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OBREZ AND TÜRP THE JOURNAL OF PROSTHETIC DENTISTRY

APRIL 1998 439

CLINICAL IMPLICATIONS

When prosthodontic rehabilitation is required in a patient who is having musculoskel-etal facial pain, the first obligation of the clinician is to differentially diagnose thepain. Clinicians should take a cautious approach to the timing of restorative treat-ment in patients who are experiencing musculoskeletal pain. The validity of themaxillomandibular registration is questionable.

THE JOURNAL OF PROSTHETIC DENTISTRY

Prosthodontic rehabilitation is intended to im-prove masticatory function, esthetics, and phonetics dueto missing, decayed, and/or fractured teeth.1 Depend-ing on the extent of the restoration, certainmaxillomandibular registrations are routinely used. Theseare (1) vertical dimension of occlusion (in situations ofloss of vertical support), (2) centric relation (in situa-tions of loss of horizontal maxillomandibular relation-ship), (3) maximum intercuspation, and (4) lateral andprotrusive mandibular border movement records (in situ-ations of extensive oral rehabilitation).

On first sight, prosthodontic and facial pain patientsseem to be two somewhat heterogeneous groups of pa-tients. The typical patient with musculoskeletal (tem-poromandibular) pain is a woman within the childbear-ing age.2 Conversely, patients who are in need ofprosthodontic care are more or less equally distributedbetween the genders and belong predominantly to the

aAssistant Professor, Department of Restorative Dentistry, College ofDentistry, University of Illinois at Chicago.

bVisiting Assistant Professor, Department of Biologic and MaterialsSciences, School of Dentistry, University of Michigan.

The effect of musculoskeletal facial pain on registration of maxillomandibularrelationships and treatment planning: A synthesis of the literature

Ales Obrez, DMD, PhD,a and Jens C. Türp, DDS, Dr Med Dentb

College of Dentistry, University of Illinois at Chicago, Chicago, Ill., andSchool of Dentistry, University of Michigan, Ann Arbor, Mich.

Statement of problem. A significant number of patients exist who are in need of prosthodonticrehabilitation 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 scienceand clinical literature, evaluates the effect of musculoskeletal facial pain on two static (physiologic restposition 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 musculoskeletalfacial pain and maxillomandibular relationships, a MEDLINE search was conducted, which was comple-mented by a hand search in selected journals.Results and Conclusions. Musculoskeletal facial pain seems to variably affect the aforementionedpositions and movements. Hence, the validity of maxillomandibular registrations in patients with existingfacial pain is questioned. In those patients with facial pain who simultaneously are in need of aprosthodontic rehabilitation, clinicians should be cautious with regard to the timing of the restorativeprocedures. (J Prosthet Dent 1998;79:439-45.)

middle and older age groups.3 On the other hand, a sig-nificant number of patients diagnosed with temporo-mandibular joint (TMJ) arthropathies are in their fiftiesand older.4 In addition, there are several general medi-cal conditions that may produce pain in the facial re-gion, and these may also appear in younger populations,for example, neuropathies. Therefore a significant pos-sibility exists for an overlap between patients who are inneed of prosthodontic rehabilitation and, at the sametime, report orofacial pain,5 though the exact demo-graphic overlap of the two groups has not been reportedin the literature. These patients can be classified intoseveral groups according to the temporal relationshipbetween pain and prosthodontic treatment. This articlefocuses only on those clinical situations where a patienthas both musculoskeletal facial pain and concurrent needfor prosthodontic treatment, with prosthodontic reha-bilitation primarily intended to restore the dentition andfunction. The few articles that have been published sofar regarding this topic focused primarily on clinical de-cision-making processes.5-9

The intent of this article is to evaluate the effect ofmusculoskeletal facial pain on maxillomandibular rela-

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440 VOLUME 79 NUMBER 4

tionships based on an assessment of the clinical and ba-sic science literature and to discuss how it might affectthe timing and sequencing of prosthodontic procedures.

METHODS

To find relevant articles, a MEDLINE literature searchwas conducted for the period from 1966 to April 1997.The key word “pain” was combined with the followingkey words (and combinations thereof): temporoman-dibular joint, mandible, occlusion, centric relation,movement, mandibular, prosthodontics, treatment, tem-poromandibular joint dysfunction syndrome, and tem-poromandibular joint disorders. The computer-basedliterature search was further supplemented with a handsearch of articles and book chapters. Whenever possible,reference was given to those articles that representedoriginal research rather than to those that described aclinical case or an opinion.

PAIN AND REGISTRATION OFMAXILLOMANDIBULAR RELATION-SHIPSVertical dimension of occlusion/vertical dimen-sion of rest

Vertical dimension of occlusion (VDO) has been de-fined as the vertical separation of the jaws that existswhen teeth are in occlusal contact.10 When occlusal con-tacts between the maxillary and mandibular teeth areinadequate or unstable, VDO must be determined bythe clinician. Various methods have been developed forthis purpose using different approaches that include theuse of preextraction records or, in their absence, oldphotographs11 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 clos-est speaking space before loss of the remaining naturalteeth,18,19 the patient’s own judgment of ideal VDO,20

and the vertical dimension of rest.21 Unfortunately, thereis little compelling evidence to argue the merit of onemethod over the other.22 In addition, there is lack of asignificant advantage of one method over the other withrespect to the final outcome desired, namely, a reason-able VDO. The factors that play the most importantrole in selecting a method are its cost and the time in-volved in its application. Among the methods previouslymentioned, use of vertical dimension of rest has becomeone of the most often used clinical methods for deter-mining the VDO.

Vertical dimension of rest, also known as physiologicrest position or mandibular rest position, is referred toas the mandibular position assumed when the head is inan upright position and the involved muscles, particu-larly the elevator and depressor groups, are in equilib-rium with respect to their tonic contraction, while the

condyles are in a neutral, unstrained position.23 Themethod of using vertical dimension of rest andinterocclusal space to determine VDO was initially sup-ported by Thompson and Brodie24 and Thompson,25 wholater modified his view regarding the positional stabilityof the hinge axis during the movement from rest to cen-tric occlusion position. The clinical use of this methodwas subsequently recommended by several clinicians.21

However, the assumption of stability of vertical dimen-sion throughout life was challenged in several studies.26-

31 For example, changes in vertical dimension of restwere demonstrated not only to be associated with age,but also with loss of teeth,27,29,32 changes in head posi-tion,33-35 the presence or absence of dentures in edentu-lous patients,36 and emotional stress.37

One of the methods to determine vertical dimen-sion of rest has been electromyography (EMG).38 Sev-eral studies that used surface electrode EMG reportedthat the electrical activity of masticatory muscles wasat its minimum or absent while the mandible was at itsclinically established vertical dimension of rest.39-41

These results suggested that this mandibular positionwas a fairly repeatable position of the mandible in spaceand that it could be assessed and verified with the EMGprocedure. However, the clinical applicability of thisprocedure was first questioned by an investigation thatdemonstrated a range of mandibular rest positions (asopposed to a specific position) associated with mini-mal electrical activity of masticatory muscles.42 Further-more, other studies demonstrated that spontaneouselectrical activity could be present in the clinically de-termined vertical dimension of rest.43-45 Finally, a studyby Rugh and Johnson46 demonstrated an average of 6mm discrepancy in mandibular opening between theclinically determined vertical dimension of rest and themandibular position of minimal muscle activity. Accord-ing to Rugh and Johnson,46 the EMG rest position ofthe mandible with minimal muscle activity exists be-yond the clinically determined vertical position of restat a position where masticatory muscles exhibit toniccontraction. These studies therefore support the theoryof Møller,47 who emphasized the role of a servocontrolmechanism48 in maintaining the determined verticaldimension of rest with muscle tonic activity. Fusimotor-initiated contraction of intrafusal fibers leads to sen-sory output through afferent nerve fibers from themuscle spindles to a servomotor system that activatesthe motor innervation and causes contraction of themuscle’s extrafusal fibers (stretch reflex).49 The studiesalso support the theory proposed by Yemm50,51 sug-gesting the primary role of viscoelastic elements andgravity in maintaining vertical dimension of the man-dible with minimal or no muscle activity found beyondthe vertical dimension of rest.

It has been suggested that the neuromuscular activityof the masticatory muscles recorded at vertical dimen-


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sion of rest occurs as a result of a stretch reflex that coun-teracts gravitational forces acting on the masticatorysystem.52 The stretch reflex, and with it the neuromus-cular activity of the elevator muscles, can be further in-fluenced by neural activity originating in other afferentperipheral pathways, for example, the mechanorecep-tors of the TMJ,53 mucosa, and periodontal ligament.They can also be affected by neural activity of the de-scending pathways from the central nervous system, forexample, reticular formation, limbic system, basal gan-glia, cerebellum, and cerebral cortex. Therefore it hasgenerally been assumed that masticatory muscle pain mayaffect the stretch reflex by increasing the activity of thetrigeminal alpha motor neurons through the gammaloop, resulting in a decrease of the interocclusal space.However, the intracellular recordings of neurons in thesubnucleus-caudalis of a decerebrated, paralyzed rabbitdid not show an increase of neural activity in thefusimotor neurons after the injection of a painful sub-stance (hypertonic saline) into the masticatory muscleswhile they were at rest.54 The effect of pain was evidentonly later when mastication was induced. It was foundthat frequency, amplitude, and velocity of masticatorycycles decreased. These results are supported by clinicalobservations in human beings.55-58 Furthermore, subse-quent clinical experiments that used hypertonic salineas a stimulant for provoking masticatory muscle pain inotherwise healthy volunteers revealed that there was nodifference in EMG activity of the painful and nonpainfulmuscles while at rest.59-61 These findings questioned thevicious cycle theory of musculoskeletal pain.62 Instead,the authors59 proposed a pain-adaptation model to ex-plain the EMG activity of painful masticatory muscleswhile acting as agonists (decreased activity) or as an-tagonists (increased activity). Contrary to the initial hy-pothesis that pain would cause the interocclusal spaceto decrease, the hypothesis based on the pain-adapta-tion model suggests that inhibition of the gamma sys-tem would lead to an increase of the interocclusal space.Unfortunately, there is a lack of well-controlled clinicalstudies that would support either of the two hypoth-eses. Such studies are needed, however, because verticaldimension at rest is already highly variable in subjectswithout pain and, as shown by Tallgren,32 patients tendto accept the interocclusal space at different VDO.

Because pain is also one of the symptoms reported bypatients diagnosed with intracapsular TMJ disorder(namely, TMJ disk interference disorders, arthropathies),similar observations are expected in this group of pa-tients. In addition to the effect of pain, structural in-congruities within the TMJ may mechanically interferewith the normal mandibular opening pattern,63 or causeanomalous motor neuron activity through arthrokineticreflex pathways.64 In patients where a significant restric-tion of the mandibular opening exists, registration of avalid record of the physiologic position of rest and de-

termination of the VDO becomes difficult, if not im-possible.

Centric relation

In an attempt to establish a reproduciblemaxillomandibular position in patients without poste-rior support or a stable interocclusal relationship, theconcept of mandibular centric relation (CR) was intro-duced. Centric relation refers to a condylar referenceposition within the TMJ, and thus indirectly to amaxillomandibular position, independent of tooth con-tact.10,65 The clinical significance of the mandibular CRhas been somewhat diluted over the years because ofchanges in its definition. The first edition of the Glos-sary of Prosthodontic Terms (GPT-1) defined centric re-lation as “the most retruded relation of the mandible tothe maxilla with its condyles in the most posterior unre-strained position in the glenoid fossae from which lat-eral mandibular movements could be made.” The defi-nition currently in use23 defines mandibular centric re-lation as “the maxillomandibular relationship in whichthe condyles articulate with the thinnest avascular por-tion of their respective disks in an anterior-superior po-sition against the posterior slope of the articular emi-nences.” According to the definition, this position is clini-cally established when the mandible is related superiorlyand anteriorly relative to the base of the cranium.23

Different clinical methods have been proposed toguide the dentate or edentulous mandible into its CRposition.66-68 Some authors recommend bilateral manipu-lation of the mandible,69 while others prefer a one-handedtechnique.70 Another group of clinicians relies predomi-nantly on the patient’s own retrusive movements of themandible.71 A mechanical system for recording themaxillomandibular relationship is the intraoral graphicrecording technique (Gothic arch tracing, central bear-ing tracing). The central bearing point, as part of themaxillary assembly, traces the movements of the patient’smandible during protrusion, retrusion, and laterotrusionin one plane, which is represented by a metal plate at-tached to the lower part of the recording assembly. It isagreed that the apex of the Gothic arch tracing indicatesthe mandibular position in its CR.71,72

Despite the fact that CR is described as a referencemandibular position, it is not fixed in space. Instead, itsposition may change over the course of time.73-77 In ad-dition, the results of a recent experimental study sug-gest that masticatory muscle pain may also influence theintraindividual position of CR.78 By using a validateddelivery system,79 5% hypertonic saline solution was in-jected into the central portion of the superficial part ofthe masseter muscle of five healthy volunteers.78 Experi-mental tonic muscle pain was thus maintained while themandibular border movements were recorded with theGothic arch tracing technique. The most posterior jawposition from which lateral border movement could be



made was compared intraindividually among baseline,painful, and sham-pain stages of the experiment. Theposition of the apex of the Gothic arch tracing signifi-cantly changed in the presence of pain. The change ob-served was on average 0.22 mm (range of 0.2 to0.6 mm) anteriorly, and varied in a transverse directionirrespective of the side of injection when compared withthe baseline. The positional change of the apex of theGothic arch was thus beyond the observed normal vari-ability range in pain-free subjects and well within thedetected range of tactile perception in dentulous andedentulous subjects.80-82 If the change in mandibularposition had been present in an anterior direction only,one could argue that the occlusal concept of long cen-tric would enable the clinician to compensate for themandibular shift.

Because of the low sample size and the current lack ofan independent validation, the results of the study byObrez and Stohler78 should be regarded as preliminaryat this stage. If verified, however, they may explain whypersons with masticatory muscle pain frequently com-plain that “their teeth do not fit anymore.” Also, theymay suggest a strong argument for caution regardingthe timing of initiation of the prosthodontic rehabilita-tion in patients with masticatory muscle pain. Becauseof the considerable interindividual variation in the ex-tent of CR when subjects are in pain, it is impossible topredict the CR position of the mandible when the sub-jects become free of pain, or when their pain intensityreduces significantly.

Mandibular border movements

Mandibular border movements are primarily used torecord at least two points on their respective trajectoriesto set articular parameters on the articulator. Specifi-cally, the protrusive mandibular border movement is usedto set the inclination of the articular eminence, whereasthe lateral border movement determines the contralat-eral transverse orientation of the medial wall of thearticulator’s condylar fossa (Bennett’s angle). Thoughthe paths of the condylar assembly of the articulatorduring these movements do not exactly correspond tothe paths of mandibular condyles, they do represent anadequate approximation.

Mandibular border movements are influenced by theskeletal anatomy of the TMJs, the occlusal structure ofthe teeth, and physiologic constraints of the ligamentsof the TMJ.

Mandibular protrusive border movement

There are two methods to register the inclination ofthe articular eminence, the dynamic recording using apantograph and the positional recording with a staticregistration. Both register the mandibular protrusivemovement relative to the maxilla, while some of themaxillary and mandibular anterior teeth maintain their

occlusal contact. The movement of the condylar headfrom the position assumed at CR to the point of pro-trusive registration is predominantly translatory andcurvilinear in shape when projected onto the sagittalplane.83 While a pantograph records this condylar pathprecisely in its whole length, the static method regis-ters at least one mandibular position on the trajectoryof the mandibular protrusive movement. When thiscondylar position and the position of the condylar headin CR are projected onto the sagittal plane, they forma line. The angle formed between this line and the hori-zontal reference line is then used as an approximationof the inclination of the articular eminence on the ar-ticulator.

Because of its curved structure, the degree of steep-ness of the articular eminence, as seen in a sagittal plane,changes continuously. Therefore it becomes evident thatthe measured angle of inclination, as determined duringstatic registration of the protrusive record, depends onthe condylar position in centric relation as well as on theextent of the condyle’s anterior position assumed dur-ing this registration. In theory, if the protrusive excur-sion of the mandible during the recording procedure istoo short or too long (namely, the condylar head posi-tioned on the preglenoid plane), the registration of theinclination of the eminence underestimates its anatomicangle. As a consequence, the occlusal contacts of theposterior teeth, fabricated on the articulator that is setaccording to the registered angle, separate during thepatient’s protrusive movement. The result may have noclinical effect in prosthodontic rehabilitation of dentatepatients with planned anterior distoclusion during pro-trusive movement. However, in edentulous patients,complete dentures set in posterior and bilaterally bal-anced articulation on the articulator may exhibit poste-rior bilateral disocclusion (Christensen’s phenomenon)during the patient’s protrusive movement and a loss ofocclusal contact on the balancing side during lateralmandibular movement.

Obrez and Stohler78 showed that experimentally in-duced pain in the masseter muscle decreased the lengthof the protrusive mandibular border movement. Thechange in its length, though not statistically significant,was demonstrated despite the fact that the painful sub-stance was injected unilaterally only into one of the mas-ticatory muscles. Because only five subjects were usedand the interindividual variability in their responses topain was high, it is difficult to predict the amount ofchange in length of the protrusive border movement asa result of masticatory muscle pain, based on the resultsof this study. These observations are supported by clini-cal studies comparing patients with temporomandibu-lar pain and control subjects.56,57

Regardless of the amount of change, the decrease ofthe protrusive mandibular border movement with simul-taneous change in position of the centric relation posi-


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tion of the mandible in patients with experimentally in-duced masticatory muscle pain (as discussed previously)question the validity of their protrusive record. For ex-ample, underestimation of the anatomic condylar guid-ance registered in patients with masticatory muscle painmay significantly affect the articulation of the posteriorteeth in patients with posterior bilateral balance (suchas patients with complete dentures) after their pain sub-sides. The occurrence of Christensen’s phenomenon isa likely clinical finding.

In patients with TMJ disk interference disorders orarthropathies, patients may exhibit significant limitationsof the mandibular protrusive movements due to struc-tural incongruities within the TMJ complex and/or painthat accompanies it.56 The extent of functional limita-tion during registration may subsequently affect the va-lidity of the protrusive maxillomandibular registration.

Mandibular lateral border movement

The lateral border movement of the mandible rarelyoccurs during function. However, the recording of thismandibular movement is important to set the orienta-tion of the medial wall of the articulator’s fossa rela-tive to the midline (Bennett’s angle). Similar to theregistration of the protrusive record, the lateral bordermovement registration can be obtained by a pantographor a static record. When the latter method is used, atleast one mandibular position should be registered onthe trajectory of the mandibular lateral border move-ment from CR. The orientation of the resultant linetoward the midline is then used to adjust the trans-verse orientation of the medial wall of the articulator’scondylar fossa. Because the path of the balancing sidecondyle-disk complex is three-dimensional, both thesetting of inclination of the condylar eminence and theorientation of the medial wall of the articulator’s condy-lar fossa influence the lateral condylar movement onthe articulator. While the inclination of the articulareminence influences the vertical component of the bal-ancing side contact pattern between the posterior teeth,the orientation of the medial wall has an effect on thehorizontal (antero-posterior and lateral) component ofthe lateral mandibular movement. The clinical effectof underestimating the anatomic inclination of the ar-ticular eminence on the lateral mandibular movement,as a consequence of a faulty registration of the protru-sive record that may have occurred in patients withmasticatory muscle pain, is similar to the clinical effectof such pain on the protrusive mandibular movement,as described earlier in this article. Namely, clinical ob-servation may reveal disocclusion of the patient’s pos-terior prosthodontic restorations during lateral man-dibular movements after pain subsides. This effect mayhave no clinical significance in the prosthodontic reha-bilitation of dentate patients. In edentulous patients,however, the posterior teeth of the dentures set in bi-

lateral balanced occlusion may disocclude on the bal-ancing side during the patient’s lateral mandibularmovement while not in pain. As a consequence, bilat-eral cross arch balance, indicated for some of the fulldenture patients, is lost.

Obrez and Stohler78 reported that experimentallyinduced masticatory muscle pain affects lateral bor-der movements with respect to both the length andtheir orientation relative to the midline. Bennett’sangle changed significantly in the presence of masti-catory muscle pain, more so on the contralateral sidewith respect to the side where pain was induced. Be-cause of the limitations of this study already men-tioned, it is difficult to predict the extent and direc-tion of change in mandibular lateral border move-ments in any patient who experiences masticatorymuscle pain. However, this study indicated thatchanges in mandibular border movements occur inthe presence of pain. Similar findings were observedin the clinical studies.56,57 Therefore it is expected thata patient receiving prosthodontic restorations, fabri-cated on an articulator that is set according to theocclusal registrations made while the patient was inpain, may subsequently exhibit working side interfer-ences during lateral mandibular movements when themasticatory muscle pain subsides. This clinical find-ing can be expected in patients receiving fixed and/or removable prosthodontic restorations.

Patients diagnosed with intracapsular TMJ disorders(TMJ disk interference disorders or arthropathies) of-ten report limitations of mandibular border move-ments.56 In addition to the effect of pain, structural in-congruities within the TMJ complex may therefore sig-nificantly affect the registration of maxillomandibularrelationships, including lateral mandibular border move-ment. Depending on the goals of the treatment pro-vided (or not) to this group of patients with respect totheir pain condition, the extent and direction of changeof the mandibular movement determine the amount ofocclusal discrepancy that may be expected after the paincondition subsides or changes with time.

CONCLUSIONS

For most of the prosthodontic rehabilitation, cer-tain maxillomandibular registrations are needed. Painseems to variably affect them (Table I), raising ques-tions about the validity of maxillomandibular registra-tions taken in patients with existing musculoskeletalfacial pain. In addition, because pain often changes itsintensity, it is expected that static and dynamic posi-tional relationships between the maxilla and the man-dible will vary with changes in pain level.78 Patientswith facial pain who are in need of more extensiveprosthodontic rehabilitation should therefore be ap-proached cautiously with respect to its initiation andthe treatment planning. Definitive prosthodontic treat-



ment should be deferred until a definite diagnosis ofthe pain condition can be established, and until factorsresponsible for the obser ved change in themaxillomandibular relationship have been revealed andthe facial pain itself has been properly managed.6,85

Prosthodontic criteria for successful oral rehabilitationin these patients cannot always be satisfied, so somedegree of compromise may be required. In addition, itis important that both the clinician and the patient un-derstand that prosthodontic treatment per se may notprevent recurrence of musculoskeletal facial pain.84

We thank Charles S. Greene and Robert S. Scapino, University ofIllinois at Chicago, for making helpful suggestions on earlier versionsof the manuscript.

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Table I. Summary of clinical findings from MEDLINE literaturesearch

Maxillomandibular relationship Effect of musculoskeletal pain

Vertical dimension of rest Change in interocclusal distance,which may or may not be clinicallysignificant56,78

Centric relation Anteriorly and asymmetricallypositioned mandible78

Maximum mandibular No change56,57 or reduction in itsprotrusive movement length78

Mandibular lateral border Decrease in its length and right-leftmovement asymmetry56,57,78


APRIL 1998 445

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64. Isberg A, Widmalm SE, Ivarsson R. Clinical, radiographic, and electromyo-graphic study of patients with internal derangement of the temporoman-dibular joint. Am J Orthod 1985;88:453-60.

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70. Ash MM, Ramfjord S. Occlusion. 4th ed. Philadelphia: WB Saunders; 1995.p. 70-2.

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76. Schubert R. Reproducibility of the terminal hinge axis position—a 1 yearstudy [in German]. Dtsch Zahnärztl Z 1985;40:96-9.

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UNIVERSITY OF ILLINOIS AT CHICAGO

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