UNIVERSIDADE ESTADUAL PAULISTA
“JÚLIO DE MESQUITA FILHO”
Instituto de Ciência e Tecnologia
Campus de São José dos Campos
ORIGINAL ARTICLE DOI: https://doi.org/10.4322/bds.2023.e3725
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Braz Dent Sci 2023 Jan/Mar;26 (1): e3725
Relationship between myofascial pain and facial types: an
observational study
Relação entre dor miofascial e tipos faciais: um estudo observacional
Francisco Ferreira da SILVA1 , Mayra Soares Ferreira BARROSO2 , Antônio Sérgio GUIMARÃES1 ,
Lidia Audrey Rocha VALADAS3 , Luciane Lacerda Franco Rocha RODRIGUES1
1 - Faculdade de Odontologia São Leopoldo Mandic, Laboratório de Pesquisa da Interface Neuroimune da Dor. Campinas, SP, Brazil.
2 - Serviço de Otorrinolaringologia, Hospital Edmundo Vasconcelos. São Paulo, SP, Brazil.
3 - Universidad de Buenos Aires. Buenos Aires, Argentina.
How to cite: Silva FF, Barroso MSF, Guimarães AS, Valadas LAR, Rodrigues LLFR. Relationship between myofascial pain and facial types:
an observational study. Braz Dent Sci. 2023;26(1):e3725. https://doi.org/10.4322/bds.2023.e3725
ABSTRACT
Temporomandibular disorder (TMD) is a term that covers a number of clinical problems involving the masticatory
muscles, TMJ and all associated structures leading to signs and symptoms such as jaw pain, otalgia, headaches and
limitation of function. In this context, TMD has been related to facial type and there are three distinct facial types
(euryprosopic, mesoprosopic, and leptoprosopic). Objective: The aim of this study was to investigate the correlation
between myofascial pain and facial types classied by the RDC/TMD Axis I. Material and Methods: this study
was composed of 64 women aged between 12 and 49 years, using data obtained from two institutions. We used
the anthropometric methodology, which meets the criteria of simplicity and reliability. We also applied the Brugsh
Facial Index. The individuals were classied as euryprosopic (51.56%), mesoprosopic (12.50%) and leptoprosopic
(35.94%), without statistical signicance among the groups (p=0,3492). Results: there is no statistical difference
between the age groups (p=0.2976) and no association between facial type and age range. Conclusion: this study
found that there was a correlation between myofascial pain and facial types, with the predominance of euryprosopic
faced women aged between 20 and 29 years when compared with other facial types and other age groups.
KEYWORDS
Temporomandibular joint dysfunction syndrome; Anthropometric methodology; Mandibular disorders; Myofascial
pain; Orofacial pain.
RESUMO
A Disfunção Temporomandibular é um termo que cobre uma série de problemas clínicos envolvendo os músculos
mastigatórios, ATM e todas as estruturas associadas que levam a sinais e sintomas como dor na mandíbula, otalgia,
dores de cabeça e limitação de função. Nesse contexto, a DTM tem sido relacionada ao tipo facial que são classicados
em três tipos distintos (euryprosopo, mesoprosopo e leptoprosopo). Objetivo: O objetivo deste estudo foi investigar
a correlação entre a dor miofascial e os tipos faciais classicados pelo RDC/TMD Eixo I. Material e Métodos: este
estudo foi composto por 64 mulheres com idade entre 12 e 49 anos, utilizando dados obtidos em duas instituições.
Utilizou-se a metodologia antropométrica, que atende aos critérios de simplicidade e de conabilidade. Também foi
utilizado o Índice Facial de Brugsh. Os indivíduos foram classicados em euriprosopo (51,56%), mesoprosopo (12,50%)
e leptoprosopo (35, 94%), sem signicância estatística entre os grupos (p = 0,3492). Resultados: não houve diferença
estatística entre as faixas etárias (p = 0,2976) e nenhuma associação entre tipo facial e faixa etária. Conclusão: este
estudo constatou que houve correlação entre dor miofascial e tipos faciais, com predomínio de mulheres euriprosopo
com idade entre 20 a 29 anos quando comparadas com outros tipos faciais e outras faixas etárias.
PALAVRAS-CHAVE
Síndrome da disfunção da articulação temporomandibular; Metodologia antropométrica; Distúrbios mandibulares;
Dor miofascial; Dor orofacial.
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Braz Dent Sci 2023 Jan/Mar;26 (1): e3725
Silva FF et al.
Relationship between myofascial pain and f acial types: an observational study
Silva FF et al. Relationship between myofascial pain and facial types: an
observational study
INTRODUCTION
According to the American Academy of
Orofacial Pain (AAOP), temporomandibular
disorder (TMD) is a term that covers a number
of clinical problems involving the masticatory
muscles, the temporomandibular joints (TMJ)
and all associated structures that can lead to
conditions such as jaw pain, otalgia, headaches
and limitation of function [1].
TMD etiology has a multifactorial
origin, which include different factors, such
as neuromuscular, social, psychological and
biological biomechanical aspects. In addition to
these factors, the etiopathogenesis of TMD is not
well understood, which makes its diagnosis and
management difcult. Therefore, it is important
to identify TMD at its beginning and associate it
with possible etiological factors, thus aiming at
the treatment [2,3].
TMD has been related to facial type [4-7].
There are three distinct facial types (euryprosopic,
mesoprosopic, and leptoprosopic) and their
variations (brachyfacial and dolichofacial).
Individuals with a long facial type (leptoprosopic)
usually have less chewing strength than those
with a mesoprosopic type [6].
The growth and the development of the
facial shape is part of human physiology, being
something of craniofacial clinical interest.
Then, the facial shape is associated with genetic
inuences and local environmental factors, such
as the chewing muscle activity. Knowing and
analyzing these characteristics profile better
enables correct diagnoses and nding strategies
for the treatment, with methods available for
handling TMD [8,9].
Some studies on the literature about muscle
activity and facial morphology have revealed
that individuals with euryprosopic faces display
a tendency to apply more forces into tightening
and chewing, when compared with narrow and
broad face individuals (leptoprosopic), which
may result in orofacial pain and TMD [9,10].
Due to the lack of evidence and clinical
importance, the goal of this study was to
investigate the correlation between myofascial
pain and facial types classied by the RDC/TMD
Axis I.
MATERIAL AND METHODS
This is a transversal study approved under
protocol number 2.333.460. Written informed
consent was obtained from all the individuals
participating in the study.
The sample consisted of 64 randomly selected
women, aged 12 to 49 years (S.D. = 8 years),
classied with myofascial pain according to the
RDC/TMD Axis I, “Research Diagnostic Criteria”.
Women with any condition that could inuence
the size of the head circumference, such as
microcephaly and a history of facial trauma, were
excluded from this study.
This sample was recruited at two different
dental institutions (Brazilian Association of
Dentistry and Menino Jesus Medical Clinic, both
in the state of Piauí, Brazil). The individuals
were randomized by Microsoft Excel Program
and submitted to anthropometric measurements
in order to calculate the facial index (Table I),
which was obtained from the association between
the morphological height of the face (Nasio-
Gnation, Na-gn) and the morphological width
of the face (Zigion-Zigion, Zy-Zy). In this
procedure, the curved compass was used, shown
in Figures 1 and 2. In calculating the Brugsh facial
index, the facial height was divided by the width
and multiplied by 100.
(Na gn) 100
IF (Zy Zy)
−×
=
−
(1)
in which,
IF less than or equal to 84.9 = (Euryprosopic);
IF greater than 84 and less than 90 = (Mesoprosopic);
IF equal to or greater than 90 = (Leptoprosopic).
A condence interval of 95% (zα = 1.96)
was adopted in the estimation of confidence
and an error margin (B) of 5% was determined
in the parameters to be estimated. The trend
Chi-square test was used to measure the degree
of association between the outcome and the
individuals’ characteristics in their respective
contexts. When the expected frequency in the Chi-
Square test was less than ve, Yates correction was
used. All analyses considered a condence interval
of 95% (95% CI) and statistical signicance of
p <0.05. Statistical Package for Social Sciences
(SPSS) 19.0 (IBM Corp., Armonk, United States)
and R version 3.4.3 were used for the data analysis.
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Braz Dent Sci 2023 Jan/Mar;26 (1): e3725
Silva FF et al.
Relationship between myofascial pain and f acial types: an observational study
Silva FF et al. Relationship between myofascial pain and facial types: an
observational study
RESULTS
Analysis of the obtained results began by
describing the age profile of the 64 patients
diagnosed with myofascial pain. Table II shows
that most patients are aged between 20 and
29 years (42.19%). Next, the patients between
30 and 39 years, (29.69%); then it shows those
between 40 and 49 years old (20.31%) and nally
the smallest part (7.81%), corresponding to those
under 20 years of age. There was no statistical
difference between age groups (p = 0.2976).
Table I - Facial types determined by the morphological index of
the face, calculated from the centesimal ratio between height and
width of the face
PATIENTS BRUGSH FACIAL
INDEX FACIAL TYPE AGE
1 93.33 Leptoprosopic 37 years
2 89.62 Mesoprosopic 22 years
3 86.95 Mesoprosopic 43 years
4. 78.26 Euryprosopic 40 years
5 91.10 Leptoprosopic 19 years
6 83.60 Euryprosopic 22 years
7 91.83 Leptoprosopic 38 years
8 83.73 Euryprosopic 29 years
9 89.90 Mesoprosopic 45 years
10 89.07 Mesoprosopic 47 years
11 108.33 Leptoprosopic 38 years
12 88.28 Mesoprosopic 26 years
13 84.12 Mesoprosopic 27 years
14 91.05 Leptoprosopic 40 years
15. 78.51 Euryprosopic 37 years
16 83.59 Euryprosopic 28 years
17 84.82 Mesoprosopic 38 years
18 85.03 Mesoprosopic 25 years
19 81.74 Leptoprosopic 19 years
20 83.62 Euryprosopic 23 years
21 82.75 Euryprosopic 19 years
22 92.68 Leptoprosopic 46 years
23 79.67 Euryprosopic 29 years
24 83.87 Euryprosopic 41 years
25 82.96 Euryprosopic 25 years
26 86.60 Mesoprosopic 32 years
27 87.70 Mesoprosopic 39 years
28 88.13 Euryprosopic 19 years
29 79.10 Euryprosopic 23 years
30 78.87 Euryprosopic 29 years
31 90.51 Leptoprosopic 20 years
32 86.99 Mesoprosopic 37 years
33 81.48 Euryprosopic 24 years
34 89.07 Mesoprosopic 46 years
35 84.42 Mesoprosopic 43 years
36 76.86 Euryprosopic 29 years
37 78.86 Euryprosopic 28 years
38 87.39 Mesoprosopic 48 years
39 81.81 Euryprosopic 33 years
40 80.71 Euryprosopic 38 years
41 84.48 Mesoprosopic 32 years
42 83.05 Euryprosopic 23 years
43 89.83 Mesoprosopic 21 years
44 80.46 Euryprosopic 40 years
45 79.54 Euryprosopic 18 years
46 89.65 Mesoprosopic 30 years
47 81.81 Euryprosopic 28 years
48 81.88 Euryprosopic 22 years
49 83.92 Euryprosopic 39 years
50 79.68 Euryprosopic 22 years
51 89.14 Mesoprosopic 40 years
52 86.61 Mesoprosopic 38 years
53 82.81 Euryprosopic 27 years
54 78.04 Euryprosopic 48 years
55 81.14 Euryprosopic 35 years
56 88.88 Mesoprosopic 21 years
57 78.33 Euryprosopic 26 years
58 82.17 Euryprosopic 34 years
59 88.28 Mesoprosopic 23 years
60 79.50 Euryprosopic 23 years
61 80.32 Euryprosopic 31 years
62 83.37 Euryprosopic 35 years
63 87.28 Mesoprosopic 29 years
64 78.03 Euryprosopic 30 years
Figure 1 - Facial height.
Figure 2 - Facial width.
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Braz Dent Sci 2023 Jan/Mar;26 (1): e3725
Silva FF et al.
Relationship between myofascial pain and f acial types: an observational study
Silva FF et al. Relationship between myofascial pain and facial types: an
observational study
Table III shows the frequency of facial types
found in the sample of individuals with myofascial
pain. The individuals were classied according
to the euryprosopic (51.56%), mesoprosopic
(12.50%) and leptoprosopic (3.594%) facial
types, without statistical signicance among the
groups (p=0.3492).
In order to verify the association between
the facial type and the age range, a chi-square
test of independence was performed (Table IV)
and no statistically signicant association was
observed (p=0.1604).
DISCUSSION
This study investigated the association
between myofascial pain occurrence and facial
types in women diagnosed with myofascial pain
by the RDC/TMD Axis I. The results showed that
in the sample of women diagnosed with myofascial
pain, the age group of 20 to 29 years stood out.
Although it is the first technique used
in craniofacial measurements and other
methods have emerged with new technology,
anthropometry is still an efcient method for
describing craniofacial morphology, since it is
simple, minimally invasive, and low cost. It also
provides reliable measurements, when conducted
by a trained professional [11-14].
In this study, craniofacial anthropometry
was used because it is considered a simple,
economical, noninvasive and reliable method.
In order to determine the variations of skull
patterns, craniometric reference points were used
to measure dimensions such as width, length and
height of the skull or the head. The indexes of
facial types classication are obtained from those
measures [13].
Epidemiological aspects, such as gender and
age, were considered for sample selection due
to the highest frequency of myofascial pain in
females of reproductive age [15,16]. However, no
consensus was found in the literature regarding
the correlation between facial types and subtypes
of temporomandibular disorders.
The euryprosopic type showed the highest
values of facial types. The literature pointed
that individuals with closed or low angles
(euryprosopic) tend to apply more force
during tightening and chewing, which may
inuence craniofacial morphology, agreeing with
Nebbe et al. [17] and Ingervall and Thilander [18],
and disagreeing with Stringert and Worms [19],
who observed in their studies a higher prevalence
of myofascial pain in hyperdivergent individuals
(leptoprosopic) when compared to hypodivergent
individuals (euryprosopic).
The present study observed a higher
prevalence of myofascial pain in young adults,
coinciding with the period when the individual’s
functional activities are more intense and
psychological factors (stress, anxiety and
depression) are more present, agreeing with
other studies such as Bove et al. [20], Araujo [21],
and Tosato and Caria [22]. It was also found
that the average age of the individuals surveyed
was 31 years, similar to the literature [23]. It is
important to point out that in the analysis of the
association between facial type and age range, no
statistically signicant association was observed.
As there is no consensus in the literature that
there is an association between myofascial pain
and facial types, the present study suggests more
research in this eld, aiming at more conclusive
results.
Table II - Age range frequency of patients diagnosed with
myofascial pain
Age n (n%) P-value*
< 20 years n (7.81%)
0.2976
20-29 years n (42.19%)
30-39 years n (29.69%)
40-49 years n (20.31%)
*Kruskal-Wallis test.
Table III - Classification of Facial Types from the sample
FACIAL
TYPES
Number of
individuals
% of
individuals value-p*
Euryprosopic 33 51.56%
Leptoprosopic 8 12.50% 0.3492
Mesoprosopic 23 35.94%
*Kruskall-Wallis test
Table IV - Representation of ages and facial types
Facial Type/
Age Eury Meso Lepto Total (%)
<20 212 5 (7.81%)
20-29 18 8 1 27(42.19%)
30-39 9 7 3 19(29.69%)
40-49 4 7 2 13(20.31%)
Total (%) 33 (51.56%) 23 (35.94%) 8 (12.5%) 64 (100%)
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Braz Dent Sci 2023 Jan/Mar;26 (1): e3725
Silva FF et al.
Relationship between myofascial pain and f acial types: an observational study
Silva FF et al. Relationship between myofascial pain and facial types: an
observational study
CONCLUSION
This study found that there was a correlation
between myofascial pain and facial types, with
the predominance of euryprosopic-faced women
aged from 20 to 29 years when compared with
other facial types and other age groups.
Author’s Contributions
FFS: Conceptualization, Methodology,
Investigation,, Writing – Original Draft
Preparation. MSFB: Validation, Formal Analysis,
Data Curation. ASG: Resources, Writing –
Original Draft Preparation, Visualization.
LARV: Data Curation, Writing – Original Draft
Preparation, Writing – Review & Editing. LLFRR:
Conceptualization, Methodology, Writing –
Review & Editing, Visualization, Supervision,
Project Administration.
Conict of Interest
The authors declare no conicts of interest.
Funding
None.
Regulatory Statement
This study was conducted in accordance with
all the provisions of the local human subjects
oversight committee guidelines and policies of
São Leopoldo Mandic College of Dentistry. The
approval code for this study is: 2.333.460.
REFERENCES
1. Hilgenberg PB, Saldanha ADD, Cunha CO, Rubo JH, Conti PCR.
Temporomandibular disorders, otologic symptoms and depression
levels in tinnitus patients. J Oral Rehabil. 2012;39(4):239-
44. http://dx.doi.org/10.1111/j.1365-2842.2011.02266.x.
PMid:22035253.
2. Sena MF, Mesquita KSF, Santos FRR, Silva FWGP, Serrano KVD.
Prevalence of temporomandibular dysfunction in children and
adolescents. Rev Paul Pediatr. 2013;31(4):538-45. http://dx.doi.
org/10.1590/S0103-05822013000400018. PMid:24473961.
3. Chisnoiu AM, Picos AM, Popa S, Chisnoiu PD, Lascu L, Picos A,etal.
Factors involved in the etiology of temporomandibular disorders:
a literature review. Clujul Med. 2015;88(4):473-8. PMid:26732121.
4. Monje F, Delgado E, Navarro MJ, Miralles C, Alonso del Hoyo
JR. Changes in the temporomandibular joint caused by the
vertical facial pattern. Study on an experimental model. J
Craniomaxillofac Surg. 1994;22(6):361-70. http://dx.doi.
org/10.1016/S1010-5182(05)80118-0. PMid:7884008.
5. Nebbe B, Major PW, Prasad NG, Grace M, Kamelchuk LS. TMJ
internal derangement and adolescent craniofacial morphology:
a pilot study. Angle Orthod. 1997;67(6):407-14. PMid:9428958.
6. Araujo RP, Groppo FC, Ferreira LE, Guimarães AS, Figueroba SR.
Correlation between facial types and muscle TMD in women:
an anthropometric approach. Braz Oral Res. 2015;29(1):S1806-
83242015000100279. http://dx.doi.org/10.1590/1807-
3107BOR-2015.vol29.0084. PMid:26154371.
7. Manfredini D, Segù M, Arveda N, Lombardo L, Siciliani G,
Alessandro Rossi,etal. Temporomandibular joint disorders in
patients with different facial morphology: a systematic review
of the literature. J Oral Maxillofac Surg. 2016;74(1):29-46. http://
dx.doi.org/10.1016/j.joms.2015.07.006. PMid:26255097.
8. Moss ML, Salentijn L. The primary role of functional matrices in
facial growth. Am J Orthod. 1969;55(6):566-77. http://dx.doi.
org/10.1016/0002-9416(69)90034-7. PMid:5253955.
9. Darwis WE, Messer LB, Thomas CD. Assessing growth and
development of the facial profile. Pediatr Dent. 2003;25(2):103-8.
PMid:12723833.
10. Bakke M, Michler L. Temporalis and masseter muscle activity
in patients with anterior open bite and craniomandibular
disorders. Scand J Dent Res. 1991;99(3):219-28. http://dx.doi.
org/10.1111/j.1600-0722.1991.tb01888.x. PMid:1871532.
11. Jefferson Y. TMD assessment using the Sassouni analysis. 1. J
Gen Orthod. 1991;2(1):11-5. PMid:1801936.
12. Proffit WR, Fields HW Jr, Sarver DM. Contemporary orthodontics.
4th ed. St. Louis: Elsevier; 2007.
13. Guyot L, Richard O, Philip N, Dutour O. Craniofacial anthropometric
patterns in genetic facial dysmorphism: methodology and
applications. Rev Stomatol Chir Maxillofac. 2002;103(2):114-9. http://
dx.doi.org/10.1016/S0035-1768(05)85823-1. PMid:11997739.
14. Di Dio LJ. The importance of anatomy. Ann Anat. 1999;181(5):455-
65. http://dx.doi.org/10.1016/S0940-9602(99)80024-7.
PMid:10560011.
15. Mazzetto MO, Rodrigues CA, Magri LV, Melchior MO, Paiva G.
Severity of TMD related to age, sex and electromyographic
analysis. Braz Dent J. 2014;25(1):54-8. http://dx.doi.
org/10.1590/0103-6440201302310. PMid:24789293.
16. Marques FBC, Lima LS, Oliveira PLE, Magno MB, Ferreira DMTP,
Castro ACR,etal. Are temporomandibular disorders associated
with facial asymmetry? A systematic review and meta-analysis.
Orthod Craniofac Res. 2021;24(1):1-16. http://dx.doi.org/10.1111/
ocr.12404. PMid:32608091.
17. Nebbe B, Major PW, Prasad NG. Adolescent female craniofacial
morphology associated with advanced bilateral TMJ disc
displacement. Eur J Orthod. 1998;20(6):701-12. http://dx.doi.
org/10.1093/ejo/20.6.701. PMid:9926637.
18. Ingervall B, Thilander B. Relation between facial morphology and
activity of the masticatory muscles. J Oral Rehabil. 1974;1(2):131-
47. http://dx.doi.org/10.1111/j.1365-2842.1974.tb00771.x.
PMid:4525024.
19. Stringert HG, Worms FW. Variations in skeletal and dental
patterns in patients with structural and functional alterations
of the temporomandibular joint: a preliminary report. Am J
Orthod. 1986;89(4):285-97. http://dx.doi.org/10.1016/0002-
9416(86)90050-3. PMid:3457527.
20. Bove SRK, Guimarães AS, Smith RL. Characterization of
patients in a temporomandibular dysfunction and orofacial pain
outpatient clinic. Rev Lat Am Enfermagem. 2005;13(5):686-
91. http://dx.doi.org/10.1590/S0104-11692005000500012.
PMid:16308625.
21. Araujo RP. Correlation between facial types and muscle subgroup
TMD. 1st ed. São Paulo: [s.n.]; 2005.
22. Tosato JP, Caria PHF. Prevalence of TMD in different age levels.
RGO. 2006;54(3):211-24.
23. Okeson JP. Bell’s oral and facial pain. 5 ed. Quintessence; 1998.
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Braz Dent Sci 2023 Jan/Mar;26 (1): e3725
Silva FF et al.
Relationship between myofascial pain and f acial types: an observational study
Silva FF et al. Relationship between myofascial pain and facial types: an
observational study
Lidia Audrey Rocha Valadas
(Corresponding address)
Universidad de Buenos Aires, Buenos Aires, Argentina.
Email: lidiavaladas@gmail.com
Date submitted: 2022 Dec 05
Accept submission: 2023 Mar 17
