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The Journal of Craniomandibular & Sleep Practice

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Myofascial Pain Dysfunction: A Case Report

Barry C. Cooper

To cite this article: Barry C. Cooper (1988) Myofascial Pain Dysfunction: A Case Report,
CRANIO®, 6:4, 346-351, DOI: 10.1080/08869634.1988.11678259

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 Myofascial Pain Dysfunction: A Case Report
By Barry C. Cooper, D.D.S.

Abstract This article follows the case of a 16-year-old female in whom

myofascial pain dysfunction was precipitated by the physical
trauma of a bicycle accident, ultimately resulting in a maximum
interincisal opening of 8 mm. The practitioner's therapeutic goal
was to fully relax the musculature and reposition the mandible
with an anatomically accurate orthotic to maintain optimal
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muscle function without accommodative function.

Barry C. Cooper, D.D.S.

Dr. Cooper received his D.D.S. degree from Co-
lumbia University School of Dental and Oral Surgery
in 1963. From 1964 to 1970, he served as assistant
clinical professor of dentistry at Columbia. Dr. Cooper
has published several articles on myofascial pain dys-
function and is co-editor of the book Management of
Facial, Head and Neck Pain, now in publication. In
1987, he chaired the Fifth Annual Convention of the
International College of Craniomandibular Orthoped-
ics in Honolulu, Hawaii. Among Dr. Cooper's profes-
sional affiliations are the American Dental Association,
the American Equilibration Society, and the Dental
Society of the State of New York. He is a Fellow of
the International College of Dentists and the Interna-
tional College of Craniomandibular Orthopedics.
He is an assistant clinical professor of otolaryngol-
ogy at New York Medical College and is director of
the myofascial pain clinic at the New York Eye and
Ear Infirmary.

346 THE JOURNAL OF CRANIOMANDIBULAR PRACTICE OCTOBER 1988, VOL. 6, NO. 4


Case Reports
yofascial pain dysfunction (MPD) is a com-
M mon illness in children and adults that can be
caused by spasm in the muscles asssociated with man-
dibular posture and function. 1.2 Occlusion of the teeth
requires a pattern of muscle activity to move the man-
dible from the posturing rest position to the occlusal
position. Occlusion is not something that occurs only
during eating; it is a position usually reached approx-
imately 2000 times a day to stabilize the jaw during
swallowing. The mandible rests about I mm from
occlusion in order to minimize the distance it must
travel on the muscularly directed path to occlusion.
When complete muscle relaxation results in a jaw po-
sition more than a millimeter from occlusion, the el-
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evator muscles adjust and remain in a partially contracted
state in order to position the mandible closer to oc-
clusion. This accommodative postural resting position
requires constant muscle activity and does not permit
complete muscle relaxation. 3 Muscle hyperactivity or
spasm can account for the clinical symptoms of MPD,
which can cause pain and limitation of function within
the head and neck, and destruction of the teeth and
supporting bony structures. Table 1 is a representation
of the symptoms most commonly reported by patients.
The list is not meant to be totally inclusive, nor are
the symptoms listed exclusively found only in myo-
fascial pain dysfunction. A comprehensive differential
diagnosis is essential.
In this case, my patient was a 16-year-old girl pre-
disposed to MPD. She had been referred by her pe-
diatrician and otolaryngologist after a bicycle accident
precipitated myofascial pain dysfunction. Nine months
prior to my examination, the patient had fallen off a
Table 1
Symptoms of Myofascial Pain Dysfunction
THE PAINFUL SYMPTOMS:
Headache, facial and ear pain, tinnitus, barotrauma
Pain in the TMJ or on mandibular movement
Oral soft tissue or dental pain
Shoulder, neck, back, chest pain
THE DYSFUNCTIONAL SYMPTOMS:
Mandibular movement: limited, deviated, slow, irregular
Head movement: limited rotation
Ears: muffling, dizziness, hearing loss, clicking
Throat: difficulty swallowing, prolonged speech
TMJ: dislocation of condyle or disk. torticollis, facial
asymmetry
SELF-DESTRUCTIVE DENTITION:
Wear on teeth, abrasion, chipping
Looseness of teeth (bone loss)
Movement of teeth, spreading or crowding
OCTOBER 1988, VOL. 6, NO. 4 THE
0734-541 0/88/0604--0346$02.00/0
THE JOURNAL OF CRANIOMANDIBULAR PRACTICE
Copyright © 1988 by Williams & Wilkins
bicycle, head first over the handlebars, hitting the left
side of her face. She experienced pain in the left side
of her face and ear, and several physicians and dentists
examined her in the ensuing months. Treatments in-
cluded endodontic therapy for a left mandibular molar
thought to be the cause of her pain, and eventually
extraction of the tooth was followed by extraction of
two maxillary molars on the same side.
In the weeks immediately following the accident,
the patient's only symptom had been pain of increasing
intensity. Later, she developed muffled ears and lim-
ited opening of her mouth. At the time of my exam-
ination, the patient reported taking Tylenol No. 3*
with codeine every four to six hours, around the clock,
which was not totally obliterating her pain. She cried
whenever she needed an analgesic and her parent gave
her the prescribed dose. Her other prescriptions in-
cluded Motrin, t Dolobid, +and Talacen. § An oral sur-
geon had injected local anesthetics into the painful
areas of the patient's face, but they failed to produce
any lasting remission of the pain or any increase in
mandibular movement.
When I examined the child, she would not permit
palpation of any part of the left side of her face, re-
porting extreme sensitivity in the entire area. Maxi-
mum interincisal opening measured between the edges
of the upper and lower central incisors was 8 mm
(normal is approximately 35-45 mm). She reported
the following symptoms, all on her left side: pain in
the head, neck, face, teeth, the area of molar extrac-
tions, and the ear; decreased hearing; clicking and pain
in the left TMJ. 4 She was unable to eat solid food
because she could neither open her mouth wide nor
chew without pain.
Electromyography was done on the anterior tem-
poralis, masseter, and diagastric muscles. 5 Results
showed moderate above-normal resting levels and poor
clenching ability. Pretreatment data (Table 2) show
weak functioning levels in both temporalis muscles
and no output (below the instrument's 16 1J.V thresh-
old) from the masseters. An electronic three-dimen-
sional study of jaw movement was performed on a
Mandibular Kinesiograph (MKG).I1 6 The patient's
velocity before treatment was 25 mrn/second on open-
ing and closing (normally > 250 mrn/second) and she
*Tylenol No. 3-McNeil Laboratories, Fort Washington, Penn-
sylvania.
+Motrin-The Upjohn Co., Kalamazoo, Michigan.
*Dolobid-Merck Sharp & Dohme, West Point, Pennsylvania.
§Talacen-Winthrop-Breon Laboratories, New York, New York.
II Mandibular Kinesiograph-Myo-Tronics, Inc., Seattle, Washing-
ton.
JOURNAL OF CRANIOMANDIBULAR PRACTICE 347
 COOPER MPD: CASE REPORT

Table 2 maintain temporarily the improved muscle function

Electromyography-Clenching* achieved by TENS and to allow her to function in a
Before treatment 5 Months' treatment rested neuromuscular occlusion. 7-' 0 Maximum open-
natural teeth with orthotic ing at that time was ll mm. In the weeks that followed,
Right Left Right Left the pediatrician treated the patient's drug dependency
TA MM MM TA TA MM MM TA while I repeated the TENS therapy and used the or-
4 I 0 2 0 0 0 0 thotic to reduce muscle spasm and pain. A CT scan
17 2 0 II 32 5 30 69 of the TMJ revealed no evidence of destructive process
13 3 I II 110 39 86 79
94
in the TM joints, demonstrated well-aerated paranasal
8 I 0 7 92 59 68
7 I 0 5 112 73 106 88 sinuses, and showed intact middle-ear structures.
7 I 0 4 87 85 94 106 During the next five months, I monitored her muscle
7 I 0 5 113 77 117 104 function and the accuracy of the neuromuscular or-
9 I 0 8 98 77 110 114 thotic electronically. A series of orthotics was made
9 3 2 13 109 93 106 112
during this period as increasing muscle relaxation per-
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II 2 2 10 102 85 Ill 102

AVG AVG
9 0 8 95 65
*Measurements in microvolts; TA = temporalis anterior; MM =
middle masseter.
Each data point is the average of 256 samples taken over 0.2
seconds with surface electrodes. Ten recordings are then averaged.
At least five repeated sets of recordings are made in order to confirm
that the data is representative of the muscle status.
EMG recording of muscle activity demonstrates weakness of
muscle function clenching in the natural dentition before treatment,
which dramatically improved with the creation of a neuromuscular
occlusion established via an orthotic appliance, tested at five months
under therapy.
opened 8 mm maximum (Figure 1). On the same day,
I used transcutaneous electrical neural stimulation for
10 hours to relax her facial muscles. Afterwards, I
inserted an orthotic appliance over her lower teeth to
mitted greater accuracy in the occlusal· position being
94 93 established. My therapeutic goal was to fully relax the
musculature and reposition the mandible with an an-
atomically accurate orthotic in the neuromuscular oc-
clusal position to maintain optimum muscle function
without accommodative function. TENS was used ex-
tensively throughout this period.
Major improvement was achieved by the end of the
second month, demonstrated by pain reduction and a
maximum interincisal opening of 24 mm. During the
next two months while she was at summer camp, the
patient felt that she did not improve. She and her
family feared that progress was at a standstill and
would proceed no further. I prescribed a home TENS
instrument for the patient to use four to five hours each
day for two weeks. After she functioned in a neuro-
muscular occlusal position through the orthotic and

TREATM~NT LIKG MONT~S T.EAtMEN T M~G

1 1 JmqOIIVSCVLAit
BEtORE 5 OCCLVSIOII
--....
""
•
\
l

' I
J

' "~'
j

v
/ '
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~elec1t1 Tnce
.• _,... Yelecllll Tnce

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s-
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··-,'-.N ;~
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Figure 1
Mandibular Kinesiograph (MKG) recordings of both velocity of mandibular movement and simultaneous frontal tracing of movement from
closure to wide opening and back to closure. LEFf recording (pretreatment) shows both dyskinetic (irregular) and bradykinetic (slow)
movement (25 rom/second), characteristic of unhealthy restricted muscle function, with a maximum vertical opening of 8 mm measured
interincisally. The tracings on the RIGHT (after five months of treatment) show the smooth. rapid velocity in opening and closing(> 250
rom/second) seen in the healthy muscular state. The frontal tracing shows a maximum interincisal opening of 40 mm.

348 THE JOURNAL OF CRANIOMANDIBULAR PRACTICE OCTOBER 1988, VOL. 6, NO. 4

 COOPER MPD: CASE REPORT

extensive TENS-induced muscle relaxation, she fi-
nally experienced release from the muscle spasm, which
permitted me to fabricate the final orthotic. When I
examined her at the end of that two weeks, I measured
her maximum interincisal opening at 40 mm. Man-
dibular Kinesiograph testing (Figure 1) recorded max-
imum velocities of mandibular movement in opening
and closing of >300 mm/second and documented a
healthy maximum opening, as observed clinically. Her
occlusal position, established by the orthotic appli-
ance, was on neuromuscular trajectory, with 1 mm
vertical freeway space from rest to occlusion, verified
by MKG analysis (Figures 2 and 3). 11 EMG recorded
healthy resting levels for the muscles tested and ex-
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romuscular occlusal position would be maintained by
the remainder of the orthotic. When her exposed teeth
had erupted into the neuromuscular position, we se-
quentially uncovered the next ones, bilaterally. This
procedure can take two or more years, depending on
eruption speed. Orthotic appliances are replaced as
they lose essential occlusal accuracy following attri-
tion. Eventually, all the teeth occluded neuromuscu-
larly, eliminating the potential for MPD to recur. The
Pre- Treatment After My< rMonitor TENS
'KG WEEP 61 OUR ~TE_~ S

cellent compressive force on voluntary clenching with

the orthotic appliance in place (Table 2). The patient
appeared to be in excellent health. She reported that
painful symptoms were gone except for slight discom-
8
fort still felt around the left angle of the mandible,
which subsequently disappeared. - ~
- ~' 'n IV ~
In order to establish a healthy long-term occlusion,
we performed a passive eruption procedure, uncov-
ering the most posterior tooth on each side of the mouth
-- -' ~
I
_..
--
by cutting away the orthotic's acrylic so that the neu- t VER ~P=1 L T-1
SLIGHT LESSENING OF SPASM
RESTING FREEWAY SPACE DEVELOPING
Pre-treatment Bef01e Myo-Monitor TENS
Figure 28
~KG wee
After six hours of TENS therapy, muscle spasm is beginning to
reduce as vertical freeway space develops in the "rest" position.
The mandible is still unsteady. An orthotic was made at that time
to provide a provisional occlusal position and assist in relaxing the
masticatory musculature.

A vertical
.J,... iI
:nterior/posterior
._
' ' ~ ~- ~[V \ v
RETEST WITH ORTHOTIC After M a-Monitor TENS

9DA fis

fater!l atl
- !- \ 'I
MKG

.-:h ~/'\ hr
,..._
V RIAP 1 mm/div
Complete Spasm- No Freeway Space
LAT 1 mm/div

c
''
Figure 2
~~ _) ~ J\,. ~ V~ t-
~
Mandibular Kinesiograph recordings of movement of the mandible
from rest to occlusion in the sweep mode. The LEFf portion of
.A a j 1 1' \rf'
each recording is the mandible at rest; the RIGHT portion represents
\. ~ '-J ~

the position of the mandible at closure (occlusion) with repeated

tapping of the teeth together. The mandibular movement is dis-
- VER AP=1 L T•1
played as three separate tracings, representing the three-dimen- SPASM BREAKING UP
sional vectors of movement. The upper tracing is the vertical vector REST UNSTABLE
of movement (closure is upward). The center tracing is anterior/
posterior vector of movement (anterior = upward, posterior = Figure 2C
downward deflection). The lower tracing is lateral movement (left After 19 days of wearing the orthotic 24 hours a day, testing
= downward, right = upward). In all three tracings, each box demonstrates that mandibular rest position has changed. Occlusion
represents I mm vertically and I second horizontally. A. Before of orthotic is now excessively far from rest position (3.0 mm
treatment, mandible is unsteady and positioned almost in occlusion vertical; normal is 0.75 to 2.0 mm). A/P discrepancy is seen in
with no freeway space between opposing teeth. sagittal view in Figure 3.

OCTOBER 1988, VOL. 6, NO. 4 THE JOURNAL OF CRANIOMANDIBULAR PRACTICE 349

 COOPER MPD: CASE REPORT

RETEST W/ FINAL ORTHOTIC (5MO) After Myo-Monitor TENS RETEST W/ FINAL ORTHOTIC After Myo-Monitor TENS
5M :>Nns
MKG

SAGI'l"l'AL j
Ant ••. Potit.
D I
\... J
' I
_j
- lA. 1
lA.. -1 -- - ",,
~
,..,.
'
FRONTAL,_
Right I Laft

VEF ~-1 LAT1 VER ~1 LAT1

Downloaded by [Australian Catholic University] at 16:07 14 August 2017

VERTICAL·1.0MM AIP.0.6ANT LAT•O.O NEUROMUSCULAR TRAJECTORY TO M.C.O.•

HEALTHY FREEWAY. STABLE OCCLUSION

Figure 20 Figure 38
Final orthotic made after five months of therapy shows healthy Sagittal/frontal views of recordings of the trajectory of movement
freeway space. Sagittal view (Figure 3) demonstrates accuracy of from TENS-induced rest position into the occlusal position estab-
AlP trajectory. lished by final treatment orthotic. TENS-stimulated involuntary
movement is identical to voluntary movement trajectory. This syn-
chronization of the therapeutic occlusion with the TENS initiated
movement trajectory proves that the orthotic's occlusion is accu-
RETEST W/ ORTHOTIC After Myo-Monitor TENS rate. This corresponds to the recording in Figure 20.
I SAGI'l"l'AL 1~DA S
Ant./ Poat,
patient has been symptom-free for three years follow-

1\t~' ing therapy.

A
~~
~ I
PIIONTAL
R/L
VEF ~-1D/div LAT 1 D/div
MANDIBLE REPOSITIONED ANTERIORLY
NEW ORTHOTIC REQUIRED
Figure 3
Mandibular Kinesiograph recordings of mandibular movement tra-
jectory from rest position after TENS to occlusion. These tracings
compare the position of the voluntary closure trajectory into the
occlusion provided by the orthotic with the neuromuscular trajec-
tory from rest toward an ideal muscularly balanced occlusal position
(referred to as myocentric occlusion). The neuromuscular trajectory
reflects involuntary mandibular movement by TENS stimulation
of masticatory muscles. Simultaneous sagittal (LEFT) and frontal
(RIGHT) views are shown. EMG recordings of muscle activity are
made simultaneously with MKG recording. The EMG data are
utilized to establish optimal rest position of the mandible as the
position that is associated with minimal electrical activity in ele-
vator muscles (temporalis and masseter) and depressor muscles
(diagastrics). A. After 19 days of therapy, recording shows that
neuromuscular trajectory (upward facing arrow), produced by the
TENS stimulated muscular contraction, is anterior to voluntary
trajectory into orthotic's occlusal position. Vertical freeway space
is excessive as well, as was seen in sweep tracing (Figure 2C).
Repeated taping shows a variety of occlusal positions (downward
facing arrows). This shows the absence of a stable, holding oc-
clusion. A new orthotic was fabricated.
Discussion
This case underlines the importance of the physi-
cian's making an early diagnosis of myofascial pain
dysfunction and referring patients to dentists trained
in diagnosing and treating craniomandibular disor-
ders.12-14 The physical trauma of a bicycle accident
precipitated MPD in a patient predisposed to muscle
spasm because of her occlusion. 3 Initially, nobody
recognized the illness as MPD, and the patient suffered
through medical and dental procedures, pharmacolog-
ical addictions, and the emotional sequelae of chronic
pain. Once the appropriate referral was made, the cause
of the muscle spasm was eliminated and the patient's
symptoms disappeared.
Reprint requests to:
Barry C. Cooper. D.D.S.
310 East 14th Street
New York. New York 10003
References
I. Schwartz, L.L. A temporomandibular joint pain dysfunction syndrome.
J Chronic Dis 1956: 3: 284.
2. Dolowitz, D .. et. al.: The role of muscular incoordination in the patho-
genesis of the temporomandibular joint syndrome. Laryngoscope
1964: 74: 790-80 I.

350 THE JOURNAL OF CRANIOMANDIBULAR PRACTICE OCTOBER 1988, VOL. 6, NO. 4

 COOPER
3. Cooper, B.C., and Rabuzzi, D. Myofacial pain dysfunction: A clinical
study of asymptomatic subjects. Laryngoscope 1985; 94(1 ): 68-
75.
4. Cooper. B.C .• and Mattucci, K.F.: Myofacial pain dysfunction: A
clinical examination procedure. /nt Surg 1985; 70(2): 165-169.
5. Jankelson, R .• and Pulley, M.L. Electromyography in Clinical Den-
tistry. Myotronics Research, Inc .• Seattle, Washington, 1984.
6. Jankelson, B.: Measurement accuracy of the mandibular kinesiograph:
A computerized study. J Prosthet Dent 1980; 44(6): 656.
7. Jankelson, B. et al. Neural conduction of the myo-monitor, stimulus:
A quantitative analysis. J Prosthet Dent 1975; 34: 245-253.
8. Jankelson, B .• and Radke, J.: The myo-monitor: Its use and abuse./nt
Dent Dig 1978; 9: 47-52 and 9: 35-39.
9. Jankelson, B .• and Swain, C.: Physiological aspects of masticatory
muscle stimulation: Myo-monitor. Int Dent Dig 1972; 3: 57-62.
10. Wessberg, G. et al.: Transcutaneous electrical stimulation as an adjunct
in the management of myofascial pain dysfunction syndrome. J
Prosethet Dent 1981; 45(3): 307-314.
II. Cooper. B., Alleva. M., Cooper, D .• and Lucente. F.: Myofacial pain
dysfunction: Analysis of 476 patients. Laryngoscope 1986; 96:
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1099-1106.
OCTOBER 1988, VOL. 6, NO. 4 THE
MPD: CASE REPORT
12. Cooper, B.C. Craniomandibular diseases. In Essentials of Otolaryn-
gology. 2nd Ed. F. Lucente, and S. Sobel. eds. New York: Raven
Press, 1988.
13. American Equilibration Society, Report of the Committee on Principles.
Concepts and Practices of the Management of Craniomandibular
Diseases: Compendium 1987; 20: 177-237.
14. Cooper. B.C. Myofacial pain dysfunction: Cause, clinical appearance.
current therapy. Primary ENT Fall 1987; 3(3).
EDITOR'S NOTE: In his writings, Dr. Cooper uses the
term "myofacial pain-dysfunction" as opposed to "my-
ofascial Pain-dysfunction," which appears more often in
the literature. He uses myofacial to mean muscles of the
face and to describe a condition caused by a malrela-
tionship between the neuromuscular, the dental occlu-
sion, and the temporomandibular joint.
JOURNAL OF CRANIOMANDIBULAR PRACTICE 351