ANATOMY

Electromyographie Analysis ofthe Masseter and Buccinator Muscles with the Pro-Fono Facial Exerciser Use in Bruxers
Renata S.R. Jardini, M.Sc: Lydia S.R. Ruiz, M.Sc. Ph.D.: Maria A.A. Moyses, M.Sc. Ph.D.

0886-9634/2401029$05.00/0,THE JOURNAL OF CRANIOMANDIBULAR PRACTICE, Copyright 2006 by CHROMA, Inc,

Manuscript received July 29. 2003: revised manuscript received June 28, 2004: accepted August 19, 2004 Address for reprint requests: Dr. Renata S.R. Jardini Av, Joaquim deSouza Pinheiro 58 Araraquara 14802-020 Brazil, SA E-mail: rsiardini@aol.cQm

ABSTRACT: The aim of this study was to evaluate the efficiency of the Pro-Fono Faciai Exerciser (ProFono Productos Especializados para Fonoaudiologia Ltda.,, Barueri/SP, Brazil) to decrease bruxism, as weil as tine correlation between the masseter and the buccinator muscies using eiectromyography (EMG). in this study, 39 individuals ranging from 23 to 48 years of age were seiected from a dental school and then underwent surface EMG at three different periods of time: 0. 10, and 70 days. They were divided into a normal control group, a bruxer control group (withoul device), and an experimental bruxer group who used the device. The bruxer group showed a greater masseter EMG amplitude when compared to the normal group, while the experimental group had deceased activity with a reduction in symptoms. The buccinator EMG spectral analysis of the expenmentai bruxist group showed asynchronous contractions of the masseter muscie (during jaw opening) after using the Pro-Fono Facial Exerciser. The normal group aiso showed asynchronous contractions. Upon correlation of the data between these muscles, the inference is that there is a reduction in bruxism when activating the buccinator muscle.

I
Dr. Renuta S.R, Jardini is a phonoaudiologisi with a M.Sc. degree and is a graduate sliident in the Department of Child and Teenager Health. University of Medical Sciences. 11 NICAM P. Campinas. Sao Paulo, Brazil.

n a multidisciplinary approach, essential for retraining the stomaiognathic system, the need for the concerted efforts of physiotherapists, dentists, and speech therapists is evident. The sy.stem consists of two different groups of oral structures, static or passive structures and dynamic or active structures, which are balanced and controlled by the central nervous system and are responsible for proper functioning of the facial muscles. The buccinator is a deep muscle with large dimensions which forms the lateral wulls of the mouth and constitutes the essential muscles of the cheeks. It participates in complex movements of the face, in the creation of facial expressions, varying its muscular activity intra- and interindividually, active when sucking and blowing, mainly when cheeks are expanded. This muscle also collaborates in the lateralization of the corners of the mouth in smiling, together with the zygomatic. the risorius, and the Icvator muscles.'-' Sicher and DubruH reported that the huecinator muscle relaxes during the jaw-opening phase and contracts during jaw-closing. It functions as an auxiliary to the

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iiiuscle.s of mastication, keeping the necessary tension in the cheeks and preventing them from folding and being bitten by the teeth. Liorca'^ and Hanson and Barrett'' quote its function as a muscle that harmonizes the facial muscles, and Lundquist.' De Sousa and Vitti.** and Blanton, et al.'' all reported through EMG evaluation that the buccinator musculature is auxiliary to, though not responsible for mastication. It participates in the jaw-opening phase and Is nol synchronized with masseter muscle activity. Among oral parafunctions, bruxism is of major interest and can be defined as "nonfunctional tooth eontact,"'"" characterized by teeth clenching or grinding., which can occur during the day or at night. Although many theories have been presented since the l%Os, bruxism etiology and pathophysiology is still unknown. It has been called occlusal in origin.'-but this theory is rejected by Rugh, et al.'^ and Okeson.'^ since not all patients respond favorably to occlusal adjustment. Bruxism has also been related to biopsychosocial factors.'^ "' sleep disordered breathing.'^ or temporomandibular disorders (TMD),"*'''' yet with no cause/effect definition.'*' With regard to the epidemiology, there is controversy due to the differences in methodologies employed, which leads to bruxism frequency ranging from 15-90^^: ofthe adult population."'^-' There are similarities in symptomatology findings, i.e., nonfunctional standards of teeth wearing, teeth fractures and restorations." -' increased tonus and masseter hypertrophy, articular locking or limitation, articular clicking, popping or clicking sounds, fatigue of the masticatory muscles upon waking or during sleep, headache, periodontal and endodontal implications."-"-' The Pro-Fono Facial Exerciser was created and developed by this author to concentrate and increase the efficiency of the exercises proposed for retraining facial muscles, supported by former EMG studies on facial flaccidity.-^ Signs of buccinator muscle interference in masseter muscle activity have been detected in other studies. These studies motivated the present research, since there are no referential data in the specialized literature. The objectives of this study were to evaluate the efficiency of the Pro-Fono Facial Exerciser as a device to reduce bruxism and to assess a possible correlation between the buccinator and the masseter mu.scles using EMG evaluation. Materials and Methods In this study, 39 individuals ranging in age from 23 to 48 years were selected from a dental school in Sao Paulo, Brazil. Most subjects were students or former students of the school. They agreed to an evaluation protocol admin-

istered by the same researcher. The diagnosis of bruxism used to select symptomatic individuals was based upon clinical studies by Kopp,--* Seligman and Pullinger,-'^ Lobbezoo and Lavigne,-" Attanasio." and Okeson,-'' to verify the presence of tooth wearing facets on the anterior occlusal surfaces ofthe incisal and posterior teeth, along with wear in the canine region. Also taken into consideration was a questionnaire completed by subjects as part of their clinical examination. The questionnaire showed whether there was muscular or articular tenderness, fatigue or stiffness of the masticatory muscles on awakening or at the end ofthe day. difficulties in mandibular opening, and even masseter hypertrophy, as described in studies by Rugh and Harlan.'^ Dahlstrom, et al..-^ and Gonzalez and Muller.''^ In the present study, the individuals were not differentiated according to etiology or degree of severity of their symptoms. This aspect will be analyzed in future research studies. The exclusion criteria for all volunteers were: a. three or more missing teeth; b. Class II or Class III occlusion according to Angle,-'' (in order to avoid any possible interference in neuromuscular patterns due to malocclusion); c. systemic disease which could affect the neuromuscular system; d. use of medications that could retard muscle movement or cause muscular force loss; and e. former (up to six months before) or current phonoaudiological treatment of the oral musculature, facial physiotherapy, or electrostimulation. In order to avoid any interference in the resulting analysis, volunteers were asked to suspend the use of oral splints while participating in the study. The individuals were divided into three groups consisting of 13 individuals in each, as follows: (GI) control group consisting of normal individuals: (G2) bruxer control group; and (G3) experimental bruxer group using the Pro-Fono Facial Exerciser after the first EMG assessment. All individuals were given specific details ofthe study and the EMG evaluation, and signed an Informed Consent approved by the Ethics Committee. They were also infonnedof the details of the EMG evaluation. Before the EMG evaluations, the volunteers were instructed and trained on the tests to be performed as follows: a. continuous blows for 5-seconds at three different times (isometric contraction of the buccinator), with one-minute intervals belween contractions while keeping cheeks taut, resulting in three experimental values: b. three 5second isotonic masticatory cycles u.sing Parafilm (American National Can, Chicago, IL) interposed, bilaterally between the posterior teeth, with a 2-minute resting interval. The results ofthe three cycles were averaged. EMG Evaluation

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The EMG registrations were completed at the Electromyography Laboratory of CEDEFACE - Oral and Facial Deformities Research and Treatment Center in Araraquara. Brazil, using a Sign Conditioner Module Lynx MCS V2, 16 channels. Sign Acquisition System (SAS) (Lynx Tecnologia Elcctronica Ltda., Sao Paulo. Brazil), w ith 12-bite dynamic band resolution, Butterworth (Lynx Tecnologia Electronica Ltda., Sao Paulo, Brazil) high pass filter of 10.6 Hz and low pass filter of 509 Hz. with a 2000 gain range and converse plate of analogical sign into digital sign (A/D). For the simultaneous presentation of the signs collected from the four channels by four surface differential silver electrodes. AQDADOS software (Lynx Tecnologia Electronica Ltda., Sao Paulo, Brazil) was used allowing sign treatment in an RMS rate, mean, minimum, maximum, and standard deviation, with a sampling frequency of 1000 Hz. based on the orientation protocol for EMG signs recording in the ./oumal of Electromyography and Kines'iology.'" A preliminary study with ten volunteers chosen for this phase of the trial was performed before data collection began and was used to standardize the routine. This preliminary study assisted with choosing materials and techniques in order to obtain EMG signs from the buccinator and masseter muscles. The surface electrode placement on the buccinator muscle was based upon previous studies.'' referring to the intersection ofthe horizontal plane ofthe labial commissure with the vertical plane ofthe visual external angle, in each hemi-face, making a right angle (90), standing the subject at a 45 angle to the examiner. For the masseter muscle, the electrode was placed on its muscular maximal bulk.- A referential electrode was attached to the right wrist of each subject. All subjects were subjected to three EMG evaluations at 0. 10, and 70 days (respectively. TO, Tl. and T2). The experimental bruxer group started using a Pro-Fono Facial Exerciser at the first evaluation. For each time period mentioned (TO, Tl, T2), three experimental data sets were collected from each of the 13 subjects (nine per individual). Treatment Pro-Fono Facial Exerciser Description The Pro-Fono Facial Exerciser consists of two flat acrylic bases of about 2x4 cm each, which fit intraorally in the vestibular region of the cheeks and are supported by the right and left labial angles. The two acrylic bases are joined by two I-mm stainless steel wire shanks, which are 12 cm long with a spring in the middle of each wire (Figure 1).

To use the Pro-Fono device, the acrylic bases are placed intraorally. The undercuts fit on ihe right and left moulh angles, allowing ihe device wires to be outside the mouth with no tooth contact. When inserted in the mouth, [he device stretches the mouth horizontally using a spring-force effect. The user compres.ses the checks to try to close the device w ith close to eight teeth, but not touching them, thus contracting the involved muscles. The lips remain open with the teeth exposed and in natural contact without clenching (^Figure 2). Recommended exercises were: a. to close the device slowly using compression force of the cheeks, and to slowly release it relaxing the muscles and repeating this movement 20 times. This is an isotonic exercise, where there is length variation in muscular fibers, based upon the principle of movement resistance, which favors the practice-''; and b. to close the device keeping the compression force ofthe cheeks for 15-20 seconds. This is an

Figure I The Pro-Honn Facial h^xcrciser (Pro-Fono Prniiutos Especializados para Fonoaudiokigia Ltda.. Barueri/SP. Brazil)

Figure 2 Photo showing correct use ofthe Pro-Fono Facial Exerciser.

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isometric exercise, where there is no length variation In muscular fibers, allowing for better control of movement and keeping mobility steady, as well as generating higher tension on muscular fibers.-*These exercises, as well as Ihe recommendations for their use, are explained in the device instruction booklet. Initially, the exercises were performed at the clinic by the experimental group and later practiced at home. The frequency indicated was from 1 to 3 exercise series, which they couid divide up during the day. The goal was to reach a maximum time of 15 minutes daily, according to the subject's tolerance to allow for minimal pain or discomfort. Statistical Analysis During the data processing, the non-normalization of the EMG sign was accepted in order to avoid the loss of the amplitude differences reached during treatment. Therefore, it was possible to analyze the Pro-Fono Facial Exerciser as a therapeutic device.-''^ The control groups were analyzed using Wilcoxon's test for two related samples. The correlation between the buccinator and masseter muscles was analyzed utilizing Pearson r coefficients and a chi-square test. The spectral EMG analysis was done using a chi-square test and for symptom evaluation, the sampling standard deviation was studied. For all the tests in this study, an alpha significance level of 5% (a=0.05) was chosen. Results Control Groups (Wilcoxon) For control groups GI (normal) and G2 (bruxers), there was no significant difference among the collections for each subject, i.e., TO=T1=T2. for both tbe buccinator and masseter muscles, indicating that each group can be expressed by its means. In all the analyses. p>().05 was obtained using the Wilcoxon test. Therefore, BGl is considered the mean of normal group buccinators, and BG2 the mean of the bruxer control group, while MGI and MG2. respectively, are the means for the masseter muscles. Mean values are. respectively: BGI-14.930.46: MGI=43.271.I2: BG2=13.210.40; MG2=64.681.99. Correlation Between Buccinator and Masseter Muscle.'; (Pearson ri Table 1 shows that the correlation analysis resulted in r,,,^,j=-0.927. based on data collected during the three exercise sets performed by each of the 13 subjects. The data showed a definite relationship between the electrical activities of the masseter and buccinator muscles, i.e.. the

buccinaior increase is related to the masseter decrease (Graph 1). This does not mean, however, that there is a cause/effect relationship. Electromyo}>rapluc Spectral Analysis (chi-square) The following criteria were adopted (Figure 3): mark 0, absence of asynchronous contraction: mark 1. weak tendency of asynchronous contraction of the buccinator muscle: mark 2, strong tendency of asynchronous contraction of the buccinator muscle: mark 3. defined asynchronous contraction ofthe buccinator muscle. For GI as well as for G2, the chi-square test confirmed that the frequencies of marks 0. 1.2. and 3 all have different values {Tables 2 and 3). It can be observed in GI (normal) that mark 3 is the most frequent, indicating that normal subjects feature asynchronous contraction. Mark 0 is the most frequent in G2 (control bruxers). indicating that bruxers do not feature asynchronous contraction. The correlation between mark 3 and mark 0 is 0.931 in G3 (experimental bruxers) (Table 4). Mark 0 decreases from TO to T2 while mark 3 increases from TO to T2 (Graph 2). G3 showed asynchronous contractions after exercise. Analysis of the relationship among groups GI, G2, and G3 makes it possible to conclude that bruxers from the control group were equal to experimental bruxers before treatment: G3T0=G2(O.O5<p<O.I). At the end of the treatment (T2). the experimental group equaled the normal group: G3T2=Gl(0.1<p<0.2). Symptom Analysis All ofthe 13 subjects in G3 were self-evaluated, using a scale of 0 to 5. regarding their individual perception of the degree of improvement of their bruxism .symptoms after six months of use of the Pro-Fono Facial Exerciser, where 0 = no improvement and 5 = no symptoms. Results showed that nine out of the 13 subjects recorded marks between four and five for their degree of symptom improvement. Discussion Bruxism has been treated by multiple disciplines leading to a holistic approach that focuses on the individual with the oral parafunction rather than on the pathophysiology. The patient must be rehabilitated using a range of treatments, which can involve dentistry, phonoaudiology, physiotherapy, psychology, and neurology, etc., but which will also promote consistent, faster, less expensive, and less invasive techniques. Since new approaches are presented as a solution for bruxism, former techniques such as occlusal adjustments

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Table 1 Correlation of Buccinator and Masseter Data, Pearson r Coefficient n=13

Subject/time

mo
1/T1 1/T2
2/TO 2fT^ 2/T2 3/TO 3rT2 AfTO 4/T1

Buccinator aven 14.262.46 11.332.05 24.092.30 11.492.64 13.163.01 14.741.80 6.903.47 16.487.08 15.003.37 9.161.46 20.085.55 41.1114.30 5.651.11 19.897.29 24.806.39 6.400.65 9.515.62 11.043.12 6.601.55 8.391.92 14.352.69 8.31 1.99 14.244.87 21.788.21 8.792.82 11.562.57 19.355.73 6.710.72 9.411.15 19.635.99 9.211.93 11.34+3,74 10.054.42 13.664.70 14.947.48 15.796.83 13.472.51 13.41 5.56 18.593.88

Masseter average 175.8222.97 167.258.05 129.3813.62 111.869.16 54.007.13 44.704.41 36.109.60 31.725.46 25.524.19 82.447.24 70.055.43 58.485.13 81.3137.30 65.8419.70 55.8725.21 130.6221.08 113.6117.76 97.34 14.08 45.3318.38 40.8710.76 29.514.38 46.444.21 32.063.65 30.394.41 56.824.87 51.935.36 49.044.23 102.53.25.73 93,226.51 67.6013.27 69.5024.58 37,7310.83 41.01+4.76 89.6916.81 97.908.76 66.179.21 44.664.07 38.964.76 35.01 11.84

-0.923

-0.928

-0.918

-0.980

Am
5/TO 5/T1 5yT2 6/TO

-0.989

6T1
6/T2 7/TO

-0.960

7/T1 7n"2 8/TO 8/T1 8n"2

9/TO

-0.999

-0.879

9n"i 9/T2

-0.915

ion-o
10/T2

ion"i

-0.915

iirro
iin"2
12/TO \2fT^ A2fT2

-0.850

-0.998

13/TO

13m
13/T2

-0.803

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140
'Olts

120 100

o
u

80 60 40 20 0

I buccinator masseter

<n a:

(Jraph 1 Mean otanipliliiiles of buccinator and masseler muscles in G3.

are thought to be rejected, as reported by Rugh. et ul.'~ and Okeson.'^ Currently, these techniques are used as preventive therapy and not tor rehabililation. In addition, the association of bruxism wilh temporomandibular dis-

3 EMG spectral analysis (top. buccinator muscle: bottom, massctcr nnisL-le).

jLU)
34

TO

T1

T2

orders (TMD) has not been scientifically proven'"'-" and requires further research for clarification. Among several therapies used for rehabilitation of bruxism, occlusal oral splint use is undoubtedly the most

Mark 0= absence of asynchronous contraction

Mark 1= weak tendence of asynchronous contrac.

Mark 2=strong tendence of asynchronous contrac.

Mark 3= defined asynchronous contraction

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Table 2 Correlation Between G1 and Marks, Chi-Square Test for One Sample

n=13
Time TO Tl MarkO 16 01 Mark 1 06 11 Mark 2 15 15 Mark 3 41 51

P
<0.001 <0.001

Table 3 Correlation Between G2 and Marks, Chi-Square Test for One Sample
Time TO T1 MarkO 54 48 Mark 1 10 ?0 Mark 2 06 06 Mark 3 08 04 P <0,001 <0.001

Table 4 Correlation Between G3 and Marks, Chi-Square Test for One Sampie
Time TO Tl T2 Mark 0 60 25 07 Mark 1 13 23 08 Mark 2 05 13 12 Mark 3 0 <0.001 17 <0.001 51 <0.001

often recommended by dentists, although it is widely considered that it does not eliminate the cause for the pathology,-''''' but it might temporarily minimize the symptoms'''-''^ and promote some degree of relief for patients and professionals lacking more adequate solutions. Some opposition is found in the literature to the indiscriminate use of oral splints. Splint use is recommended only in serious cases and is always associated with an accurate diagnosis of bruxism.-'-^** and also with a correct and adequate adaptation."* Muscular balance and relaxation-"' together with a completnent of physiothera-

peutic techniques have also been recommended for bruxism treatment in addition to biofeedback use in diurnal bruxism cases.-''" According to Jardini,-' the buccinator muscle is more often used as the object of study and rehabilitation by facial esthetists.-*- facial physiotherapists.-*"-'^ dermatologists, and also esthetic phonoaudiologists, who focus strongly on aspects linked to tissue sagging and skin tonus. Muscular rehabilitation itself is restricted to facial palsies and paresis.*-'-'^ Due to the complexity of buccinator muscle functions, the authors are limited to a description of it only as a participant in facial movement with no consensus as to its specific participation during mastication and to whether it is more evidenced in the jaw closing or the jaw opening phase.^ * The buccinator muscle also causes voluntary jaw lowering by interposition of the cheeks between the teeth when there is pain in serious bruxers.'" With of use of the Pro-Fono Facial Exerciser for facial sagging rehabilitation to strengthen the buccinator muscle,--' the studies of this muscle could be related to masticatory activity and could also clarify its real functions. It is important to state that no causal relationship could be found between facial sagging and bruxism in the groups studied. Further research is needed focusing specifically on this subject. With the results of this study, it is possible to conclude that the masseter mu.scle's amplitude decreased significantly with the amplitude increase of the buccinator muscle after using the Pro-Fono Facial Exerciser. The exerciser tended to equalize to Gl normal individuals after 70 days of use. It is important to remark that the correlation test does not prove a cause/effect relationship between these two muscles. Further research should be carried out using mullifactorial analysis of variance and neuroelectromyography. Bruxism relief was confirmed by subjective symptom evaluation, from the users of Pro-Fono Facial Exerciser. Symptomatology differentiation in relation to improvement was not researched, but there was indiscriminate reduction in the sytnptoms of pain, tiiaxillary fatigue sensation, restriction of mandibular opening, locking, tenderness to palpation, and headaches. We are developing longitudinal studies aitTied to follow up the subjects in this study. In the spectral analysis of normal individuals, the buccinator muscle has a double function. The main and most evident function is the mandible elevatory movement, synchronized with the masseter muscle, described in the majority of anatomy-physiology texts. The secondary function is the jaw lowering, asynchronous with the masseter muscle, described by LundquJst.' De Souza and

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o
Graph 2 Asynchronous coiUraclion of Ihe buccinator muscle in G3.

T1 nT2
Mark 0 Mark 1 Mark 2
15. 16. 17.

Mark 3
Rugh JD. Harljn J: NiKlurnul biuxism and lemporoniandibular disorders. :4(/i7V('Mro/ 1988:9:329-341. Pin^iilorc G. Chrobak V. Petrie J: The social ani) psychological factors of bruxism. I Prosih Denr 1991: 65:3. Okeson JP. Phiiiips BA. Berr>' DTR. Cook YR. Cabelka JF: Nocturnal bruxing events in subjecis wiih sleep-disordered breaihing und amlrol subject. 7 Cni,iicmimJih Di-:ordFut Onil Pain 1991: 5;:5K-264. Ciark GT. Beemsterboer PL, Rugh JD: Nivtumal masseier muscle activity and lhe sympLoms of ma,'iticator>'dysfunction,,/ Orui Reliah 1981: 8:2792H6. Magnusson T, Carlsson GE. Egentiark I: Changes in subjective symptoms of craniomandibular disorders in children and adole.scents during a len years pcritKl,,/ Omjac Pain 1981: 7(1 ):76-82. Lobbezoo F. Lavigne GD: Do bruxism and temporomandibular disorders have a cause-and-efTccl relationship../ Orofac Pain 1997: I; 15-23. Tbompstin BA, Blount BW, Krumhol/TS: Treatment approuche.s to bruvism. Am Fani Phy. 1994: 49(7):16i7-l622. Molina OF, Sanlos J, Nelson SJ, Nowlin T: A chnical study of specific sigas and symptoms of CMD in bruxers classified by the degree of severity. .1 Craniomaiidib PriHi 1999: l7(4):268-279. Jardini RSR: Avaliai;ao eletromiografica do musculo bucinador flacido usandoo Exercilador ac\i\. Pr<\-f<mii K Anial C\ 2IKI2; l4l3l:33l-342, KoppS: Pain und functionaldislurbancesofthe masticatory system-areview of etiology and principles of treatment. .SiiWDcHfy 1982; 6:49-60. Seligman DA, Pullinger AG: The degree to which denial attrition in modem society is a tunciion of age and of canine contact../ Oriifar Fain 1995: 9:266-275. Okeson JP: Bfll's orqlm iui piiins. Chicago: Quintessence. 1995. Dahlstrom L. Carlsson GE, Carlsson SGA: Comparison of effects of biofeedback and occusal splint therapy on mandibular dysfunction. Dcpartnienl of Slomaiii^miihir Physiology University of Gcileborg Report No. _W, 1981. Gonzalez MC. Muller B: Esiudio clinico de la hipertrofia maseterina. Acta Odtmtoi Venez 1998; 36(21:18-24. Angle EH: Malocclusion. In: Tieuimeni of mulocclusion of teeth angle's .iy.sleni. 7lh ed. Philadclphi;i: Wiiite Denial Mlj;. Co,. 1907; 28;59. Pimenla FB. Pita AG. Fontazia RHBIS, Porciuncula HF. Jardini RSR: Localizagao extema do mu.sculo bucinador para analise eleiriimiografiea. .lOdontoi/m 2002.36. Ponntry L: Eleiromiogralla e icsies de velocidade de condugao nervosa. In: O'Sullivan S. Shmil/ JJ. Fisioteiapia: avalim^iio e IrutamentQ. 23rd ed. Sao Paulo: Manole. 1983:183-223. Joumal of Eleciromyography and Kinesiology 2001: 1:11. Siegel S: Estaiisiiia naopurametrnapani us cieniia.', do iumportamenUK Sao Paulo: McGraw-Hill. 1975. Curi, PR: Regras de decisao e suas implica^oes na analiie de dados. In: Metodoloj^ia du pesquisii dentifica. UNESP. Botucatu. 1991: 9:176-202. Okeson JP: Miinaj^ement oftemporoinandihiiiwdisorders andoicliision. 4th ed. St. Louis: Mosby. 1998, Solberg WK, Clark GT, Rugh JD: Nocturnal EMG evaluation of bruxism patients undergoing slion-term splint therapy. J Ora/fleftiiM 1975; 2:215223. Shan SC, Yun WH: Influence of an ix'clusal splint on integrated elecirotnyography of Ihe masseter muscle../ Oral Rchahil 1991; 18:253-256, Clark GT. Beemsterboer PL. Solberg WK. Rugh JD: Nocturnal electromyographic evaluation of myofascial pain dysfunction in paticnis undergoing

Vitti** and Bhinlon. et al.'' As demonstrated in the present study, Ihe bruxcr subjects lost or drastically minimized the intercalated contraction, asynchronous with the masseter muscle. The intercalated contraction is recovered with buccinator muscle activation while using the ProFono Facial Exerciser to minimize symptoms. These are precedents for the multifactorial analysis of bruxism etiology, which were related and associated in the current article with the facial musculature rehabilitation for the group studied. This is especially true with buccinator strengthening, supported with the use ofthe Pro-Fono Facial Exerciser. References
1. Viiii M. Bu'imalian JV. Ouellclle PL. Milchell DL. Easlmari WP. Seaborn RD: Electrnmyograpiiit invesiigalions iif ihL' longue and circumorLiI muscular sling wiih line-wire electrodes../ Pen! Ra 1975; 54:S44-849. Basiiiiijian JV, De Luca CJ; Muscles alive - rlwirJiiiiaiiiiis revfalecl hy fleeiromvogruphw Sth ed. Ballimore: Williams and Wilkins. 19H.';; 20:432462. Morale RC: Terapia de ri'^ula(;do orofackil. Mennon: Sao Paulo. 1999. Siclier H. Dubrul EL: Oral anatonn. Rth ed. Ishiaku: EuroAmerica 1991: 3:113-114. Llorca FO: Amiiominhiimuna. 4lh cd. Barcelony: Cieniifica Medica. 1970: TomohMIK. Hanson M[.. Barren RH: FiiiiJdmeiinil.s of ornfiii-ial m\-riiloi;\. .Springfickl: Chiirlt.s Thomas: I9SH. Lundquist DO: .4n electromyiigraphic analysis of the lunelimi of lhe huccinaior mustlc a.^ an aid to dL-nture retention and siahili/aticm, J Prosthel DciU 1W9: 9(11:45-52. De SousLi OM. Vitii M: F.siuiio elclromiografieo dd riitisL'ulo huL-inadiir. OHospikil I9(i5; 6X131:105-117. BlanlonPL. Biggs NL. Perkins RC: Elecirtimyographic analysis of the buccinalor muselc../ Dent Re.-. 1970; 49:389-.394. Holmgren K. Sheik ho les lam A. Riise C: Elfecl of a lull-arch maxillary ocflusal splint on paraiuiicional uetiviiy during sleL"p in palienl wiih noclurnal bruxism and signs and sympHims of craniomandibular disorders. .1 hoslhDeni 1993; 69:3. Allanasio R: An overview ot bruxism and il.s nianagemeni. Dc/jf (7/(i Norlh An, 1997: 41(21:229-241. Dawsdn PE: Lviiliiimon. dia^misix and ireaimenl of oalusalpmhlems. St. Louis: Mosby. 1974, Rugh JD. Barghi N. Drago CJ: Ex peri mental (Kclusal discrepancies and nt>ctumal bnixism../ Pio.sih Deni I9H4; 51:4. Okeson JP: Fiindaim'imd.s iij oiTlmi/m and temporoiiiaiidihiilar disorders. SI. Louis: Mosbv. 1985.

IK,

19.

20. 21. 22.

23. 24. 25.

2.

26. 27. 2K. 29. 30.

3. 4. ."i. 6. 7.

31, 32, 33, 34. .15. 36.

8. 9. 1(1.

11. 12. 13. 14.

37. 38.

36

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Dr. Lydia S. R. Ruiz holds M.Sc. and Ph.D. decrees and is an assistant professor in the Depanment of Physics. Universidadc Estadiial Paiilisiu. Haiini. SP. Brazil. Dr. Maria A.A. Moyses holds M.St..und Ph.D. dearevs and is an associated prcfesMir in thf Department of Peilicitrics, University of Medical Sciences. IWICAMPlCampinas. SP. Hrazii

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