. The sEMGvalues were
examined by the same operator with no
knowledge of the purpose of the record-
ing.
Statistical analysis
A paired t-test was performed using Stata
statistics package to obtain a comparison
between mean and variance values of
electromyography data between depen-
dent or independent groups. Differences
with a value of p < 0.05 and p < 0.005
were regarded as signicant and highly
signicant, respectively.
The rst step was to make a paired t-test
for independent samples to compare the
closed eyes condition between study and
control group. The null hypothesis implies
that for closed eyes, the study and control
group show no signicant difference. In
this case, the closed eyes sEMGs for the
control and study groups behave in a homo-
geneous way. The alternative hypothesis
implies that closed eyes sEMGs for the
study and control groups show signicant
difference. In this case, the two groups are
different in the rest closed eyes sEMGs.
The second step was to perform a paired
t-test for dependent samples to compare
sEMG data, in closed and open eyes, in
study and control groups separately. The
null hypothesis suggests that the open eyes
condition does not change the sEMG pat-
tern of the closed eyes condition. The
alternative hypothesis suggests that the
open eyes condition changes the sEMG
pattern compared with the closed eyes
condition, implying a signicant effect
of visual input on sEMG data.
Results
Table 1 shows the age and sex of all
participants. Comparison according to
the age of the individual showed no sig-
nicant differences between the groups.
Table 2 gives the EMG mean values and
standard deviation (in parenthesis) for the
study and control groups in the closed eyes
condition. The study group showed a sta-
tistically signicant increase in left
(p < 0.01) and right masseter (p < 0.03),
in left (p < 0.01) and right (p < 0.0003)
anterior temporalis and in left sternoclei-
domastoid (p < 0.01) sEMG activity com-
pared with control group. Table 3 gives the
EMG results for the open eyes condition.
The study group showed a statistically
signicant increase in left (p < 0.01)
and right (p < 0.03) masseter, in left
(p < 0.002) and right (p < 0.007) anterior
temporalis and in left sternocleidomastoid
(p < 0.02) sEMG activity compared with
the control group.
Table 4 gives the EMG values for the
study group in the closed and open eye
conditions. A highly signicant increase
for sEMG activity in the open eye condi-
tion was observed in left and right anterior
temporalis (p < 0.003) and right digastric
(p < 0.03). Table 5 gives the value for the
control group in the closed and open eye
conditions. No signicant differences
were observed in the sEMG values.
Discussion
The purpose of this study was to determine
the effects of myogenous facial pain on
rest sEMG activity of head and mastica-
tory muscles and the effect of visual input
on rest sEMG activity in patients with
myogenous facial pain.
770 Monaco et al.
Fig. 3. Spontaneous dry swallowing for the TMD patient shown in Fig. 1. See text for
abbreviations. The numbers on the right of the tracks represent the RMS in microvolts for
each muscle.
Table 3. sEMG mean values and standard deviation for study and control group in open eyes
condition. Values are represented in microvolts. See text for abbreviations.
Control group Study group p
LTA 1.85(1.59) 3.65(1.86) 0.002
**
RTA 1.75(2.01) 3.81(1.57) 0.007
**
LMM 1.06(0.50) 1.65(1.10) 0.01
*
RMM 1.03(0.45) 1.58(1.28) 0.03
*
LSM 1.50(0.77) 2.71(2.68) 0.02
*
RSM 1.55(0.47) 1.81(1.33) ns
LDA 1.83(0.74) 1.96(1.02) ns
RDA 1.72(0.76) 2.17(1.23) ns
ns: non-signicant.
*
Signicant difference.
**
Highly signicant difference.
Table 2. sEMG mean values and standard deviation for study and control group in closed eyes
condition. Values are represented in microvolts. See text for abbreviations.
Control group Study group p
LTA 1.43(0.83) 2.39(1.64) 0.01
*
RTA 1.25(0.63) 2.24(1.32) 0.0003
**
LMM 1.04(0.46) 1.52(0.95) 0.01
*
RMM 1.06(0.45) 1.69(1.54) 0.03
*
LSM 1.50(0.56) 2.34(1.93) 0.01
*
RSM 1.57(0.54) 1.63(1.28) ns
LDA 1.85(0.82) 2.00(1.17) ns
RDA 1.69(0.80) 1.96(1.25) ns
ns: non-signicant.
*
Signicant difference.
**
Highly signicant difference.
Masticatory muscle activity, controlled
by the trigeminal nerve, is regulated by
several inputs coming from the proprio-
ception of neuromuscular spindles. These
inputs have an important role in mainte-
nance and in modication of muscular
base tone: a non-physiologic trigeminal
proprioception can induce an altered mas-
ticatory muscle efferent activity. There is a
convergence of nociceptive and proprio-
ceptive afferences in the sensorial nuclei
of the trigeminal nerve
12
, including neck
and C1C3 proprioception. It is possible
that nociceptive stimuli, such as myogen-
ous facial pain, can induce an alteration of
masticatory muscle resting tone. The sig-
nicant difference of LTA, RTA, LMM,
RMM, LSM sEMGactivity between study
and control groups with eyes closed seems
to conrm this hypothesis.
Proprioception messages from the neck
muscles are integrated in the central ner-
vous system and contribute to control
balance and body orientation
10
. Centripe-
tal impulses from neck proprioceptors
cooperate with the labyrinth impulses to
promote oculomotor muscular activity
through the cervicalvestibularocular
reex
9
.
Some important encephalic nuclei (tri-
geminal nuclei, oculomotor nuclei, vestib-
ular nuclei, accessorial nerve nuclei) are
integrated in the medial longitudinal fas-
ciculus. Ocular proprioceptive receptors
send afferent signals to trigeminal and
cuneate nuclei. The anatomic and physio-
logic links of these anatomical structures
imply a co-ordinated integration of pro-
prioceptive ocular and stomatognathic
afferences.
Some studies suggest that mandible
elevator muscles of individuals with class
I pain (according with Angles classica-
tion) without TMD signs or symptoms
have constant sEMG values in the man-
dibular rest position and in the absence of
exteroceptive stimuli
6,25
.
There is heated discussion about the
usefulness of sEMG in the diagnosis and
study of TMD but most reviews suggest
some cautions. It is generally thought that
the physiological variables that have to be
taken into account are age, sex, skeletal
morphology and psychological factors.
The authors agree with this, so to improve
their data they screened the study and
control group for the criteria given in
the Materials and Methods section. They
think that doing this could overcome the
problem.
There is no agreement on the actual
effect of morphology on the anterior tem-
poralis muscle. Some authors (specially
during the 1980s) suggested some kind of
relation
15,33
, but others (in the late 1990s
and more recently) propose that there is no
correlation
5,23,30,31
.
The same argument could be made for
psychological factors. There is some evi-
dence about the incidence of depression
and anxiety, especially cognitive symp-
toms, in myogenous facial pain, but there
is no clear evidence in the literature that
these factors could inuence the sEMG
values of stomatognathic muscles. For
example, RISSE
`
N et al.
26
showed no sig-
nicant correlation between the psycho-
physiological stress reaction and sEMG,
and no association was found between
sEMG activity and pain, and between
negative stress rating and pain. Others
have reported that patients with pain had
higher anxiety, especially cognitive symp-
toms, and feelings of muscle tension than
did controls. These authors stated that
EMG activity in the masseter regions
was not signicantly different between
the pain and control groups
16,18
.
Many sEMG studies are concerned with
functional activity, such as clenching, and
few of them have studied the rest position.
None of them used the present strict inclu-
sive criteria, and none studied the differ-
ence between the anterior temporalis
sEMG in open and closed eye conditions.
The present work is not concerned with
the rest activity of one muscle, isometric
activity during clenching or other func-
tional and specic activities of the stoma-
tognathic system. It tries to show through
sEMG activity that changing the physio-
logical status (open versus closed eyes), in
some way, could be considered a non-
specic stimulus requiring orientation
activity.
The results of sEMG activity at rest
observed in the healthy group, comparing
closed and open eye conditions, agree with
those of HOLMGREN et al.
8
who did not nd
any signicant change in resting masseter
activity when visual input was varied, and
disagree with the studies of MIRALLES that
found a signicant decrease in sEMG
values of the above mentioned muscles
in the closed eye condition
19
. Different
methods could explain the discrepancy
between the present results and those of
MIRALLES.
The selection criteria in the HOLMGREN
and MIRALLES studies differ from the pre-
sent ones. The authors strict inclusion
criteria for the control group included,
among the others, a complete ophthalmol-
ogist and orthoptist evaluation to conrm
absence of visual defects. MIRALLES work
focused on EMG activity of the sterno-
cleidomastoid and masseter muscles in the
supine and lateral decubitus positions. The
Effects of myogenous facial pain on muscle activity of head and neck 771
Table 4. sEMG mean values and standard deviation for study group in closed and open eyes
conditions. Values are represented in microvolts. See text for abbreviations.
Closed eyes Open eyes p
LTA 2.39(1.64) 3.65(1.86) 0.003
**
RTA 2.24(1.32) 3.81(1.57) 0.003
**
LMM 1.52(0.95) 1.65(1.10) ns
RMM 1.69(1.54) 1.58(1.28) ns
LSM 2.34(1.93) 2.71(2.68) ns
RSM 1.63(1.28) 1.81(1.33) ns
LDA 2.00(1.17) 1.96(1.02) ns
RDA 1.96(1.25) 2.17(1.23) 0.03
*
ns: non-signicant.
*
Signicant difference.
**
Highly signicant difference.
Table 5. sEMG mean values and standard deviation for control group in closed and open eyes
conditions. Values are represented in microvolts. See text for abbreviations.
Closed eyes Open eyes p
LTA 1.43(0.83) 1.85(1.59) ns
RTA 1.25(0.63) 1.75(2.01) ns
LMM 1.40(0.46) 1.06(0.50) ns
RMM 1.06(0.45) 1.03(0.45) ns
LSM 1.50(0.56) 1.50(0.77) ns
RSM 1.57(0.54) 1.55(0.47) ns
LDA 1.85(0.82) 1.83(0.74) ns
RDA 1.69(0.80) 1.72(0.76) ns
ns: non-signicant.
*
Signicant difference.
**
Highly signicant difference.
present results concern the anterior tem-
poralis muscle, in the upright seated posi-
tion, with the head in a neutral position.
One result quoted by the authors was that
after 5 min in lateral decubitus in a dark
room and in the rest position, the sEMG of
the sternomastoid and masseter was
reduced in both groups: 22 patients with
myogenic cranio-cervical-mandibular
dysfunction and 18 healthy subjects.
MIRALLES rest position is difcult to
consider as a reference point. The author
concluded by saying that the signicant
change in EMG activity, mainly observed
at rest, suggests that the visual input effect
is weak. But it is possible that after 5 min
in decubitus, in a dark room, people, if
they are healthy, fall asleep, resulting in
this change in sEMG activity. Moreover,
the change between waking and the rst
sleep stage (sleep onset latency), detect-
able only with a polysomnograph record,
range from 3 to 15 min in the healthy.
HOLMGRENs work did not compare
patients with healthy controls, did not take
into account visual defects, data were not
consistent regarding open or closed eyes
and concentrated attention on the sEMG
(anterior temporalis and masseter mus-
cles) effects of splint therapy. The present
data, in part, conrm those of HOLMGREN,
but extend the observation because what
the authors have seen seems to be an effect
due to myogenous facial pain and does not
seem related simply to opening the eyes.
MIRALLES considered open eyes the
reference condition and closed eyes the
test condition. On the contrary, according
to WIDMALM et al.
34
, in order to avoid or
signicantly reduce artefacts on the scalp
muscles, the present study considered
closed eyes the reference condition and
open eyes the test condition.
The present study showed a signicant
inuence of visual input on LTA, RTA
and LDA sEMG activity in the study
group subjects, as previously con-
rmed
21,22
. This suggests that ocular pro-
prioceptive stimuli, in patients with
myogenous facial pain, are an important
input that could lead to tonic muscular
adjustments of mandibular posture.
Patients with myogenous facial pain, once
their physiological adaptation mechan-
isms have been overridden, represent an
alarmed postural system that suffers the
changes of environmental demands.
The present ndings indicate that in
patients with myogenous facial pain, the
open eyes condition, compared with the
closed eyes one, is associated with a
change in the head and neck sEMG activ-
ity in the mandibular rest position. This
behaviour is not present in the healthy
control subjects, suggesting that indivi-
duals with class I without myogenous
facial pain signs or symptoms and with
clinically veried correct vision accept the
exteroceptive visual input without an
adaptive mechanism on the sEMG pattern
of the stomatognathic system.
These observations suggest that the
visual input effect could be a good pro-
vocation test for assessing a neuromuscu-
lar reply that will be more signicant in
neurogenic facilitation areas
13
.
Future investigation will be aimed at
evaluating these variables in a longitudinal
model and evaluating thembefore and after
the resolution of myogenous facial pain in
order to clarify the mechanism at work.
Competing interests
None declared.
Funding
None.
Ethical approval
Not required.
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Address:
Annalisa Monaco
Gnatology Clinic and
Prosthetic Department
University of LAquila
Via Vetoio Delta 6 CAP 67100 LAquila
Italy
Tel: +39 0862 433837
Fax: +39 0862 433826
E-mail: annalisamonaco@yahoo.it
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