myofacial pain dysfunction syndrome, oral surgery

1. DEPARTMENT OF ORAL & MAXILLOFACIAL SURGERY
MYOFACIAL
PAIN
DYSFUNCTION
SYNDROME
KIRTHANA MUTHU SHANMUGAN
NU13UDL050
ROLL NO:40
IV BDS

2. 1.DEFINITION
MPDS was introduced by Laskin in 1960s.It refers to a group muscle disorders
characterized by diffuse facial pain and limited mouth opening.It can involve TMJ,
muscles of the face & associated head and neck structures.
MPDS is the most common cause of masticatory pain & limited function for which
patient seeks dental consultation & the source of the pain treatment.
2.HISTORY
Costen (1934)- occlusal etiology in TMJ pain. (Bite raising era)
He reported association of bite like ear pain, sinus pain, decreased hearing, tinnitus,
dizziness, burning & vertigo & occipital headaches.
Scwartz (1956)- TMJ pain dysfunction syndrome & blamed the masticatory &
perimasticatory musculature leading towards the symptoms.
He noted altered psychologic make up and advocated use of muscle relaxants,
restrictions of oral openings for resting the muscles.
Laskin (1969)- Myofascial Pain Dysfunction Syndrome.
He implicated psychophysiologic theory stating that psychological stress leads to
myospasm & advised tranquilizers, muscle relaxants.
3.ETIOLOGY
The MPDS can be visualized as a vicious cycle of several contributing factors such
as :-
-Muscular hyper function.
-Bruxism secondary to stress & anxiety with occlusion.
-Internal Joint Problems such as Disk Displacement disorders or Degenerative Joint
Disease(DJD).
-Physical disorders.
-Injuries to the tissues.
-Para functional habits.
-Disuse.
-Nutritional problems.
-Physiological stress.

3. -Sleep disturbances.
4.PATHOGENESIS
All Etiological factors leads to micro or macro trauma to musculoskeletal system
leading to muscle spasm
This hyper tonicity may lead to muscle fatigue and accumulation of metabolic
byproducts such as Lactic acid, prostaglandins, bradykinins, histamine
The accumulation of these chemical pain mediators, lowers pain threshold to
mechanical and chemical stimuli leading to MPDS
5.CLINICAL FEATURES
30 % of population suffers
Sex : Female- male ratio is 3:1
Age : 15-40 years
Laskin’s Cardinal symptoms of MPDS :-
Pain or discomfort anywhere about the head or neck.
Limitation of motion of the jaw.
Joint noises– grating, clicking, snapping.
Tenderness on palpation of the muscles of mastication.
Negative characteristics:-
Absence of clinical, radiographic or biochemical evidence of organic changes in TMJ.
Lack of tenderness in TMJ area when palpated via external auditory meatus.
Clinical characteristics
A zone of reference
Trigger points in muscles
Occasional associated symptoms
The presence of contributing factors.
TRIGGER ZONES
These are localized tender areas within taut bands of skeletal muscles when stimulated
by macro-micro traumatic episodes.

4. Associated symptoms of MPDS
Neurologic
Tingling
Numbness
Blurred vision
Twitches
Lacrimation
Otologic
Tinnitus
Ear pain
Dizziness
Vertigo
Diminished hearing
Gastrointestinal tract
Nausea
Vomiting
Diarrhea
Constipation
Dry mouth
Musculoskeletal
Fatigue
Tension
Tiredness
Weakness
Joint pain

5. Various masticatory muscles and their clinical effects
6.INVESTIGATIONS
CASE HISTORY
History of the patient
-Mode of onset, duration, frequency & quality of pain. Site & reference point of pain.
-Time of the day, at which pain is most pronounced.
-Occupation.
-Sleeping habits.
-Parafunctional habits.
-H/O previous trauma, prolonged dental work etc.
-Family or emotional problems.
-Associated symptoms.
-Aggravating & relieving factors.
Physical examination
Physical examination consists of an evaluation of entire masticatory system along
with head and neck region .
Articular / joint examination
Dental examination
Muscular examination
Cervical examination
Articular/TMJ function & Range of motion
 Amount of oral opening and the excursions
-Direction of opening-opening path and amount of deviation should be noted.
-Early opening deviation-> spasm of lateral pterygoid muscle on the sides towards the
deviation is seen

6. -Gradual deviation->muscle imbalance
 Extent of movement
i. ROM - >Range of motion
-Should be inspected for hypomobility or hypermobility & associated pain, if present.
-Normal Value: 40-50 mm
-Hypomobility without pain->early indication of disease
ii. AROM -> Active range of motion
-Tests all anatomic structures
-Limited AROM with pain indicates structural restrictions
iii. PROM ->Passive range of motion
-Tests all inert structures
-restricted movements suggest all contractile elements, I.e. muscle problems.
 Palpation for tenderness
-simultaneous palpation on both the joint, with index finger laterally over the joint and
through the external auditory meatus in open and closed movement is done.
-Any areas of tenderness on palpation should be noted.
 Grading of click or crepitation-noise evaluation.
-Early , immediate or wide open zones of condylar excursion are noted
-It should be noted whether the sound is on opening , closing or both.
 Auscultation(stethoscopic evaluation), if needed
MUSCULAR EXAMINATION
Systemic palpation of the muscles and their tendons is the best way to ascertain both
subclinical and clinical existing levels of dysfunction. The areas responsive to
palpation have been called trigger points. The muscles are palpated bilaterally and
simultaneously with frim but gentle pressure lasting for 1 or 2 minutes.
It is helpful for the following:
Location of muscle pathology.
Evaluation of muscle tone.
Location of trigger points.
Evaluation of temperature change.
Location of swelling.
Identification of anatomic landmarks.
DENTAL/OCCLUSAL EVALUATION
Gross occlusal discepancies, prematurities or interferences shoud be noted.

7. Anterior open bite, collapsed bite, cross bite, reduced vertical dimension, etc. should
also be noted. Attrition, wear facets, mobility of teeth, missing teeth should be
checked. Type of malocclusion, skeletal, dentofacial deformities should be looked for.
CERVICAL EXAMINATIONS
Here, the neck group of muscles are palpated and neck range of motion should also be
checked.
Shoulder & neck muscles are palpated as they control anteroposterior & lateral
position of the head.
A few examinations that are done are as follows :-
Hyoid bone palpation
Radiographic evaluation : it is helpful in diagnosis of the following
i) Intra-articular pathologies.
ii) Osseous pathological process.
iii) Soft tissue pathologies.
Panoramic radiography.
Tomograms.
Transcranial radiograph
8.MANAGEMENT
EDUCATION REGARDING PRESENTING ILLNESS
1.Re-educate the patient about the mechanism involved &factors causing or
aggravating the disorders.
2.Reassurance:The patient is assured of the benign character of the myospasm.The
patient should be explained that there will not be any residual deformities after the
treatment.
3.Suggestion:May act as the powerful tool in the treatment.The calm attitude of the
clinician and reassurance given suggest that recovery is bound to happen.
MUSCLE RELAXATION TECHNIQUES & MUSCLE EXERCISES
1. Tongue exercise
-The patient is asked to keep his tongue as posteriorly as possible while keeping the
mandible in aretruded position.In this position mainly rotary movements are
performed.
2. Mouth opening exercise
-The patient is asked to open his mouth slowly, rhythmically, within the pain limit, 10
times in sucession.
Next the patient is asked to repeat in such execises with the addition of one
modification, I.e. voluntary resistance.
3. Voluntary Resistance
-This technique is based on the pyhsiologic principle of reciprocal muscle
inhibition(reflex inhibition).

8. MEDICATIONS
NSAIDs to reduce inflammation & pain in muscles & joint.
-Aspirin : 2 tabs 0.3 to 0.6gm/ 4 hourly.(ECOSPIRIN)
-Piroxicam: cap. 10 to 20mg /once daily.(FELDENE)
-Ibuprofen : 200 to 600mg/3 times a day.(BRUFEN)
-Pentazocine: 30 mg i.v./i.m./s.c. every 3– 4 hrs max.- 360mg. (TALWIN,
TALACEN)
Muscle relaxant.
-Methocarbamol : muscle relaxant- 1500mg/ 4 times a day for 2-3 days,1000mg i.v./ 8
hrly (ROBAXIN)
-Metaxalone- (SKELAXIN)
-Chlorzoxazone - (FLEXON MR)- 400 mg, 325mg, 250 mg
Antidepressant-
-Diazepam- (VALIUM, CALMPOSE) & chlordiazepoxide (sedative)
5 to 10mg /2 to 3 times a day.(LIBRIUM)
-Amitriptyline: - 25mg/ 3- 4 times a day or at bedtime.(ELAVIL, VANATRIP).
Physiotherapeutic modalities
Heat application.
Ultrasound.
Cryotherapy.
Massage with counter-irritants & vibrators.
Use of vapocoolent spray.
Tetanizaing & sinusoidal currents.
Electrogalvanic stimulation.
Transcutaneous electronic nerve stimulator (TENS).
Active stretch exercises.
STRESS MANAGEMENT
-Managing daily stress is one of the best ways to help restore harmony between the
muscles and TMJ.
Biofeedback techniques
BRUXISM PROSTHESIS
1. Soft mouth guard
- made up of soft resin
-maybe fashioned for either upper and lower teeth and is designed even for centri
contact of all the teeth.
2. Anterior occlusion prosthesis
-Lucia jig
-Anterior bite plane
3. Mandibular posterior coverage
4. Complete maxillary or mandibular coverage

9. APPLIED KINESIOLOGY
1.What is it: Dental kinesiology is the study of motion and function of the jaws, oral
musculature, the accompanying neurological,vascular and other system network and
the impact of these muscle functions and neurological dynamics have on dental and
systemic health.Its basic application is for reduction and prevention of muscle spasm.
ANAESTHESIA
1. Muscle and fascia (trigger points)
2. TMJ (intracapsular & extracapsular)
3. Refrigerated spray
Other therapies
1. Surgery: eminectomy, zygomectomy, menisectomy,high condlectomy with
material inteposed between the articulating surfaces and orthoplasty plus
menisectomy are most frequently advocted.
2. Restoration: Faulty overfilled restorations should be removed to avoid interceptive
contacts.Sometimes complete mouth rehabilitation is equired to achiece centric
occlusion.
3. Prosthodontic theraphy: It has been shown that overclosure due to bilatel loss of
posterior teeth can cause TMJ pain. In such cases, bilatelal fixed or removable
replacement should be done to achieve normal vertical dimension.
4. Orthodontic theraphy
5. Orthognathic Surgery: when there’s skeletal discrepancies causing malocclusion,
orthonathic surgery is indicated.

11. National Journal of Maxillofacial Surgery,Trends in Management of Myofacial
Pain,Uma Shanker Pal, Lakshya Kumar,1 Gagan Mehta, Nimisha Singh, Geeta
Singh, Mayank Singh,and Hemant Kumar Yadav2,2014 Jul-Dec; 5(2): 109–116