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Surface Electromyography as a Method for Diagnosing Muscle Function in Patients with Congenital Maxillofacial Abnormalities

Surface Electromyography as a Method for Diagnosing Muscle Function in Patients with Congenital... Hindawi Journal of Healthcare Engineering Volume 2020, Article ID 8846920, 6 pages https://doi.org/10.1155/2020/8846920 Review Article Surface Electromyography as a Method for Diagnosing Muscle Function in Patients with Congenital Maxillofacial Abnormalities 1 2 1 Liliana Szyszka-Sommerfeld , Mariusz Lipski , and Krzysztof Woz´niak Department of Orthodontics, Pomeranian Medical University in Szczecin, Al. Powstan´co´w Wlkp. 72, 70111 Szczecin, Poland Department of Preclinical Conservative Dentistry and Preclinical Endodontics, Pomeranian Medical University in Szczecin, ´ ´ Al. Powstancow Wlkp. 72, 70111 Szczecin, Poland Correspondence should be addressed to Liliana Szyszka-Sommerfeld; liliana.szyszka@gmail.com Received 11 August 2020; Revised 8 September 2020; Accepted 9 September 2020; Published 22 September 2020 Academic Editor: Jacek Piskorowski Copyright © 2020 Liliana Szyszka-Sommerfeld et al. +is is an open access article distributed under the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. Electromyography (EMG) is the most objective and reliable method available for imaging muscle function and efficiency, which is done by identifying their electrical potentials. In global surface electromyography (sEMG), surface electrodes are located on the surface of the skin, and it detects superimposed motor unit action potentials from many muscle fibers. sEMG is widely used in orthodontics and maxillofacial orthopaedics to diagnose and treat temporomandibular disorders (TMD) in patients, assess stomatognathic system dysfunctions in patients with malocclusions, and monitor orthodontic therapies. Information regarding muscle sEMG activity in subjects with congenital maxillofacial abnormalities is limited. For this reason, the aim of this review is to discuss the usefulness of surface electromyography as a method for diagnosing muscle function in patients with congenital malformations of the maxillofacial region. Original papers on this subject, published in English between 1995 until 2020, are located in the MEDLINE/PubMed database. cooperation between different muscles, and variability in 1. Introduction their activity over time [1]. Another disadvantage of surface Electromyography (EMG) is the most objective and reliable electromyography is its sensitivity to imbalances in im- method available for imaging muscle function and effi- pedance, and this may reduce the accuracy of EMG re- ciency, which is done by identifying their electrical poten- cordings and, as a consequence, result in low reproducibility. tials [1]. Electromyography takes two forms, i.e., To ensure the reproducibility of this method, the inter- intramuscular and global (surface electromyography, electrode distance should be fixed, and a standard procedure sEMG), depending on the way the electrodes are applied. In for positioning the electrodes should be used to exclude the case of intramuscular EMG, a needle and fine-wire variability in electrode placement [2–4]. +e inconsistency electrodes are inserted into muscle tissue through the skin, in the impedance and reliability of sEMG could also be solved through normalization, which is the basic component whereas in global EMG surface electrodes are located on the surface of the skin. Moreover, another difference between of the data analysis. +e normalization process is important these two approaches lies in the fact that intramuscular EMG for the preliminary processing of raw values to ensure detects single motor unit potential (motor unit action po- further analysis. +e standardized data provide information tential (MUAP)), while surface electromyography identifies on the impact of occlusion on neuromuscular activity and superimposed MUAPs from many muscle fibers. As these ensure removal most of biological and technical noise, such signals include a weighted summation of the spatial and as anatomical variations, skin, and electrode impedance. +e temporalis activity of many motor units, the analysis of process of normalizing the EMG results entails converting sEMG recordings is limited to general muscle activity, them into quotient indices. In this way, muscle electrical 2 Journal of Healthcare Engineering muscle sEMG activity in subjects with congenital maxillo- activity could be presented as a percentage of another high- reproducible activity of this muscle recorded under the same facial abnormalities is limited. For this reason, the aim of this review is to discuss the usefulness of surface electromyog- conditions, such as maximum voluntary contraction (MVC) (%MVC). +e other possibility of quantitative analysis is to raphy as a method for diagnosing muscle function in pa- relate the electrical potentials of the muscles to the reference tients with congenital malformations of the maxillofacial values obtained from the EMG measurements performed in area. Patients with these abnormalities often suffer from the submaximal voluntary contraction (subMVC) [5, 6]. +e aesthetic, morphological, and functional problems in the undoubted advantage of global electromyography that dentofacial region. Congenital maxillofacial defects have compensates for the abovementioned limitations is its significant psychological and socioeconomic effects on a patient’s quality of life and require a multidisciplinary team noninvasiveness [1]. Due to the simplicity of this method, its safeness, and availability, it has been used in studies on approach if it is to be managed properly. Clefts of the lip, alveolus, and/or palate are the most frequent head and neck children [7–9]. +e methodology of sEMG recordings, including elec- congenital deformities that significantly affect the functions of the stomatognathic system and disrupt normal facial trode placement, EMG signal processing, and modelling, is based on the Surface Electromyography for Non-Invasive structure [7, 9]. Assessment of Muscles (SENIAM) and +e International Society of Electromyography and Kinesiology (ISEK) rec- 2. Material and Methods ommendations [1]. Masseter and anterior temporalis muscles are the Original peer-reviewed papers on this subject, published in muscles most frequently evaluated by sEMG. Masticatory English between 1995 until 2020, are located in the MED- muscle electrical activity can be assessed during static tests LINE/PubMed database. +e literature search strategy was (rest, maximum, or sub-maximum voluntary clenching) or conducted as follows: keyword “surface electromyography” during active tests, such as opening or closing the mouth, was combined with each of “congenital maxillofacial ab- protrusion, retrusion, lateral deviation of the mandible, normalities,” “cleft lip and palate,” “Down syndrome,” chewing, swallowing, or speaking [1]. Rest activity is one of “hemifacial microsomia,” “craniosynostosis.” the most important static activities analysed. +ere is no isoelectric line observed in the sEMG recordings in this position determined by freeway space. However, some re- 2.1.ImagingofMuscleFunctioninCleftLipandPalate(CLP) search has shown that the clinical rest position is an active PatientsbymeansofsEMG. Clefts of the lip, alveolus, and/or muscle position because of the tone of the muscles involved palate are the most frequent congenital facial malformations in it [10]. Another important static test, which is frequently that significantly affect the functions of the stomatognathic analysed, is maximum voluntary contraction (MVC). +e system and disrupt dentofacial aesthetics [23, 24]. Besides EMG recordings during isometric contraction can be per- dysfunctional facial expressions, patients with cleft lip and formed while clenching the teeth as hard as possible for 3 to palate may have serious functional problems with sucking, 5 seconds, usually in an intercuspal position or during swallowing, breathing, chewing, speaking, hearing, and maximum clenching with a control substance, i.e., with social integration [25, 26]. Abnormal jaw growth in CLP cotton rolls placed on the mandibular second premolar and patients can result in severe malocclusion, which in turn may molars [11, 12]. EMG muscle potentials should also be affect the functioning of the maxillofacial muscles [7]. evaluated in a fatigue test, which involves a continuous 10- Successful treatment of a cleft patient involves multidisci- second sub-maximum or maximum isometric muscle plinary surgical and nonsurgical care performed from birth contraction. Median power frequency (MPF) and time- through to adulthood [27]. In a few published studies, frequency distributions are the most objective and reliable surface electromyography was used to detect the electrical EMG parameters for evaluating muscle resistance to fatigue potentials of the superior orbicularis oris muscle and [1]. In turn, the most frequent dynamic activity analysed by masticatory muscles in cleft lip and palate patients sEMG is mastication. It is usually expressed by such pa- [7, 9, 28–33]. rameters as the duration of the masticatory act, the number In a study by Szyszka-Sommerfeld et al. [9], the authors of cycles, and its effectiveness depending on the forces analysed the electrical activity of the superior orbicularis oris generated and food consistency [13]. +e use of electro- muscle by means of sEMG in patients ranging in age from 6 myographic indices, such as the activity index (Ac), sym- to 13 years. +eir study cohort comprised 45 children op- metry (percentage overlapping coefficient (POC), and erated on for unilateral complete cleft lips and palates torque coefficient (To, Tc)), makes it possible to assess the (UCCLP). +ey were compared with 40 control subjects with activity, coordination, and symmetry of the homologous, no cleft lip and palate. Electromyographical recordings were synergistic, and antagonistic muscles [1]. taken in the rest position and during saliva swallowing, lip According to the literature, surface electromyography is protrusion, and reciprocal compression of the lips, as well as widely used in orthodontics and maxillofacial orthopaedics while producing the bilabial phonemes /p/, /b/, and /m/ to help diagnose and treat patients with temporomandibular associated with the vowel /a/. +e authors observed that disorders (TMD), as well as to assess stomatognathic system patients with unilateral repaired complete cleft lip and palate dysfunctions in patients with malocclusions or monitor have abnormal upper lip function characterized by higher orthodontic therapies [8, 14–22]. Information regarding EMG activity of the superior orbicularis oris muscle during Journal of Healthcare Engineering 3 of the chewing cycle in the cleft group might be a conse- saliva swallowing and reciprocal compression of the lips in the cleft group. +us, they suggested that the excessive force quence of malocclusion and might result in functional in- efficiency, making mastication more difficult. applied by a repaired cleft lip to underlying structures during saliva swallowing and lip compression may affect facial Li et al. [30] evaluated masticatory muscle function in 29 morphology. Furthermore, the authors observed that EMG patients aged from 11 and 21 years with unilateral cleft lip values at rest and when producing the bilabial phonemes /p/, and palate (UCLP) and anterior crossbite. +e control group /b/, and /m/ combined with the vowel /a/ were comparable consisted of 28 noncleft subjects with normal occlusion. in both groups. +ey observed that the temporalis muscle EMG potentials at Ravera et al. [28] assessed superior orbicularis oris rest were significantly higher in UCLP patients compared to the controls. +e results of their study also showed altered muscle function at rest, during saliva swallowing, speaking, chewing, and apple swallowing in 14 children operated on masseter muscle function at rest and significantly lower masseter muscle electrical activity during maximum for unilateral CLP and ranging in age from 6 to 12 years. All cleft patients had clinically short upper lips, abnormal lip clenching in the intercuspid position in the cleft group. Surface electromyography was also used to image seal, and inhibited sagittal development of the midface. +e control group included 14 noncleft children aged between 8 masticatory muscle function in cleft lip and palate subjects and 11 years. +e authors noted significantly higher results with pain-related temporomandibular disorders (TMDs) for the electrical potentials of the superior orbicularis oris [31, 32]. TMDs are a collective term associated with a muscle at rest and during saliva swallowing in the cleft number of clinical conditions that affect the masticatory group, while EMG activity levels during speech were similar muscles, the temporomandibular joint (TMJ), and associ- in both cleft and noncleft subjects. +ey stated that the ated structures. +e main signs and symptoms of TMDs are muscle and joint sensitivity or pain, joint noises, and de- higher electrical activity of the upper lip at rest and during swallowing of saliva in children with CLP suggests that upon rangements in the movements of the mandible [34–36]. Patients with clefts are potentially at risk of developing higher functional demands their activity increases less than that in noncleft children. +ey also suggested that greater TMD, due to psychosocial burdens and malocclusions predisposing them to this disorder [37]. electrical potentials of the superior orbicularis oris muscle reflects increased force on the maxilla and as a consequence, Szyszka-Sommerfeld et al. [31] evaluated temporalis and the surgical treatment of cleft lip has an iatrogenic effect on masseter EMG activity in 31 CLP patients with pain-related facial growth. TMD and 32 CLP subjects with no TMD aged between 6 and Szyszka-Sommerfeld et al. [7] analysed masticatory 14 years. +ey observed that masticatory muscle activity at muscle activity by means of sEMG in children surgically rest in pain-related TMD cleft subjects was significantly treated for unilateral complete cleft lip and palate. +e higher and masticatory muscle EMG potentials during maximum voluntary clenching were markedly lower than authors also assessed the possible factors associated with such EMG activity. +e study population included 82 those in cleft children with no TMD diagnosis. Moreover, they found a significant increase in the Asymmetry Index for children with mixed dentition and Class I occlusions. +e cleft group consisted of 25 children aged between 6 and 13 temporalis and masseter muscle rest activity in pain-related years. +ey were compared with 57 control subjects aged TMD patients. +e authors concluded that cleft children between 6 and 12 years with no cleft lip and palate. +e EMG diagnosed with pain-related TMD have altered masticatory recordings of the temporalis and masseter muscles were muscle activity, and this can affect their muscle function. performed at rest and during maximum voluntary con- In another study by Szyszka-Sommerfeld et al. [32], the traction (MVC). +eir results showed that children with authors analysed the diagnostic efficiency of sEMG in UCCLP had altered temporalis muscle function at rest identifying CLP subjects with temporomandibular disor- compared with noncleft subjects. +ey also found that the ders. +eir sample comprised 88 patients with cleft lip and palate and mixed dentition. +e study population was presence of malocclusion, such as posterior crossbite, affects the temporalis muscle activity in cleft patients. +e authors subdivided into three groups: a pain-free TMD group, a TMD-pain group, and a non-TMD group. +e electrical declared that early diagnosis and orthodontic treatment of malocclusions are necessary to achieve the correct occlusion activity of the temporalis and masseter muscles was assessed and improvement in muscle function in these patients. in the rest position and during maximum voluntary con- da Costa et al. [29] used sEMG to analyse masticatory traction. +e results of the study revealed that surface muscle function at rest and during isometry and mastication electromyography is diagnostically useful in recognition of in 33 children with complete cleft lip and palate as well as in CLP patients with pain-related TMD and it could be used as 33 noncleft patients aged between 6 and 12 years. +ey found an adjunctive tool in the identification of this disorder. +ey found that the highest diagnostic efficiency of sEMG in much higher EMG potentials of the temporalis and masseter muscles in cleft subjects at rest and during inactive period of terms of identifying subjects with TMD and pain-related TMD was observed for the mean values of temporalis and mastication, whereas electrical activity in the left masseter muscle and temporalis muscles during active period of masseter muscle activity as well as the Asymmetry Index of the masseter muscles in a rest position. mastication and in every muscle during isometry was sig- nificantly lower. +e authors also observed that the muscles sEMG was also used to detect muscle electrical potentials of cleft children remained active for longer than in patients while monitoring orthodontic or surgical therapies in cleft with no cleft. da Costa et al. suggested that the higher length lip and palate patients. Sabbag et al. [33] assessed the EMG 4 Journal of Healthcare Engineering involvement. It primarily affects the ear, mouth, and jaw activity of the masseter and temporalis muscles in 32 nonsyndromic complete unilateral CLP patients surgically areas, though it may also involve the eye, cheek, neck, and other parts of the skull, as well as nerves and soft tissue [44]. treated with 2 different palate repair protocols (one-stage vs. two-stage). +e EMG potentials of the masticatory muscles Craniosynostosis is a developmental craniofacial malfor- were recorded at rest and during chewing. +e authors mation, resulting in impairment of brain development and observed similar masseter and temporalis EMG activity abnormally shaped skull. +e main cause of craniosynostosis while mastication and at rest after one- and two-stage palate is premature closure of one or more cranial sutures. When closure. left untreated, craniosynostosis can cause serious compli- cations, such as impairment of mental development, facial abnormality, sensory, respiratory and neurological dys- 2.2. Assessment of Muscle Function in Patients with Down function, anomalies affecting the eye, psychological dis- Syndrome (DS) by means of sEMG. Down syndrome is a turbances, sleeping impairment, and eating difficulties [45]. chromosomal alteration caused by trisomy 21. Many Telich-Tarriba et al. [41] used sEMG to assess masti- comorbidities are associated with DS, including obstructive catory muscle function in patients with hemifacial sleep apnea and masticatory muscle alteration. One of the microsomia (HFM). +ey compared the bite force and characteristics most commonly found in patients with Down electrical activity of masseter muscle in 20 children with syndrome is the presence of generalized muscular hypoto- hemifacial microsomia and 10 healthy controls with a mean nia, particularly of the masticatory and oropharyngeal age of 7.2 years. EMG recordings were performed in muscles, which directly affect the stomatognathic system, maximum intercuspation and at rest from both sides of the resulting in speech, swallowing, and mastication impair- face. +e authors found that masseter muscle EMG po- ments in these individuals [38, 39]. Few studies have assessed tentials in maximum intercuspation were significantly muscle activity in DS patients by means of sEMG. In a lower in HFM patients compared with both the healthy side published paper, sEMG was used to evaluate masticatory and the control group. Moreover, they observed significant muscle function while monitoring orthodontic therapy in differences in the masseter muscle EMG activity of affected subjects with Down syndrome [39, 40]. and nonaffected sides at rest in children with hemifacial Giannasi et al. [39] assessed the therapeutic effects of microsomia. surface neuromuscular electrical stimulation, mastication Suzuki et al. [42] investigated the relationship between apparatus, and a mandibular advancement device with an mandibular ramus height and masticatory muscle function embedded thermosensitive microchip on masticatory in 29 patients with hemifacial microsomia. +ey observed muscle function, physiological sleep variables, and salivary that decreased mandibular ramus height was significantly parameters in patients with Down syndrome aged between correlated with both reduced masseter muscle EMG po- 18 and 40 years. sEMG was used to detect temporalis and tentials and the amount of mandibular lateral deviation at masseter muscle electrical potentials. Following an analysis the time of maximum opening on the affected side. +e of the study results, the authors stated that the primary authors suggested that decreased mandibular ramus height outcomes would be an improvement and/or reestablishment may cause dysfunction of the masseter muscles but not the of masticatory muscle function and physiological sleep temporalis muscle on the affected side in patients with variables in these target subjects since patients with DS hemifacial microsomia. commonly exhibit generalized muscular hypotonia and Martini et al. [43] analysed masticatory muscle function dysfunction of the oropharyngeal musculature. in 15 patients with craniosynostosis after cranioplasty, as Mazille et al. [40] used video and sEMG recordings to well as in 25 7-year old nonoperative healthy controls. +e investigate the therapeutic impact of wearing an orthetic maximum bite force and EMG activity of the temporalis and intra-oral appliance on chewing variables in 8 Down syn- masseter muscles were assessed. +e results of the study drome subjects with a mean age 27±6 years. +e simul- revealed that the EMG potentials of the temporalis muscle taneous use of EMG and video recordings revealed the correlated positively with the bite force and showed a slightly presence of lower jaw movements not corresponding to lower resting activity in the control group, whereas muscle EMG activities in the masticatory muscles. +e authors fatigue occurred slightly faster in both muscles of children observed that, compared to the pretreatment state, wearing who had been operated on, but no statistically significant an occlusal appliance lowered chewing frequency and in- differences between the two groups were observed. creased masticatory time. 3. Conclusions 2.3. sEMG Recordings of Patients with Other Congenital MaxillofacialAbnormalities. Surface electromyography also +is literature review of studies involving surface electro- provided the basis for assessing masticatory muscle activity myography demonstrated its usefulness as a method of in patients with other congenital maxillofacial anomalies, muscle function imaging in patients with congenital ab- such as hemifacial microsomia or craniosynostosis [41–43]. normalities of the maxillofacial region. sEMG could be used Hemifacial microsomia is the second most common con- as an additional tool in the diagnosis or monitoring or- genital anomaly of the craniofacial region behind cleft lip thodontic therapies in these patients, thereby expanding our and palate. +is malformation is characterized by asym- knowledge about the anatomy, physiology, and pathology of metric facial growth with mandibular and muscle their stomatognathic system. 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Surface Electromyography as a Method for Diagnosing Muscle Function in Patients with Congenital Maxillofacial Abnormalities

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Hindawi Journal of Healthcare Engineering Volume 2020, Article ID 8846920, 6 pages https://doi.org/10.1155/2020/8846920 Review Article Surface Electromyography as a Method for Diagnosing Muscle Function in Patients with Congenital Maxillofacial Abnormalities 1 2 1 Liliana Szyszka-Sommerfeld , Mariusz Lipski , and Krzysztof Woz´niak Department of Orthodontics, Pomeranian Medical University in Szczecin, Al. Powstan´co´w Wlkp. 72, 70111 Szczecin, Poland Department of Preclinical Conservative Dentistry and Preclinical Endodontics, Pomeranian Medical University in Szczecin, ´ ´ Al. Powstancow Wlkp. 72, 70111 Szczecin, Poland Correspondence should be addressed to Liliana Szyszka-Sommerfeld; liliana.szyszka@gmail.com Received 11 August 2020; Revised 8 September 2020; Accepted 9 September 2020; Published 22 September 2020 Academic Editor: Jacek Piskorowski Copyright © 2020 Liliana Szyszka-Sommerfeld et al. +is is an open access article distributed under the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. Electromyography (EMG) is the most objective and reliable method available for imaging muscle function and efficiency, which is done by identifying their electrical potentials. In global surface electromyography (sEMG), surface electrodes are located on the surface of the skin, and it detects superimposed motor unit action potentials from many muscle fibers. sEMG is widely used in orthodontics and maxillofacial orthopaedics to diagnose and treat temporomandibular disorders (TMD) in patients, assess stomatognathic system dysfunctions in patients with malocclusions, and monitor orthodontic therapies. Information regarding muscle sEMG activity in subjects with congenital maxillofacial abnormalities is limited. For this reason, the aim of this review is to discuss the usefulness of surface electromyography as a method for diagnosing muscle function in patients with congenital malformations of the maxillofacial region. Original papers on this subject, published in English between 1995 until 2020, are located in the MEDLINE/PubMed database. cooperation between different muscles, and variability in 1. Introduction their activity over time [1]. Another disadvantage of surface Electromyography (EMG) is the most objective and reliable electromyography is its sensitivity to imbalances in im- method available for imaging muscle function and effi- pedance, and this may reduce the accuracy of EMG re- ciency, which is done by identifying their electrical poten- cordings and, as a consequence, result in low reproducibility. tials [1]. Electromyography takes two forms, i.e., To ensure the reproducibility of this method, the inter- intramuscular and global (surface electromyography, electrode distance should be fixed, and a standard procedure sEMG), depending on the way the electrodes are applied. In for positioning the electrodes should be used to exclude the case of intramuscular EMG, a needle and fine-wire variability in electrode placement [2–4]. +e inconsistency electrodes are inserted into muscle tissue through the skin, in the impedance and reliability of sEMG could also be solved through normalization, which is the basic component whereas in global EMG surface electrodes are located on the surface of the skin. Moreover, another difference between of the data analysis. +e normalization process is important these two approaches lies in the fact that intramuscular EMG for the preliminary processing of raw values to ensure detects single motor unit potential (motor unit action po- further analysis. +e standardized data provide information tential (MUAP)), while surface electromyography identifies on the impact of occlusion on neuromuscular activity and superimposed MUAPs from many muscle fibers. As these ensure removal most of biological and technical noise, such signals include a weighted summation of the spatial and as anatomical variations, skin, and electrode impedance. +e temporalis activity of many motor units, the analysis of process of normalizing the EMG results entails converting sEMG recordings is limited to general muscle activity, them into quotient indices. In this way, muscle electrical 2 Journal of Healthcare Engineering muscle sEMG activity in subjects with congenital maxillo- activity could be presented as a percentage of another high- reproducible activity of this muscle recorded under the same facial abnormalities is limited. For this reason, the aim of this review is to discuss the usefulness of surface electromyog- conditions, such as maximum voluntary contraction (MVC) (%MVC). +e other possibility of quantitative analysis is to raphy as a method for diagnosing muscle function in pa- relate the electrical potentials of the muscles to the reference tients with congenital malformations of the maxillofacial values obtained from the EMG measurements performed in area. Patients with these abnormalities often suffer from the submaximal voluntary contraction (subMVC) [5, 6]. +e aesthetic, morphological, and functional problems in the undoubted advantage of global electromyography that dentofacial region. Congenital maxillofacial defects have compensates for the abovementioned limitations is its significant psychological and socioeconomic effects on a patient’s quality of life and require a multidisciplinary team noninvasiveness [1]. Due to the simplicity of this method, its safeness, and availability, it has been used in studies on approach if it is to be managed properly. Clefts of the lip, alveolus, and/or palate are the most frequent head and neck children [7–9]. +e methodology of sEMG recordings, including elec- congenital deformities that significantly affect the functions of the stomatognathic system and disrupt normal facial trode placement, EMG signal processing, and modelling, is based on the Surface Electromyography for Non-Invasive structure [7, 9]. Assessment of Muscles (SENIAM) and +e International Society of Electromyography and Kinesiology (ISEK) rec- 2. Material and Methods ommendations [1]. Masseter and anterior temporalis muscles are the Original peer-reviewed papers on this subject, published in muscles most frequently evaluated by sEMG. Masticatory English between 1995 until 2020, are located in the MED- muscle electrical activity can be assessed during static tests LINE/PubMed database. +e literature search strategy was (rest, maximum, or sub-maximum voluntary clenching) or conducted as follows: keyword “surface electromyography” during active tests, such as opening or closing the mouth, was combined with each of “congenital maxillofacial ab- protrusion, retrusion, lateral deviation of the mandible, normalities,” “cleft lip and palate,” “Down syndrome,” chewing, swallowing, or speaking [1]. Rest activity is one of “hemifacial microsomia,” “craniosynostosis.” the most important static activities analysed. +ere is no isoelectric line observed in the sEMG recordings in this position determined by freeway space. However, some re- 2.1.ImagingofMuscleFunctioninCleftLipandPalate(CLP) search has shown that the clinical rest position is an active PatientsbymeansofsEMG. Clefts of the lip, alveolus, and/or muscle position because of the tone of the muscles involved palate are the most frequent congenital facial malformations in it [10]. Another important static test, which is frequently that significantly affect the functions of the stomatognathic analysed, is maximum voluntary contraction (MVC). +e system and disrupt dentofacial aesthetics [23, 24]. Besides EMG recordings during isometric contraction can be per- dysfunctional facial expressions, patients with cleft lip and formed while clenching the teeth as hard as possible for 3 to palate may have serious functional problems with sucking, 5 seconds, usually in an intercuspal position or during swallowing, breathing, chewing, speaking, hearing, and maximum clenching with a control substance, i.e., with social integration [25, 26]. Abnormal jaw growth in CLP cotton rolls placed on the mandibular second premolar and patients can result in severe malocclusion, which in turn may molars [11, 12]. EMG muscle potentials should also be affect the functioning of the maxillofacial muscles [7]. evaluated in a fatigue test, which involves a continuous 10- Successful treatment of a cleft patient involves multidisci- second sub-maximum or maximum isometric muscle plinary surgical and nonsurgical care performed from birth contraction. Median power frequency (MPF) and time- through to adulthood [27]. In a few published studies, frequency distributions are the most objective and reliable surface electromyography was used to detect the electrical EMG parameters for evaluating muscle resistance to fatigue potentials of the superior orbicularis oris muscle and [1]. In turn, the most frequent dynamic activity analysed by masticatory muscles in cleft lip and palate patients sEMG is mastication. It is usually expressed by such pa- [7, 9, 28–33]. rameters as the duration of the masticatory act, the number In a study by Szyszka-Sommerfeld et al. [9], the authors of cycles, and its effectiveness depending on the forces analysed the electrical activity of the superior orbicularis oris generated and food consistency [13]. +e use of electro- muscle by means of sEMG in patients ranging in age from 6 myographic indices, such as the activity index (Ac), sym- to 13 years. +eir study cohort comprised 45 children op- metry (percentage overlapping coefficient (POC), and erated on for unilateral complete cleft lips and palates torque coefficient (To, Tc)), makes it possible to assess the (UCCLP). +ey were compared with 40 control subjects with activity, coordination, and symmetry of the homologous, no cleft lip and palate. Electromyographical recordings were synergistic, and antagonistic muscles [1]. taken in the rest position and during saliva swallowing, lip According to the literature, surface electromyography is protrusion, and reciprocal compression of the lips, as well as widely used in orthodontics and maxillofacial orthopaedics while producing the bilabial phonemes /p/, /b/, and /m/ to help diagnose and treat patients with temporomandibular associated with the vowel /a/. +e authors observed that disorders (TMD), as well as to assess stomatognathic system patients with unilateral repaired complete cleft lip and palate dysfunctions in patients with malocclusions or monitor have abnormal upper lip function characterized by higher orthodontic therapies [8, 14–22]. Information regarding EMG activity of the superior orbicularis oris muscle during Journal of Healthcare Engineering 3 of the chewing cycle in the cleft group might be a conse- saliva swallowing and reciprocal compression of the lips in the cleft group. +us, they suggested that the excessive force quence of malocclusion and might result in functional in- efficiency, making mastication more difficult. applied by a repaired cleft lip to underlying structures during saliva swallowing and lip compression may affect facial Li et al. [30] evaluated masticatory muscle function in 29 morphology. Furthermore, the authors observed that EMG patients aged from 11 and 21 years with unilateral cleft lip values at rest and when producing the bilabial phonemes /p/, and palate (UCLP) and anterior crossbite. +e control group /b/, and /m/ combined with the vowel /a/ were comparable consisted of 28 noncleft subjects with normal occlusion. in both groups. +ey observed that the temporalis muscle EMG potentials at Ravera et al. [28] assessed superior orbicularis oris rest were significantly higher in UCLP patients compared to the controls. +e results of their study also showed altered muscle function at rest, during saliva swallowing, speaking, chewing, and apple swallowing in 14 children operated on masseter muscle function at rest and significantly lower masseter muscle electrical activity during maximum for unilateral CLP and ranging in age from 6 to 12 years. All cleft patients had clinically short upper lips, abnormal lip clenching in the intercuspid position in the cleft group. Surface electromyography was also used to image seal, and inhibited sagittal development of the midface. +e control group included 14 noncleft children aged between 8 masticatory muscle function in cleft lip and palate subjects and 11 years. +e authors noted significantly higher results with pain-related temporomandibular disorders (TMDs) for the electrical potentials of the superior orbicularis oris [31, 32]. TMDs are a collective term associated with a muscle at rest and during saliva swallowing in the cleft number of clinical conditions that affect the masticatory group, while EMG activity levels during speech were similar muscles, the temporomandibular joint (TMJ), and associ- in both cleft and noncleft subjects. +ey stated that the ated structures. +e main signs and symptoms of TMDs are muscle and joint sensitivity or pain, joint noises, and de- higher electrical activity of the upper lip at rest and during swallowing of saliva in children with CLP suggests that upon rangements in the movements of the mandible [34–36]. Patients with clefts are potentially at risk of developing higher functional demands their activity increases less than that in noncleft children. +ey also suggested that greater TMD, due to psychosocial burdens and malocclusions predisposing them to this disorder [37]. electrical potentials of the superior orbicularis oris muscle reflects increased force on the maxilla and as a consequence, Szyszka-Sommerfeld et al. [31] evaluated temporalis and the surgical treatment of cleft lip has an iatrogenic effect on masseter EMG activity in 31 CLP patients with pain-related facial growth. TMD and 32 CLP subjects with no TMD aged between 6 and Szyszka-Sommerfeld et al. [7] analysed masticatory 14 years. +ey observed that masticatory muscle activity at muscle activity by means of sEMG in children surgically rest in pain-related TMD cleft subjects was significantly treated for unilateral complete cleft lip and palate. +e higher and masticatory muscle EMG potentials during maximum voluntary clenching were markedly lower than authors also assessed the possible factors associated with such EMG activity. +e study population included 82 those in cleft children with no TMD diagnosis. Moreover, they found a significant increase in the Asymmetry Index for children with mixed dentition and Class I occlusions. +e cleft group consisted of 25 children aged between 6 and 13 temporalis and masseter muscle rest activity in pain-related years. +ey were compared with 57 control subjects aged TMD patients. +e authors concluded that cleft children between 6 and 12 years with no cleft lip and palate. +e EMG diagnosed with pain-related TMD have altered masticatory recordings of the temporalis and masseter muscles were muscle activity, and this can affect their muscle function. performed at rest and during maximum voluntary con- In another study by Szyszka-Sommerfeld et al. [32], the traction (MVC). +eir results showed that children with authors analysed the diagnostic efficiency of sEMG in UCCLP had altered temporalis muscle function at rest identifying CLP subjects with temporomandibular disor- compared with noncleft subjects. +ey also found that the ders. +eir sample comprised 88 patients with cleft lip and palate and mixed dentition. +e study population was presence of malocclusion, such as posterior crossbite, affects the temporalis muscle activity in cleft patients. +e authors subdivided into three groups: a pain-free TMD group, a TMD-pain group, and a non-TMD group. +e electrical declared that early diagnosis and orthodontic treatment of malocclusions are necessary to achieve the correct occlusion activity of the temporalis and masseter muscles was assessed and improvement in muscle function in these patients. in the rest position and during maximum voluntary con- da Costa et al. [29] used sEMG to analyse masticatory traction. +e results of the study revealed that surface muscle function at rest and during isometry and mastication electromyography is diagnostically useful in recognition of in 33 children with complete cleft lip and palate as well as in CLP patients with pain-related TMD and it could be used as 33 noncleft patients aged between 6 and 12 years. +ey found an adjunctive tool in the identification of this disorder. +ey found that the highest diagnostic efficiency of sEMG in much higher EMG potentials of the temporalis and masseter muscles in cleft subjects at rest and during inactive period of terms of identifying subjects with TMD and pain-related TMD was observed for the mean values of temporalis and mastication, whereas electrical activity in the left masseter muscle and temporalis muscles during active period of masseter muscle activity as well as the Asymmetry Index of the masseter muscles in a rest position. mastication and in every muscle during isometry was sig- nificantly lower. +e authors also observed that the muscles sEMG was also used to detect muscle electrical potentials of cleft children remained active for longer than in patients while monitoring orthodontic or surgical therapies in cleft with no cleft. da Costa et al. suggested that the higher length lip and palate patients. Sabbag et al. [33] assessed the EMG 4 Journal of Healthcare Engineering involvement. It primarily affects the ear, mouth, and jaw activity of the masseter and temporalis muscles in 32 nonsyndromic complete unilateral CLP patients surgically areas, though it may also involve the eye, cheek, neck, and other parts of the skull, as well as nerves and soft tissue [44]. treated with 2 different palate repair protocols (one-stage vs. two-stage). +e EMG potentials of the masticatory muscles Craniosynostosis is a developmental craniofacial malfor- were recorded at rest and during chewing. +e authors mation, resulting in impairment of brain development and observed similar masseter and temporalis EMG activity abnormally shaped skull. +e main cause of craniosynostosis while mastication and at rest after one- and two-stage palate is premature closure of one or more cranial sutures. When closure. left untreated, craniosynostosis can cause serious compli- cations, such as impairment of mental development, facial abnormality, sensory, respiratory and neurological dys- 2.2. Assessment of Muscle Function in Patients with Down function, anomalies affecting the eye, psychological dis- Syndrome (DS) by means of sEMG. Down syndrome is a turbances, sleeping impairment, and eating difficulties [45]. chromosomal alteration caused by trisomy 21. Many Telich-Tarriba et al. [41] used sEMG to assess masti- comorbidities are associated with DS, including obstructive catory muscle function in patients with hemifacial sleep apnea and masticatory muscle alteration. One of the microsomia (HFM). +ey compared the bite force and characteristics most commonly found in patients with Down electrical activity of masseter muscle in 20 children with syndrome is the presence of generalized muscular hypoto- hemifacial microsomia and 10 healthy controls with a mean nia, particularly of the masticatory and oropharyngeal age of 7.2 years. EMG recordings were performed in muscles, which directly affect the stomatognathic system, maximum intercuspation and at rest from both sides of the resulting in speech, swallowing, and mastication impair- face. +e authors found that masseter muscle EMG po- ments in these individuals [38, 39]. Few studies have assessed tentials in maximum intercuspation were significantly muscle activity in DS patients by means of sEMG. In a lower in HFM patients compared with both the healthy side published paper, sEMG was used to evaluate masticatory and the control group. Moreover, they observed significant muscle function while monitoring orthodontic therapy in differences in the masseter muscle EMG activity of affected subjects with Down syndrome [39, 40]. and nonaffected sides at rest in children with hemifacial Giannasi et al. [39] assessed the therapeutic effects of microsomia. surface neuromuscular electrical stimulation, mastication Suzuki et al. [42] investigated the relationship between apparatus, and a mandibular advancement device with an mandibular ramus height and masticatory muscle function embedded thermosensitive microchip on masticatory in 29 patients with hemifacial microsomia. +ey observed muscle function, physiological sleep variables, and salivary that decreased mandibular ramus height was significantly parameters in patients with Down syndrome aged between correlated with both reduced masseter muscle EMG po- 18 and 40 years. sEMG was used to detect temporalis and tentials and the amount of mandibular lateral deviation at masseter muscle electrical potentials. Following an analysis the time of maximum opening on the affected side. +e of the study results, the authors stated that the primary authors suggested that decreased mandibular ramus height outcomes would be an improvement and/or reestablishment may cause dysfunction of the masseter muscles but not the of masticatory muscle function and physiological sleep temporalis muscle on the affected side in patients with variables in these target subjects since patients with DS hemifacial microsomia. commonly exhibit generalized muscular hypotonia and Martini et al. [43] analysed masticatory muscle function dysfunction of the oropharyngeal musculature. in 15 patients with craniosynostosis after cranioplasty, as Mazille et al. [40] used video and sEMG recordings to well as in 25 7-year old nonoperative healthy controls. +e investigate the therapeutic impact of wearing an orthetic maximum bite force and EMG activity of the temporalis and intra-oral appliance on chewing variables in 8 Down syn- masseter muscles were assessed. +e results of the study drome subjects with a mean age 27±6 years. +e simul- revealed that the EMG potentials of the temporalis muscle taneous use of EMG and video recordings revealed the correlated positively with the bite force and showed a slightly presence of lower jaw movements not corresponding to lower resting activity in the control group, whereas muscle EMG activities in the masticatory muscles. +e authors fatigue occurred slightly faster in both muscles of children observed that, compared to the pretreatment state, wearing who had been operated on, but no statistically significant an occlusal appliance lowered chewing frequency and in- differences between the two groups were observed. creased masticatory time. 3. Conclusions 2.3. sEMG Recordings of Patients with Other Congenital MaxillofacialAbnormalities. Surface electromyography also +is literature review of studies involving surface electro- provided the basis for assessing masticatory muscle activity myography demonstrated its usefulness as a method of in patients with other congenital maxillofacial anomalies, muscle function imaging in patients with congenital ab- such as hemifacial microsomia or craniosynostosis [41–43]. normalities of the maxillofacial region. sEMG could be used Hemifacial microsomia is the second most common con- as an additional tool in the diagnosis or monitoring or- genital anomaly of the craniofacial region behind cleft lip thodontic therapies in these patients, thereby expanding our and palate. +is malformation is characterized by asym- knowledge about the anatomy, physiology, and pathology of metric facial growth with mandibular and muscle their stomatognathic system. 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