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Case Report: 32 year old patient with orofacial pain…… The importance of Cranial Nerve VII

May 11, 2010

Muscles innervated by crainial nerve number 7 (CNVII) are some of the most overlooked muscles in the world of manual medicine.  The muscles of fascial expression are often omitted from examinations, treatments, and soft tissue management systems despite their potential to contribute to, and/or causepain symptoms and dysfunction in patients.  The contribution of these muscles to headache symptoms for example while ignored my manual therapists, is a direct target of therapeutic intervention for headache and plastics specialists.

When examining the literature outside of the manual therapy focused journals regarding these tissues, one will note a very large amount of work has been done.  A study in the European Journal of Neurology by Calandre (2006) for example found pericranial allodynia to be a symptom in the majority of Migraine suffers.  Studies by the same author

also demonstrate common fascial expressions that occur most frequently in the headache state including furrowed eyebrows, closed eyes, slow eye blinks, lip pursuing, facial grimacing, and flat facial affect – all of which can contribute to the development of myofascial triggers and pain symptoms.  Other studies by Guyuron in the Journal of Plastic Reconstructive Surgery (2000) examined the surgical removal of the Corrugator Supercilii

in migraine suffers, which is also sometimes done along with transection of the zygomaticotemporal branch of the trigeminal nerve, and/or with repositioning of the temple soft tissues.  Results form this work demonstrates significant relief if not abolition of migraine symptoms.  Of note, examination and treatment of the Corrugator Supercilii (with Functional Range Release™) is one of my “go to’s” for chronic headache suffers.

In addition, the prevelance of facial ticks, and habitual fascial expressions often lead to the development of trigger points in many of these “un-important” muscles such as the platysma, zyogmaticus major, occipitalis, frontalis, auricularis group, obicularis oculi, buccinators, etc.

It is for this reason that palpation/examination of all of these structures is included in our FUNCTIONAL ANATOMIC PALPATION SYSTEMS™ seminars, and treatment is taught/demonstrated in our FUNCTIONAL RANGE RELEASE™ soft tissue management seminars.  In my opinion, knowledge of these structures and the symptoms they can cause will often make the difference between a good manual practitioner, and a great one in the eyes of the patient suffering from dysfunction in these areas.  I am always insistent on including examination of these structures in head an neck pain patients as it has been my experience that they are often either the cause of the problem, secondary to it, or contributing.

CASE REPORT: a 32-year old male patient complaining of a 6 month history of maxillary pain was referred to me by an orthodontist after having been seen by 3 oral surgeons who utilized a combination of 4 plain film x-rays, one ultrasound, and one MR in addition to physical examination of the TM complex before concluding the patients symptoms to be a ‘mystery.

Buccinator trigger point referral

History revealed just prior to the onset of the symptoms, the patient had braces put in (approx 1 month before) in order to correct for a severe overbite.

The pain was described as a dull ache located in the area of the upper teeth on the lateral aspect of the face (in the maxilla).  Examination of the TM complex revealed no abnormalities nor did palpatory examination of the capsule, temporalis tendon, masseter, etc.  Palpation of the zygomaticus major caused non-reproductive pain.

Palpation of the buccinator muscle caused a complete reproduction of the patient’s dull achy pain (when held for a period of 8-10 seconds as is often necessary with trigger point referral patterns).

Theory – it is well known that one of the main functions of the buccinator muscle is to keep the

The Buccinator Muscle

cheek taught to prevent inward folding during chewing.  I have also commonly observed with CN VII innervated muscles that tonnus changes can occur rapidly with the introduction of new stimuli….for example, when people who don’t often wear hats wear them for prolonged periods it is common for them to have pain in the pericranial muscles; similarly when one wears a new pair of glasses, they often complain of lateral head pain in the auricular muscles.

It is my theory that due to the introduction of the new ‘hardware’ in the patient’s mouth, the buccinator muscle became ‘overactive’ (ie. Increased neural drive from CN VII) in order to avoid contact of the buccal mucosa with the braces, which lead to the development of the trigger point.

Treatment for this patient consisted of two sessions of Functional Range Release™ which lead to a complete resolution of the pain symptoms.

Anatomy Review: The Buccinator

From:  the skin of the cheeks on the lateral aspect of the face, and from the pterygomandibular raphe

To: the orbicularis oris at the angle of the mouth

Innervation: buccal branch of Facial (CN 7)

Action: active during smiling, keeps cheeks taut to prevent inward folding during chewing


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