REVIEW ARTICLE

The mandibular muscles and their importance

in orthodontics: A contemporary review
Andrew Pepicelli,a Michael Woods,b and Christopher Briggsc
Melbourne, Australia

It is widely accepted that the orthodontist should have a thorough understanding of the craniofacial
musculature and its association with the growth and development of the dentofacial complex. There is still
much controversy regarding the influence of the mandibular muscles on normal growth and development,
and on orthodontic treatment and stability. This review presents an outline of the mandibular muscles and the
vertical facial pattern. The different methods by which the mandibular muscles have been investigated are
discussed. The potential influence of these muscles on normal morphologic variation in different people is
also discussed, along with the implications for contemporary orthodontic treatment and stability. (Am J
Orthod Dentofacial Orthop 2005;128:774-80)

T
he practice of contemporary orthodontics in-
volves the understanding and application of
many biomechanical principles that enable the
orthodontist to achieve a desired outcome. Orthodon-
tists have developed many techniques based on these
principles to effect favorable changes in the dentofacial
complex. Treatment planning in orthodontics is, how-
ever, not based entirely on biomechanical consider-
ations, but it also requires an awareness of the cranio-
facial muscular environment of each patient. The
muscles of the maxilla and mandible would seem to be
of paramount importance in the etiology and active
treatment of malocclusions and jaw deformities, and
also for the stability of such treatment.
The mandibular muscles are generally considered to
be the masseter, temporalis, medial pterygoid, and
lateral pterygoid.1 Mandibular muscle function and
form correlate with the morphologic features of the
craniomandibular apparatus to which the muscles are
related.2 Many attempts have been made to investigate
the seemingly complex relationship between features of
the mandibular muscles and the vertical facial pat-
tern.2-22
It is well recognized that there are different under-
lying patterns in the vertical dimension of the face.
From the University of Melbourne.
a
Former graduate student; private practice, Melbourne, Australia.
b
Professor and chairman, Department of Orthodontics.
c
Associate professor and deputy head, Department of Anatomy and Cell
Biology.
Reprint requests to: Dr Michael Woods, Orthodontic Unit, School of Dental
Science, University of Melbourne, 711 Elizabeth St, Melbourne 3000 Victoria,
Australia; e-mail, mgwoods@unimelb.edu.au.
Submitted, May 2004; revised and accepted, September 2004.
0889-5406/$30.00
Copyright © 2005 by the American Association of Orthodontists.
doi:10.1016/j.ajodo.2004.09.023
774
Mandibles can grow in more vertical or horizontal
directions.23,24 Several authors have attempted to de-
scribe the normal variation in the vertical dimension of
the human face. They have generally described three
basic types. Some of the more commonly used and
accepted terminologies include:
● Dolichofacial, mesofacial, and brachyfacial25
● Hyperdivergent, neutral, and hypodivergent26
● Relatively long, average, and relatively short facial
types27
● Backward and forward rotating patterns28
● Skeletal open bite and skeletal deepbite29
Schudy26 believed that variations in the vertical
dimension of the face were more significant in identi-
fying facial types than variations in the anteroposterior
dimension. Although certain trends obviously exist,
particular skeletal morphology is not necessarily asso-
ciated with particular occlusal traits. Dolichofacial,
mesofacial, and brachyfacial patterns can exist with
all types of Angle occlusions.30 The obvious clinical
significance is that not all patients can be treated alike,
because not all faces are alike.31
THE RELATIONSHIP BETWEEN CRANIOFACIAL
MORPHOLOGY AND THE MANDIBULAR MUSCLES
Bite-force and facial morphology
In dolichofacial subjects, significantly smaller max-
imum molar bite forces have been found during maxi-
mum effort than in mesofacial and brachyfacial sub-
jects.13,18,29 This implies a correlation between bite
force and facial morphology, and these findings have
been used to support the theory that the form of the face
partly depends on the strength of the mandibular
muscles.32 Ingervall and Helkimo13 found that adults
American Journal of Orthodontics and Dentofacial Orthopedics
Volume 128, Number 6
with weak muscles have a greater variation in facial
morphology than those with strong muscles, and it was
believed that this argues for the primary importance of
the mandibular muscles in forming the face. Therefore,
according to Kiliaridis,33 strong muscles produce faces
with similar morphologic features, whereas weak mus-
cles cannot influence the morphology to such an extent.
Variation between people with weak muscles is there-
fore wide, and those with weak mandibular muscles can
belong to either the mesofacial or the dolichofacial
group.
An important determinant of the maximum force
that can be produced by a muscle is apparently its
cross-sectional area.34 Significant positive correlations
have been reported between the cross-sectional areas of
the masseter and medial pterygoid and the maximum
molar bite force.35-37 Hannam and Wood10 found a
statistically significant correlation between masseter
and medial pterygoid cross-sectional areas and molar
bite force but no correlation between cross-sectional
areas and the muscle moment arms.
Cross-sectional area of the mandibular muscles
and facial morphology
Many authors have described the relationship be-
tween the cross-sectional area of the mandibular mus-
cles and facial morphology.3,7,16,20 A common finding
has been that the masseter and medial pterygoid mus-
cles have large cross-sections in people with short
anterior face heights and small gonial angles. In con-
trast, Van Spronsen et al4 reported no significant
correlations between either anterior facial height or
posterior facial height and any jaw elevator cross-
sectional areas in 32 men with normal skull shapes,
when studied with magnetic resonance imaging.
Position, orientation and mechanical advantage of
the mandibular muscles
According to Takada et al,2 a short posterior face
height with steep mandibular plane and large gonial
angles is often associated with an anteriorly inclined
superficial masseter relative to the occlusal plane and a
superior positioning of its insertion on the mandible.
This is consistent with the observations of Proctor and
DeVincenzo17 several years earlier. Similarly, after the
dissection of 2 specimens, Haskell et al11 reported that
the superficial masseter was angled considerably more
anteriorly with a much more acute angle to the occlusal
plane in a dolichofacial specimen when compared with
a brachyfacial specimen. Van Spronsen et al,6 however,
observed that the orientation of the mandibular muscles
in mesofacial and dolichofacial subjects can be strik-
ingly similar. The issue of whether masseter angula-
Pepicelli, Woods, and Briggs 775
tion is constant relative to the occlusal plane is
controversial. Although Proctor and DeVincenzo17
noted a constant angular relationship (about 69°)
between the superficial masseters and the occlusal
planes in 2 groups with contrasting vertical facial
patterns, others have not been able to demonstrate such
a constant relationship.2,10,11,14
The efficiency with which a muscle generates a
force at a particular point on the lever arm would seem
to be related to its mechanical advantage, which has
been defined as the ratio of the moment arm of the
muscle to the moment arm of the load.38 Throckmorton
et al39 attempted to explain that the significantly
smaller bite force of dolichofacial subjects might to a
large extent be due to the reduced mechanical advan-
tage of the mandibular muscles in these subjects.
Although this has formed the basis for the contempo-
rarily accepted concept of muscular mechanical advan-
tage, it is not universally accepted. Sasaki et al,36 for
instance, found that the variation of maximum bite
force could be accounted for largely by muscle cross-
sectional areas rather than simply by muscle lever arms.
Cause and effect relationship between muscle
function and craniofacial morphology
There is often a relationship between form and
function,12 but it is not known whether a genetically
determined facial morphology dictates the strength of
the mandibular muscles or whether a strong muscula-
ture influences the form of the face.3,13,40 In animal
studies, it has been shown that interference with the
development of the jaw and facial muscles can lead to
major changes in the shapes of jaw bones.41-44 It has
also been shown that human subjects with strong bite
forces tend to have brachyfacial patterns, in contrast to
those with weak bite forces, who tend to have doli-
chofacial patterns. This difference in bite force has led
to much speculation about the etiology of vertical facial
patterns.19 According to Proffit and Fields,19 it is
possible that the lower bite force in dolichofacial
people might allow greater eruption of the posterior
teeth than might otherwise occur, and so are directly
related to the excessive tooth eruption and backward
rotation of the mandible often seen in such subjects.
Similarly, Ingervall and Helkimo13 suggested that the
interindividual form of the face is smaller in persons
with strong muscles than in those with weak muscles.
This would support the hypothesis that the muscles do
actually contribute to the final shape of the face. Further
support for this theory presumably came from the
findings of Ingervall and Bitsanis,40 who showed that
training the jaw muscles in dolichofacial children
776 Pepicelli, Woods, and Briggs
strengthened these muscles and induced a favorable
anterior mandibular growth rotation.
Whether the bite force differences play a role in
determining the ultimate facial morphology or merely
reflect the mechanical advantage obtained by the mus-
cles in the different facial types has been a matter of
some controversy.18 The model proposed by Throck-
morton et al,39 which depicts the unfavorable mechan-
ical position of the mandibular muscles in dolichofacial
subjects, implies that the muscular function is influ-
enced by skeletal form.32 The fact that the dolichofacial
pattern can be recognized before an age at which
decreased occlusal forces are present strongly suggests
that the decreased forces are an effect of the condition,
rather than a cause.19
It has been suggested that subjects with increased
vertical craniofacial dimensions have relatively ob-
liquely oriented jaw muscles, with a consequent re-
duced potential to restrain the vertical component of
craniofacial growth.5 This situation is obviously differ-
ent to that in brachyfacial subjects, with vertically
oriented jaw muscles, which would be expected to
restrain the vertical component of growth and contrib-
ute to the forward rotation of the mandible; this is a
characteristic of this group. The relationship between
the growth patterns of the skull and characteristic jaw
muscle function and orientation in subjects with in-
creased vertical dimension has received considerable
attention.3,4,7,18,29,45-47 None of these authors, however,
has provided an ultimate answer about whether jaw-
muscle function determines the outcome of craniofacial
growth or vice versa.5
CONSIDERATION OF THE MANDIBULAR
MUSCLES AND VERTICAL FACIAL PATTERN
DURING ORTHODONTIC TREATMENT
Schudy26 and Creekmore31 claimed that the vertical
dimension is the most important to the clinical ortho-
dontist. This importance has been borne out by the
pioneering work of Bjork,48 who used metallic implants
to show that the mandibular corpus rotates during
growth, with the shape kept stable by associated sub-
stantial surface remodelling. Bjork and Skieller49 re-
ported that about half of any rotation at the lower
border of the mandible is masked by this compensatory
remodelling. At the posterior border of the ramus, about
80% of the mandibular rotation is masked by compen-
satory remodelling. Although they showed that the
mandible can rotate either backward or forward during
growth, in most cases, it seems that the mandible
rotates forward in the face relative to the anterior
cranial base.50 Growth rotations of the maxilla and
mandible were also discussed in detail by Schudy.51
American Journal of Orthodontics and Dentofacial Orthopedics
December 2005
According to him, if condylar growth is greater than
vertical growth in the molar region, the mandible
rotates forward, resulting in a more horizontal move-
ment of the chin with less ultimate increase in anterior
facial height. Conversely, if vertical growth in the
molar region is greater than that at the condyles, the
mandible would rotate backward, resulting in a greater
anterior facial height with less effective horizontal
projection of the chin. To describe these 2 patterns,
Schudy coined the terms hypodivergent and hyperdi-
vergent.
THE SIGNIFICANCE OF MANDIBULAR ROTATION
TO THE ORTHODONTIST
Since Bjork48 first drew attention to the mandibular
growth rotations that occur in normal facial growth,
interest in their clinical relevance has gradually grown.
Forward-rotating brachyfacial subjects tend to have
deep overbites, whereas backward-rotating dolichofa-
cial subjects tend to have open bites.49,51-54 The pres-
ence of a deep overbite or an open bite, however, is by
no means automatically associated with a brachyfacial
or a dolichofacial pattern, and not all forward mandib-
ular rotations result in deepening of the overbite.53
Brachyfacial patients do, however, present problems in
the correction and retention of deep overbites. These
facial types seem to resist vertical posterior dentoalve-
olar development.31,55-56 Dolichofacial patients present
problems in the prevention, correction, and retention of
open bites.31 A backward rotation of the mandible can
easily occur in these patients if the facial pattern is not
considered during treatment.56,57 This can lead to a
detrimental increase in profile convexity in some pa-
tients.58 In general, most brachyfacial patients require
bite-opening mechanics during orthodontic treatment,
in what is often a powerful muscular environment. On
the other hand, dolichofacial patients usually require
some limiting of vertical development during treatment
to avoid extrusion of the posterior teeth. It has been said
that the more extreme the rotation of the mandible
during growth in either direction, the greater the clini-
cal problem for the clinician.53
SPECIFIC ASPECTS OF ORTHODONTIC
TREATMENT WITH REFERENCE TO THE
MANDIBULAR MUSCLES AND VERTICAL
FACIAL PATTERN
Extrusive mechanics
Most orthodontic mechanics are extrusive, and this
extrusion appears to maintain or even increase the
vertical dimension during orthodontic treatment.59 It is
not surprising, therefore, that there is a greater potential
for the undesirable extrusion of molars in dolichofacial
American Journal of Orthodontics and Dentofacial Orthopedics
Volume 128, Number 6
subjects compared with brachyfacials, who have stron-
ger musculature that tends to resist extrusive forces
during orthodontic treatment.57,60 Furthermore, if mo-
lar extrusion does occur during treatment in brachyfa-
cial patients, there is likely to be a strong tendency
toward reintrusion through the influence of the muscles
during swallowing and chewing. Thus, it might be
difficult to cause permanent extrusion of the molars and
backward rotation of the mandible in such patients,57
even though this is a main aim of treatment. During
treatment, extrusive forces with such mechanics as
intermaxillary elastics or particular headgears should
probably be avoided in patients with backward-rotating
tendencies57,61-65 to try to limit, as much as possible,
any undesirable backward rotation of the mandi-
ble.31,58,61 Vaden and Kiser64 warned that, in such
patients, it is crucial to really control the vertical
dimension if stability, facial balance, and harmony are
the ultimate goals of treatment.
Extractions and timing of treatment
Staggers66 reported on the changes in the vertical
dimension between premolar and second molar extrac-
tion groups and found no significant differences be-
tween them. It has been shown that, if premolars are
extracted in dolichofacial patients, there is still likely to
be a slight increase in the vertical dimension, whereas,
in brachyfacial patients, there is likely to be no change
or even a slight decrease.63,67 Extrusion of posterior
teeth with growth and treatment has been shown to be
the reason for this usual maintenance of the vertical
dimension during treatment involving premolar extrac-
tions.66,68
The recognition of different muscular patterns,
growth rotations of the mandible, and profile concavity
or convexity will influence the premolar extraction
decision in each patient.69,70 Pubertal growth and the
so-called E-spaces are important components of the
orthodontic management of most brachyfacial patients,
whose treatment often begins in the late mixed denti-
tion without premolar extractions.71-73 On the other
hand, in dolichofacial patients, treatment often begins
later (unless severe crowding warrants early extraction
with space maintenance). The aim of not only aligning
teeth but also placing them in positions of muscular
stability and facial balance will often require the
extraction of premolars in dolichofacial patients.69
Although Gianelly74 did not mention vertical facial
pattern or the influence of the muscles on orthodontic
treatment, he did discuss the notion of preserving the
E-spaces by starting treatment in the late mixed denti-
tion stage. According to him, the leeway space would
allow the relief of crowding in up to 75% of patients,
Pepicelli, Woods, and Briggs 777
enabling much orthodontic treatment to be carried out
without premolar extractions. This might seem to be an
ideal approach to the treatment of brachyfacial patients.
Vaden,75 however, claimed that, in most dolichofacial
patients, the extraction of premolars is absolutely nec-
essary. The greater tendency toward premolar extrac-
tions in dolichofacial patients than in brachyfacials has
been discussed previously.31,52,63,64
Surgical considerations
Jacobs and Sinclair76 suggested that the optimum in
efficiency of treatment, stability, and esthetic change in
orthognathic surgery patients would be obtained by
postponing the levelling of mandibular curves of Spee
until after surgery. In Class II deep-bite patients, it is
common practice to leave final levelling until after
surgery so that, at least in theory, postsurgical extrusion
of the posterior teeth will enhance any surgical increase
in lower face height. Surgical manipulation of the jaws
alters the environment in all 3 dimensions so the teeth
can be placed in their final, well-detailed positions.77 If,
on the other hand, presurgical levelling is attempted in
brachyfacial patients, it would have to overcome the
heavy bite forces associated with such patterns.76 In
other patients with longer lower anterior facial heights,
most of the levelling should probably be carried out
before surgery72-74,76-78 to avoid, as much as possible,
postsurgical extrusive effects. Arch coordination and
preparation are generally more easily achieved in these
longer-faced patients because of the decreased vertical
muscular anchorage.76,77
Muscular anchorage
In 1978, Bench et al60 introduced the concept of
muscular anchorage. According to this concept, the
facial type described by the cephalometric morphology
reflects a particular underlying muscular pattern. The
teeth would be controlled with natural anchorage in a
brachyfacial pattern, where the musculature is strong,
but there would be less muscular anchorage in doli-
chofacial subjects with weak mandibular musculature.
It seems that weaker musculature would be less able to
overcome the molar-extruding and bite-opening effects
of orthodontic treatment. Ricketts et al79 claimed that
the values for the oral gnomon and facial gnomon were
excellent indicators of mandibular morphology and the
associated muscular function.
Retention
The position and function of the lips are well accepted
to influence incisor alignment and stability. The facial and
mandibular muscles are also critical influences.79,80 For
instance, Ricketts et al81 suggested that preferred incisal
778 Pepicelli, Woods, and Briggs
positions and angulations at the end of active treatment
might vary depending on the underlying vertical facial
type, with brachyfacial patients tolerating more protrusive
and proclined incisors than dolichofacial patients. It has
been suggested that brachyfacial patterns might allow
greater expansion of the arches during treatment, in
contrast to dolichofacial patterns with generally weaker
mandibular muscle forces that might allow less expansion
during treatment.81,82 Although the pretreatment vertical
facial pattern has been discussed as a possible factor in
determining occlusal stability after treatment,83 no direct
relationship has been found.82
CONCLUSIONS
The results of many studies of the relationship
between the mandibular muscles and craniofacial mor-
phology would seem to confirm the ever-present but
still elusive relationship between form and function. A
general consensus of the studies on the relationship
between mandibular muscles and head dimensions is
that subjects with strong or thick mandibular muscles
have wider transverse craniofacial dimensions. In ad-
dition, tendencies toward parallelism between the
jaw bases and between the occlusal and mandibular
lines, as well as small gonial angles and smaller
lower anterior facial height have also been noted.
Although it is widely accepted that dolichofacial pa-
tients have relatively weak mandibular muscles com-
pared with brachyfacials, it is still not known whether
the strength of the mandibular muscles determines
craniofacial morphology or vice versa. Bite-force dif-
ferences between brachyfacial and dolichofacial sub-
jects have been claimed to be related to the strength or
the mechanical advantage of the mandibular muscles.39
The effects of the mandibular muscles associated
with different types of tooth movements should be
considered during orthodontic treatment planning. The
choice of treatment mechanics, the timing of treatment,
and any extraction decision might well be quite differ-
ent for different underlying vertical patterns, even for
the management of similar occlusions. Any one tech-
nique or philosophy of treatment in which all patients
are managed similarly, without consideration of the
vertical facial type, would appear to be inadequate.
From a review of all the available historical and
contemporary literature, it is reasonable to suggest that
subjects at either extreme of the vertical facial spectrum
are likely to pose the greatest challenges to the ortho-
dontist during treatment.
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