MUSCLES OF

MASTICATIO
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CONTENTS:
• INTRODUCTION
• EMBRYOLOGY
• ANATOMY
• CLINICAL EXAMINATION
• DISORDERS
• APPLIED ASPECT

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INTRODUCTION:
• MASTICATION:
• Is the process of grinding and chewing food into smaller pieces in the
oral cavity of the head turning it into a food bolus.
• Apart from teeth and tongue, certain muscles known as the
masticatory muscles partake in specific movements of
temporomandibular joint during mastication process to allow the
initial stages of digestion to occur.

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EMBRYOLOGY:
• Derived from the mesoderm of first pharyngeal
arch

• Appear by 4th – 5th weeks of intrauterine life

• begin differentiation in 7th week & nerves begin
in 8th week.
• By the end of 10th week, mandibular arch
muscles have become well organized bilaterally
into 4 muscles of mastication

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MUSCLES OF MASTICATION:
• Primary muscles are

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• Accessory muscles

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MASSETER:

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MASSETER:
• Quadrilateral muscle, covers the lateral surface of ramus of mandible.
• Consists of 3 superimposed layers blending anteriorly.
• A)Superficial Layer:
Largest
Origin:
Arises by a thick aponeurosis from the zygomatic process of maxilla
& from the anterior 2/3rds of the lower border of the zygomatic arch.
Its fibres pass downwards and backwards to be inserted into the angle
& lower half of lateral surface of the ramus of the mandible

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• B)Middle Layer:
Arises from medial aspect of the deep surface of the anterior 2/3rds
of the zygomatic arch and from the lower border of the posterior third
this arch.
Inserted into the middle of the ramus of the mandible.
• C) Deep Layer:
Arises from the deep surface of the zygomatic arch.
Inserted into the upper part of the ramus of the mandible & into the
coronoid process.

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• Relations:
Platysma
Risorius
Zygomatic major superficial
Parotid gland & duct
Transverse facial vessels
Temporalis deep
Ramus of mandible

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Parotid gland- posterior margin
Buccinator anterior margin
Buccal branch of mandibular nerve
Actions:
Elevates the mandible to occlude the teeth in mastication
Nerve supply:
Masseteric branch of the anterior trunk of the mandibular nerve.

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• Vascular supply:
Masseteric branch of maxillary artery, facial artery and the transverse
facial branch of the superficial temporal artery.

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TEMPORALIS:

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TEMPORALIS:
• Fan shaped
• Arises from the temporal fossa upto the temporal line (except the
part formed by the zygomatic bone) and from the deep surface of the
deep temporal fascia.
• Its fibres converge and descend into a tendon which passes through
the gap between the zygomatic arch and the side of the skull.
• It is attached to medial surface, apex ,anterior and posterior borders
of the coronoid process & to the anterior border of the ramus almost
upto the 3rd molar tooth.
• Its anterior fibres are oriented vertically, the posterior fibres are
horizontally and the middle fibres obliquely.

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• Relations:
• Skin
• Auriculares anterior & superior
• Temporal fascia
• Superficial temporal vessels
• Auriculo temporal nerve superficial
• Temporal branches of facial nerve
• Epicranial aponeurosis
• Zygomatic arch
• masseter

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• Temporal fossa posterior
• Infratemporal fossa
• Zygomatic bone- anterior
• Masseteric nerve and vessels – behind
• Actions:
Elevates the mandible
Posterior fibres retract the protruded mandible
Side to side grinding movements

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• Nerve supply:
Deep temporal branches of anterior trunk of mandibular nerve.
• Vascular supply:
Deep temporal branches of maxillary artery.

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LATERAL PTERYGOID:

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LATERAL PTERYGOID MUSCLE:
• Short, conical
• A) Upper Head:
Arises from the infratemporal surface and the infratemporal crest
of greater wing of sphenoid bone.
• B) Lower Head:
Arises from the lateral surface of lateral pterygoid plate.
From the two origins, its fibres converge and pass backwards and
laterally, to be inserted into a depression on the front of the neck of the
mandible

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• Relations:
• Mandibular ramus
• Masseter deep or superficial
• Maxillary artery
• Superficial head of medial pterygoid
• Tendon of temporalis superficial
• Deep head of medial pterygoid
• Spheno mandibular ligament deep
• Middle meningeal artery
• Mandibular nerve

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• Temporal and masseteric branches mandibular nerve – upper border
• Lingual and inferior alveolar nerve- lower border
• Actions:
Depresses the mandible
Protrude the mandible
Side to side grinding movements
• Nerve supply:
Anterior trunk of mandibular nerve
• Vascular supply:
Pterygoid branches from maxillary artery
Ascending palatine branch of facial artery

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MEDIAL PTERYGOID:

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MEDIAL PTERYGOID MUSCLE:
• Thick, quadrilateral
• A) Deep Head:
Arises from the medial surface of the lateral pterygoid plate of
sphenoid bone & is therefore deep to the lower head of lateral
pterygoid.
• B) Superficial Head:
Arises from the maxillary tuberosity and the pyramidal process of
palatine bone and therefore lies on the lower head of lateral pterygoid.

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• Its fibres descend posterio laterally and are attached by a strong
tendinous lamina to the posteroinferior part of medial surface of ramus
and angle of mandible.
• Relations:
Ramus of mandible- laterally
Tensor veli palatini- medially
• Actions:
Elevates the mandible
Protrude movements, grinding movements
• Nerve supply:
Medial pterygoid branch of mandibular nerve
• Vascular supply:
Pterygoid branches of the maxillary artery
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MYLOHYOID:
• Flat , triangular
• Forms floor of the mouth, lies superior to the
digastric muscle.
• Attaches to the mylohyoid line of mandible.
• Posterior fibres runs medially and slightly
downwards to the front of the body of the
hyoid bone near its lower border.
• Middle and anterior fibres from each side
decussate in a median fibrous raphae that
stretches from symphysis menti to hyoid bone.

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• Relations:
Platysma
Anterior belly of digastric
Submandibular gland inferior
Facial and submental vessels
Mylohyoid vessels , nerve
Geniohyoid
Hyoglossus, styloglossus
Hypoglossal, lingual nerves superior
Glands
Lingual , sublingual vessels
• Mucus membrane of the mouth- posteriorly
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• Actions:
Elevates the floor of the mouth in the 1st stage of deglutition
Elevates the hyoid bone
Depresses the mandible
• Nerve supply:
Mylohyoid branch of mandibular nerve
• Vascular supply:
Sublingual branch of lingual artery
Mylohyoid branch of inferior alveolar artery
Submental branch of facial artery

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GENIOHYOID:
• Narrow muscle , which lies above the medial part of
mylohyoid.
• Arises from the inferior mental spine.
• It runs backwards and slightly downwards attaches
to the anterior surface of the body of the hyoid
bone.
• Actions:
• Elevates the hyoid bone
• Depresses the mandible

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• Vascular supply:
Lingual artery
• Nerve supply:
1st cervical spinal nerve through hypoglossal nerve

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ANTERIOR BELLY OF DIGASTRIC
MUSCLE:
• Originated from the digastric fossa of mandible.
• Its fibres runs downwards and backwards.
• Inserted in to intermediate tendon
• Actions:
Depresses the mandible
• Nerve supply:
Nerve to mylohyoid
• Vascular supply:
Facial artery

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STYLOHYOID:
• Small muscle, lies on upper border of posterior belly
of digastric.
• Originated from posterior surface of styloid process.
• Its tendon is perforated by posterior belly of
digastric tendon & inserted into junction of body
and greater cornua of hyoid bone.
• Nerve supply:
Facial nerve
• Actions:
Pulls the hyoid bone upwards and backwards.
• Vascular supply:
Facial , posterior auricular, occipital arteries
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CLINICAL EXAMINATION OF
MUSCLES:
• MASSETER:

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• TEMPORALIS:

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• LATERAL PTERYGOID, MEDIAL PTERYGOID:

Functional manipulation:

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AREAS OF PAIN REFERRED FROM THE
MUSCLES OF MASTICATION

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CLINICAL EXAMINATION OF
MUSCLES:
• patient’s response is placed in one of 4 categories.
• zero (0) - no pain or tenderness
• 1 - the palpation is uncomfortable (tenderness or soreness).
• 2 - indefinite discomfort or pain.
• 3 -patient shows evasive action or eye tearing or verbalizes a desire
not to have the area palpated again.

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DISORDERS:
• Masticatory muscle disorders
A. Protective co-contraction
B. Local muscle soreness
C. Myofascial pain
D. Myospasm
E. Centrally mediated myalgia

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PROTECTIVE CO-CONTRACTION:
• First response of the masticatory muscles
• It is a central nervous system response to injury or threat of injury
• In the presence of an event, the activity of appropriate muscles seems
to be altered so as to protect the injured part from further injury.
• A patient who is experiencing protective co-contraction will
demonstrate a small increased amount of muscle activity in the
elevator muscles during mouth opening.
• During closing of the mouth, increased activity is noted in the
depressing muscles.
• Is not a pathologic condition.

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• Causes:
Altered sensory or proprioceptive input
Constant deep pain input
Increased emotional stress
• Clinical Characteristics:
Myalgia
Structural dysfunction
No pain at rest
Increased pain with function
Feeling of muscle weakness

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• DEFINITIVE TREATMENT:
It consists of altering the restoration to harmonize with the existing
occlusion.
• SUPPORTIVE THERAPY:
It begins with instructing the patient to restrict use of the mandible
to within painless limits.
Soft diet
NSAIDs
Muscle exercises and other physical therapies are not indicated

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LOCAL MUSCLE SORENESS (NONINFLAMMATORY
MYALGIA):
• Local muscle soreness is a primary, noninflammatory, myogenous pain
disorder and is often the first response of the muscle tissue to
continued protective co-contraction.
• It represents a change in the local environment of the muscle tissues.
• Causes:
Protracted co-contraction
Trauma-Local tissue injury
Unaccustomed use
Increased emotional stress
Idiopathic myogenous pain
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• Clinical Characteristics:
Structural dysfunction
Minimum pain at rest
Increased pain to function
Actual muscle weakness
Local muscle tenderness

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• DEFINITIVE TREATMENT:
The primary goal is to decrease sensory input (such as pain) to the
CNS.
Eliminate any ongoing altered sensory or proprioceptive input.
Eliminate any ongoing source of deep pain input (whether dental or
other).
SUPPORTIVE THERAPY:
NSAIDs
Manual physical therapy techniques such as passive muscle stretching
and gentle massage may also be helpful.

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MYOSPASM (TONIC CONTRACTION
MYALGIA):
• It is an involuntary, CNS-induced tonic muscle contraction.
• Causes:
Deep pain input
Local metabolic factors within the muscle tissues associated with fatigue or
overuse
Idiopathic myospasm mechanisms
• Clinical Characteristics:
Structural dysfunction
Pain at rest
Increased pain with function
Local muscle tenderness
Muscle tightness 49
• DEFINITIVE TREATMENT:
Myospasms are best treated by reducing the pain and then passively
lengthening or stretching the involved muscle.
Reduction of the pain can be achieved by manual massage,
vapocoolant spray, ice, or even an injection of local anesthetic into the
muscle in spasm.
Once the pain is reduced, the muscle is passively stretched to its full
length.
• SUPPORTIVE THERAPY:
physical therapy techniques
Soft tissue mobilization such as deep massage and passive stretching
are the two most important immediate treatments.

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MYOFASCIAL PAIN (TRIGGER POINT
MYALGIA):
• Myofascial pain is a regional myogenous pain condition characterized
by local areas of firm, hypersensitive bands of muscle tissue known as
trigger points.
• A trigger point is a circumscribed region in which just a relatively few
motor units are contracting.
• Causes:
Protracted local muscle soreness
Constant deep pain
Increased emotional stress
Sleep disturbances
Local , systemic factors
Idiopathic trigger point mechanism 51
• Clinical characteristics:
• Structural dysfunction
• Pain at rest
• Increased pain with function
• Presence of trigger points

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• DEFINITIVE TREATMENT:
Eliminate the source
Reduce the local and systemic factors that contribute to myofascial
pain
If a sleep disorder is suspected, proper evaluation and referral should
be made.
Tricyclic antidepressant-10-20 mg of amitriptyline before bedtime
Most important-elimination of the trigger points-
Spray and-stretch technique: vapocoolant spray (e.g.,
fluoromethane)
Pressure and Massage
Injection and Stretch
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CENTRALLY MEDIATED MYALGIA
(CHRONIC
MYOSITIS)
• Is a chronic, continuous muscle pain disorder originating
predominantly from CNS effects that are felt peripherally in the
muscle tissues.
• This disorder clinically presents with symptoms similar to an
inflammatory condition of the muscle tissue and therefore is
sometimes referred to as myositis.
• Periodic episodes of muscle pain do not produce centrally mediated
myalgia.
• A prolonged and constant period of muscle pain, lead to centrally
mediated myalgia.

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• Clinical characteristics:
Structural dysfunction
Pain at rest
Increased pain with function
Local muscle tenderness
Feeling of muscle tightness
Muscle contracture

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• DEFINITIVE TREATMENT:
• Restrict mandibular use to within painless limits.
• Avoid exercise and/or injections.
• Disengage the teeth.
• NSAID-Ibuprofen 600mg, 4 times /day- 2 weeks.
• SUPPORTIVE THERAPY:
• Gentle isometric jaw exercises are helpful for increasing the strength
of hypotrophic muscles

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FIBROMYALGIA (FIBROSITIS):
• It is a chronic, global, musculoskeletal pain disorder.
• In which there is tenderness at 11 or more of 18 specific tender sites
throughout the body.
• Pain must be felt in three of the four quadrants of the body and be present
for at least 3 months.
• Clinical characteristics:
Structural dysfunction
Pain at rest
Increased pain with function
Weakness and fatigue
Presence of tender points
Sedentary physical condition
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• DEFENITIVE TREATMENT:
NSAIDs
Tricyclic antidepressant -10 to 50 mg of amitriptyline at bedtime
Cyclobenzaprine (Flexril)- 10 mg at bedtime
• SUPPORTIVE THERAPY:
Physical therapy modalities and manual techniques- moist heat,
gentle massage, passive stretching, and relaxation training

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CENTRALLY MEDIATED MOTOR
DISORDERS:
• Nocturnal bruxism and oromandibular dystonia
• NOCTURNAL BRUXISM:
• Involuntary habitual grinding of the teeth, typically during sleep
• A factor that may lead or contribute to a masticatory muscle disorder is
muscle hyperactivity
• Emotional stress
• MANAGEMENT:
• occlusal appliance
• 1 mg of clonazepam before sleep
• 10 to 20 mg of amitriptyline per night
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 OROMANDIBULAR DYSTONIAS:
• DYSTONIA= disordered tonicity of muscle
• when the myospasm uncontrollably repeats itself, it is considered
to be a dystonia
• It is a focal dystonia whereby repetitive or sustained spasms
occur in the masticatory, facial, or lingual muscles.
• These spasms result in involuntary and often painful jaw opening,
closing, deflecting, retruding , or a combination of these actions.
• MANAGEMENT:
• Cholinergics ,benzodiazepams, antiparkinsonism drugs,
anticonvulsants ,baclofen, carbamazepine, and lithium
• Botulinum toxin injections
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APPLIED ASPECT:

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MANDIBULAR FRACTURES
• In case of mandibular fractures,
when angle fractures are horizontally unfavourable, the masseter,
temporalis & medial pterygoid cause upward and medial displacement
of proximal segment.
when angle fractures are vertically unfavourable, the medial and
lateral pterygoids result in medial displacement of proximal segment.
In bilateral parasymphysis fracture, geniohyoid, genioglossus
muscles cause posteroinferior displacement of fractured segment.
Which results in posterior displacement of tongue and airway
obstruction.
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ZYGOMATIC BONE FRACTURES:
• A plane exists beneath the temporal fascia,
which is attached to the superior surface of
zygomatic arch and the muscle and which
passes beneath the arch.
• An elevator introduced into this plane
through an incision above the hairline may
therefore be placed beneath the fractured
zygomatic bone in order to reduce the
fracture

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ORTHOGNATHIC SURGERIES
• In orthognathic surgeries,
in IVRO technique , once the cut is complete, the proximal segment is
retracted laterally to expose the entire length of the medial pterygoid
muscle.
The objective is to remove only enough muscle from the anterior and
medial surface of the proximal segment to allow bony overlap, while
maintaining an adequate sling of pterygoid and masseter muscle along
the posterior border to prevent condylar sag or avascular necrosis of
inferior tip of the proximal segment

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• In bilateral sagittal split osteotomy,
The masseter muscle attachment should maintained as far as
possible without sacrificing adequate exposure.
Strip enough of the masseter muscle to allow easy visualization of
the osteotomy area and also strip the lower fibers of temporalis muscle
attachments from the anterior border & coronoid process.

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MASSETERIC HYPERTROPHY:
• Masseteric hypertrophy is a relatively uncommon
condition that can occur unilaterally or bilaterally.
• Unilateral- or bilateral hypertrophy of the masseter muscle
is characterized by an increase in the volume of the muscle
mass.
• This condition is benign, asymptomatic, and must be
differentiated from parotid gland illnesses, Odontogenic
problems, and rare neoplasms of muscular tissue.
• A hypertrophied masseter will alter facial lines, generating
discomfort and negative cosmetic impacts for many
patients.

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• clenching, bruxing, or heavy gum chewing and this occurs primarily in
younger patients.
• Treatment:
• Muscle relaxant, psychiatric care.
• Excision of the internal layer of the masseter muscle and reduction of
the thickened bone in the region of the mandibular angle treatment
of choice.
• Botulinum toxin.

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SUBMASSETERIC SPACE
INFECTIONS:
• Infection of mandibular 3rd molar
• It tracks backwards, lateral to the ramus of mandible and pus localizes
deep to the attachment of masseter in the sub masseteric tissue
space.
• Swelling
• Muscle spasm
• Trismus

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EXTRACTIONS
• In mandibular 3rd molar extractions,
vestibule is formed by the attachment of
buccinator buccally, mylohyoid lingually and
temporalis attaches along the anterior border of
ramus till 3rd molar.
excessive stripping of temporalis muscle will cause
hematoma, pain, trismus.

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REFFERENCES:
• GRAY’S ANATOMY
• B D CHAURASIA HUMAN ANATOMY
• OKESEN –TEMPOROMANDIBULAR DISORDERS
• FONCESA
• ESSENTAIL OF ORTHOGNATHIC SURGERY- REYNEKE

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“The most important thing you can do
for your patient is to make the correct
diagnosis. It is the foundation for
success.”
-OKESON

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