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Does professional violin/viola playing influence facial morphology?

1. Introduction

Kovero et al. study the possible effect of long-term violin and viola playing on the facial skeleton: professional violin and violin playing involves asymmetric face, neck and shoulder muscle activity (repeated or continuous application of pressure or force is known to influence bone morphology), reducing growth of the facial height. It does not totally prevent it: there is a positive correlation between age and facial height also in the player group. Yeo et al. hold that patients who play musical instruments (especially wind and stringed instruments) and vocalists are prone to particular types of orofacial problems, and identify orthodontic problems, soft tissue trauma, focal dystonia, denture retention, herpes labialis, dry mouth and temporomandibular joint (TMJ) disorders as orofacial problems of career musicians. Steinmetz et al. say that professional musicians are subjected to high impacts on neck, shoulders, and the upper extremities, when playing their instruments.

2. Long-term violin and viola playing has a modifying effect on dentofacial morphology

Kovero et al. argue that this continuance of growth of facial height in adulthood proclines the maxillary incisors and increases the length of the mandibular corpus. The instrument is pressed against the mandibular angle at the left, and the right condyle is pressed into the articular fossa during playing. Kovero et al. reason that long-term violin and viola playing has a modifying effect on dentofacial morphology: this effect is manifested as smaller facial heights, greater proclination of the maxilliary incisors and greater length of the mandibular corpus in violin/viola players than in controls (with regard to facial symmetry, the forces and pressures involved in violin and viola playing are not unfavourable (they seem to reduce rather than increase facial asymmetry). (1)

Yeo et al. write that with the popularity of musical instruments, dentists are treating an increasing number of musicians of all ages and abilities: the treatment of orofacial problems may have adverse consequences for the players of woodwind instruments, some stringed instruments (violin and viola) and vocalists. Patients should be questioned about the frequency and duration of their musical sessions. The dentist can gain a greater understanding of the patient's radiographs and study models. Playing a wind instrument is a complex neuromuscular task that requires increased orofacial muscle activity. Yeo et al. maintain that musicians report a variety of orofacial problems, which interfere with their playing or cause general discomfort. Forces produced by the playing of wind instruments are larger than forces produced by average muscle contractions. Brass instruments can help to reduce overjet and decrease overbite. Instruments with a small aperture can help to reduce overjet. Focal dystonia has been reported in violinists and musicians who play both woodwind and brass instruments. Woodwind players tend to have outbreaks on the lower lip and brass instrument players on the upper lip. The violin is held parallel to the floor between the shoulder and the jaw but with the position and pressure of the jaw and shoulder constantly changing. Yeo et al. point out that the pressure exerted in supporting the viola during playing has resulted in fracturing of molar cusps in some individuals. Violinists and violists report neck pain more frequently than the population norm, pain in the masseter and temporalis muscles, and are prone to TMJ disorders, particularly pain in the region of the right TMJ, due to the pressure on the mandible of holding the instrument and the clenching of the masticatory muscles. Treatment options for TMJ disorders and neck pain include modification of the shoulder rest (measures which have given some relief to players: resting the instrument on the clavicle, chewing sugarfree gum during practice, and sitting rather than standing).
   'Fiddler's neck' is commonly found in violin (59 per
   cent) and viola (67 per cent) players where the instrument
   rests on the left side of the neck. This can range
   from a chronic dermatitis to serious infection and severe
   pain. Contributing factors include pressure, friction, perspiration
   and poor hygiene, and may also include allergy
   to some wood. It is important to rule out more serious
   diseases, such as cervical lymphadenopathy associated
   with malignancy, and diseases of the salivary gland. To
   reduce the incidence of the 'fiddler's neck', a custommade
   chin rest is recommended for the violin or viola
   player. Other treatment options include altering posture,
   padding of the chin rest, shorter practice times, growing
   a beard (although follicle irritation may occur) and
   placing a cloth between the instrument and the neck. (2)

3. Violin playing and the presence of signs and symptoms of temporomandibular disorder (TMD)

Rodriguez-Lozano et al. determine that there is an association between violin playing and the presence of signs and symptoms of temporomandibular disorder (TMD). Rodriguez-Lozano et al. studied a group of violinists in the Murcia region of Spain, who were examined for TMD, the results were compared with those from a random control group who did not play any musical instrument, and the groups were matched by age and gender (statistical analysis was carried out using SPSS 15.0 statistical software). Compared with the control subjects, the violinists as a group had significantly more pain in maximum mouth opening (P < .005), parafunctional habits (P = .001), and occurrence of temporomandibular joint sounds (P < .005) as determined by chi-squared. (3) Bache and Edenborough discover the dangers hidden within the confines of the orchestral practice room, and look at the dangers associated with other types of music making. Musicians who tour have unique stresses placed on their health. Bache and Edenborough say that playing a musical instrument requires highly coordinated, repetitive fine movements under adverse conditions of unusual posture and considerable force. focal dystonias are caused by overactive neural plasticity in the motor cortex, predisposed by a hereditary component and male sex. Guitarists and harpists can develop calluses, subungual haematomata, and paronychias. Damage from playing an instrument is not restricted to damage to the musician. Wind musicians have decreased pulmonary function compared with a control group. (4)

4. The particular impacts of individual symptom clusters on the musicians' capacity to play their musical instrument

Steinmetz et al. argue that craniomandibular dysfunction (CMD) symptoms occur frequently in violin/viola and wind players and can be associated with pain in the neck, shoulders and arm. Musical performance requires complex and precise sensorimotor function. Up to 80% of professional musicians suffer from medical problems when playing their instruments: such musicians experience problems and pain in the musculoskeletal system, which are characterized as playing-related musculoskeletal disorders (PRMD). Interdisciplinary collaboration between manual therapists and orthodontists is vital in the determination and optimization of splint position in perfect occlusion and in a neuromuscular rest position. Steinmetz et al. elucidate the particular impacts of individual symptom clusters on the musicians' capacity to play their musical instrument. Steinmetz et al. aim to follow-up musicians with CMD, undergoing treatment with oral splints, and to elucidate influences of CMD symptoms on playing their musical instruments. The impact of CMD on the whole musculoskeletal system is well recognized. Craniomandibular dysfunctions are frequently associated with pain and discomfort in the shoulder and the whole upper extremity. Musicians with musculoskeletal problems should be examined for CMD symptoms and treated accordingly. Steinmetz et al.'s data lend added support to the evidence-base, confirming efficacy of oral splint treatments in CMD-associated pain and problems in neck, shoulder, and the upper extremities in musicians. (5)

5. Conclusion

Kovero et al. remark that the players are subject to the vibrations and weight of their instrument, which they hold between the left shoulder and left angle of the mandible for long periods daily (the concept of orthodontic and orthopaedic treatment is based on the fact that bone growth and morphology can be modified by pressure). According to Yeo et al., career musicians express reluctance to attend dentists who are not sensitive to their specific needs. General practitioner dentists who understand how the instruments impact on the orofacial structures and are aware of potential problems faced by musicians are able to offer preventive advice and supportive treatment to these patients, especially those in the early stages of their career. Steinmetz et al. demonstrate a significant and clinically important improvement of pain intensity and pain frequency in different anatomical regions.


(1.) Kovero, O. et al. (1997), "The Effect of Professional Violin and Viola Playing on the Bony Facial Structures", European Journal of Orthodontics 19: 39-45.

(2.) Yeo, D.K.L. (2008), "Specific Orofacial Problems Experienced by Musicians", Australian Dental Journal 47(1): 10.

(3.) Rodriguez-Lozano, F. et al. (2010), "Prevalence of Temporomandibular Disorder-related Findings in Violinists Compared with Control Subjects", Oral Surgery, Oral Medicine, Oral Pathology, Oral Radiology, and Endodontology 109(1): 15-19.

(4.) Bache, S. and Edenborough, F. (2008), "A Symphony of Maladies", British Medical Journal 337: 26-46.

(5.) Steinmetz, A. et al. (2009), "Professional Musicians with Craniomandibular Dysfunctions Treated with Oral Splints", CRANIO: The Journal of Craniomandibular Practice 27(4): 221-230.


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Author:Gligor, Mihaela R.
Publication:Analysis and Metaphysics
Article Type:Report
Geographic Code:1USA
Date:Jan 1, 2009
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