Paradoxical masseteric bulging after botulinum neurotoxin type A injection.

Paradoxical masseteric bulging refers to an unexpected occurrence of masseter muscle bulging or protrusion following the administration of botulinum toxin injections, contrary to the anticipated muscle weakening effect. It may occur secondary to toxin failing to diffuse through the entire masseter muscle due to the presence of an inferior tendon structure within the superficial masseter that divides it into a superficial and deep belly. We report a clinical case of paradoxical masseteric bulging in a female in her late 40s who developed this adverse effect within a week of her masseter botulinum neurotoxin type A injections. We also describe the masseter two-site injection technique for the management of this complication.

Sex-related differences in response to masseteric injections of glutamate and nerve growth factor in healthy human participants.

The neurophysiological mechanisms underlying NGF-induced masseter muscle sensitization and sex-related differences in its effect are not well understood in humans. Therefore, this longitudinal cohort study aimed to investigate the effect of NGF injection on the density and expression of substance P, NMDA-receptors and NGF by the nerve fibers in the human masseter muscle, to correlate expression with pain characteristics, and to determine any possible sex-related differences in these effects of NGF. The magnitude of NGF-induced mechanical sensitization and pain during oral function was significantly greater in women than in men (P < 0.050). Significant positive correlations were found between nerve fiber expression of NMDA-receptors and peak pain intensity (rs = 0.620, P = 0.048), and expression of NMDA-receptors by putative nociceptors and change in temporal summation pain after glutamate injection (rs = 0.561, P = 0.003). In women, there was a significant inverse relationship between the degree of NGF-induced mechanical sensitization and the change in nerve fiber expression of NMDA-receptors alone (rs = - 0.659, P = 0.013), and in combination with NGF (rs = - 0.764, P = 0.001). In conclusion, women displayed a greater magnitude of NGF-induced mechanical sensitization that also was associated with nerve fibers expression of NMDA-receptors, when compared to men. The present findings suggest that, in women, increased peripheral NMDA-receptor expression could be associated with masseter muscle pain sensitivity.

Management of unilateral idiopathic masseter muscle hypertrophy with botulinum toxin type A.

Masseter hypertrophy (MH) is an uncommon disorder which can cause both aesthetic and functional problems. The most common aetiological factors associated with MH are habit of chewing gum, clenching and/or bruxism. The treatment of MH includes conservative management as well as surgical resection of the enlarged muscle and/or bone. Injection of botulinum toxin type A is a relatively new and minimally invasive method for management of masseter muscle hypertrophy, which offers many advantages over conventional surgical management. This paper reports a case of unilateral MH of unknown origin which was treated with injection of botulinum toxin type A, resulting in satisfactory reduction in the volume of muscle and improvement of facial aesthetics.

Treatment with the essential amino acid L-tryptophan reduces masticatory impairments in experimental cerebral palsy.

Purpose Children with cerebral palsy (CP) often exhibit difficulties in feeding resulting from deficits in chewing. This study investigates the therapeutic potential of L-tryptophan (TRI) to reduce deficits in chewing in rats subjected to an experimental model of CP.Methods A total of 80 Wistar albino rats were used. Pups were randomly assigned to 4 experimental groups: Control Saline, Control TRI, CP Saline, and CP TRI groups. The experimental model of CP was based on the combination of perinatal anoxia associated with postnatal sensorimotor restriction of the hind limbs. TRI was administered subcutaneously during the lactation period. Anatomical and behavioral parameters were evaluated during maturation, including body weight gain, food intake, chewing movements, relative weight and the distribution of the types of masseter muscle fibers.Results The induction of CP limited body weight gain, decreased food intake and led to impairment in the morphological and functional parameters of chewing. Moreover, for a comparable amount of food ingested, CP TRI animals grew the most. In addition, supplementation with TRI improved the number of chewing movements, and increased the weight and proportion of type IIB fibers of the masseter in rats subjected to CP.Conclusion These results demonstrate that experimental CP impaired the development of mastication and that TRI supplementation increased masticatory maturation in animals subjected to CP.

Change in jaw occlusive power by paralysis of masseter muscle with a neuromuscular blocker: Sion's masseter muscle paralysis.

STUDY OBJECTIVE: We aimed to determine whether jaw occlusive power decreases with the injection of neuromuscular blocking agents in masseter muscle - a method we named Sion's masseter muscle paralysis (SMP). METHODS: A randomized, placebo-controlled animal study was conducted in which researchers were blinded to group allocation. We used 12 male mongrel dogs aged 10-12 months and weighing 30-35 kg. Four groups were formed: a conventional dose (CD) group (0.004 mg/kg succinylcholine in 4 ml normal saline [NS]); a high dose (HD) group (0.04 mg/kg succinylcholine in 4 ml NS); a placebo group (4 ml NS); and no intervention group. To measure the jaw occlusive power, 1 kg weight was hung sequentially on a specifically designed device on the animal's lower jaw. At -4, -2, 0', +2, +4, +6, +8, +10, +20, and +30 min, we measured the jaw occlusive power, oxygen saturation (SpO2), and end-tidal carbon dioxide (ETCO2). RESULTS: After SMP, jaw occlusive power began to decline in CD and HD group. The arithmetical mean jaw occlusive power values at -4, -2, 0', +2, +4, +6, +8, and +10 min were 9.7, 9.7, 9.7, 8.7, 8.3, 7.3, 6.7, and 6.3 kgw in the CD group and 9.7, 9.3, 8.7, 8.0, 6.7, 5.0, 5.0, and 5.3 kgw in the HD group. No abnormalities in SpO2or ETCO2were detected. CONCLUSION: Jaw occlusive power was decreased after SMP with succinylcholine, without inducing respiratory complication.

Local anaesthesia decreases nerve growth factor induced masseter hyperalgesia.

The aim of this investigation was to evaluate the effects of local anaesthesia on nerve growth factor (NGF) induced masseter hyperalgesia. Healthy participants randomly received an injection into the right masseter muscle of either isotonic saline (IS) given as a single injection (n = 15) or an injection of NGF (n = 30) followed by a second injection of lidocaine (NGF + lidocaine; n = 15) or IS (NGF + IS; n = 15) in the same muscle 48 h later. Mechanical sensitivity scores of the right and left masseter, referred sensations and jaw pain intensity and jaw function were assessed at baseline, 48 h after the first injection, 5 min after the second injection and 72 h after the first injection. NGF caused significant jaw pain evoked by chewing at 48 and 72 h after the first injection when compared to the IS group, but without significant differences between the NGF + lidocaine and NGF + IS groups. However, the mechanical sensitivity of the right masseter 5 min after the second injection in the NGF + lidocaine group was significantly lower than the second injection in the NGF + IS and was similar to the IS group. There were no significant differences for the referred sensations. Local anaesthetics may provide relevant information regarding the contribution of peripheral mechanisms in the maintenance of persistent musculoskeletal pain.

Comparison between Conventional Blind Injections and Ultrasound-Guided Injections of Botulinum Toxin Type A into the Masseter: A Clinical Trial.

The aim of the study was to propose a more efficient and safer botulinum toxin type A (BoNT-A) injection method for the masseter by comparing the conventional blind injection and a novel ultrasonography (US)-guided injection technique in a clinical trial. The 40 masseters from 20 healthy young Korean volunteers (10 males and 10 females with a mean age of 25.6 years) were included in this prospective clinical trial. The BoNT-A (24 U) was injected into the masseter of each volunteer using the conventional blind and US-guided injection techniques on the left and right sides, respectively, and analyzed by US and three-dimensional (3D) facial scanning. One case of PMB (paradoxical masseteric bulging) was observed on the side where a conventional blind injection was performed, which disappeared after the compensational injection. The reduction in the thickness of the masseter in the resting state differed significantly at 1 month after the injection between the conventional blind injection group and the US-guided injection group by 12.38 ± 7.59% and 17.98 ± 9.65%, respectively (t(19) = 3.059, p = 0.007). The reduction in the facial contour also differed significantly at 1 month after the injection between the conventional blind injection group and the US-guided injection group by 1.95 ± 0.74 mm and 2.22 ± 0.84 mm, respectively (t(19) = 2.908, p = 0.009). The results of the study showed that the US-guided injection method that considers the deep inferior tendon by visualizing the masseter can prevent the PMB that can occur during a blind injection, and is also more effective.

Botulinum Toxin Therapy for Managing Sleep Bruxism: A Randomized and Placebo-Controlled Trial.

The purpose of this study is to evaluate the effects of botulinum toxin type A (BoNT-A) for managing sleep bruxism (SB) in a randomized, placebo-controlled trial. Thirty SB subjects were randomly assigned into two groups evenly. The placebo group received saline injections into each masseter muscle, and the treatment group received BoNT-A injections into each masseter muscle. Audio-video-polysomnographic recordings in the sleep laboratory were made before, at four weeks after, and at 12 weeks after injection. Sleep and SB parameters were scored according to the diagnostic and coding manual of American Academy of Sleep Medicine. The change of sleep and SB parameters were investigated using repeated measures analysis of variance (RM-ANOVA). Twenty-three subjects completed the study (placebo group 10, treatment group 13). None of the SB episode variables showed a significant time and group interaction (p > 0.05) except for electromyography (EMG) variables. The peak amplitude of EMG bursts during SB showed a significant time and group interaction (p = 0.001). The injection decreased the peak amplitude of EMG bursts during SB only in the treatment group for 12 weeks (p < 0.0001). A single BoNT-A injection cannot reduce the genesis of SB. However, it can be an effective management option for SB by reducing the intensity of the masseter muscle.

Behavioural, electrocorticographic, and electromyographic alterations induced by Nerium oleander ethanolic extract: Anticonvulsant therapeutics assessment.

Nerium oleander Linn. is an Apocynaceae shrub which is among the most toxic ornamental plants. Although seizures are one of the symptoms associated with N. Oleander poisoning in humans, only a few studies are available on the behavioural and electrophysiological alterations caused by this plant poisoning. This study aimed at providing a thorough description of the electroencephalographic (EEG) and electromyographic (EMG) profiles throughout the experimental poisoning of Wistar rats (200-250 g) using ethanolic extract of N. oleander (EENO). Further, seizure control was assessed using different anticonvulsants. Male Wistar rat's behaviour was assessed upon EENO (150 mg/kg) administration and the animals were evaluated for muscle and neural activities through EMG and EEG recordings, respectively. The behavioural test showed two distinct phases of CNS activity: Phase I - myorelaxation and depression, and Phase II - excitability (agitated behaviour and seizures). Such phases were consistent with the EEG and EMG tracing patterns attained. Within the first 400 s of the recordings, during Phase I, the EMG showed no tracing amplitude variation. Later, the tracing pattern was changed and an intensification of the muscle contraction power in higher frequencies was observed during Phase II. The EEG showed initially a slight flattening in the tracings with a reduction in the intensity of the signal as per spectrogram of frequency attained. Thereafter, during Phase II, much higher amplitude tracings could be noted with an intensification of the signal, compatible with seizures. Seizure control was evaluated using four agents: phenytoin, phenobarbital, diazepam and scopolamine (at 10 mg/kg in all cases). While scopolamine was not effective in the seizure control, diazepam was the most efficient drug for the attenuation of the poisoning. Our results indicate the possibility of including phenytoin, phenobarbital and diazepam, mainly the latter, in the poisoning therapeutic protocol, including for those individuals who could be more susceptible to the poisoning by Nerium oleander as in the case of epileptic patients.

Decreased mandibular cortical bone quality after botulinum toxin injections in masticatory muscles in female adults.

This study aimed to clarify how masticatory muscle atrophy induced by botulinum toxin (BTX) injection affects cortical bone quality of the mandible using 3D modeling technology. A total of 39 young (26.9 ± 6.0 years) and 38 post-menopausal (55.3 ± 6.3 years) females were included. Computed tomography (CT) images were obtained before and after 12 months of treatment. Predictor variables were application of a stabilization splint, and/or two times of BTX injection in the bilateral temporalis and masseter muscles within a six-month interval. Outcome variables were changes in average Hounsfield units (HU) and cortical thickness of region of interest (ROI). 3D mandibular models were reconstructed using CT images, and models were used to calculate average HU and cortical thickness of ROIs, including inferior half of the lateral surface of ascending ramus, coronoid process, and temporomandibular joint condyle. Cortical bone quality at muscle insertion site was influenced by decreased muscle thickness but seemed not to be affected by decreased functional loading. Reduced functional loading seemed to influence cortical bone quality of the condyles. These effects were more remarkable in post-menopausal females. Hence, decreased masticatory muscle thickness may lead to alterations of the mandibular cortical structures, especially in post-menopausal females.

Histological features of masticatory muscles after botulinum toxin A injection into the right masseter muscle of dystrophin deficient (mdx-) mice.

OBJECTIVE/BACKGROUND: The most frequently used animal model for human DMD (Duchenne muscular dystrophy) research is the mdx mouse. In both species, characteristic histological changes like inflammation, muscle fiber degeneration and fibrosis are the same, but in contrast to humans, in mdx mice, phases of muscle fiber degeneration are compensated by regeneration processes. AIM: Therefore, the interest of this study was to evaluate histological features in masticatory muscles after BTX-A injection into the right masseter muscle of wild type and dystrophic (mdx) mice, illustrating de- and regeneration processes induced by this substance. MATERIAL AND METHODS: The right masseter muscle of 100 days old healthy and mdx mice were selectively paralyzed by a single intramuscular BTX-A injection. Masseter as well as temporal muscle of injection and non-injection side were carefully dissected 21 days and 42 days after injection, respectively, and fiber diameter, cell nuclei position, necrosis and collagen content were analyzed histomorphologically in order to evaluate de- and regeneration processes in these muscles. Statistical analysis was performed using SigmaStat Software and Mann Whitney U-test (significance level: p < 0.05). RESULTS: At both investigation periods and in both mouse strains fiber diameter was significantly reduced and collagen content was significantly increased in the right injected masseter muscle whereas fiber diameters in mdx mice were much smaller, and these differences were even more apparent at the second investigation period. Necrosis and central located nuclei could generally be found in all mdx mice muscles investigated with an amount of centronucleation exceeding 60%, and a significant increase of necrosis six weeks after injection. In wild type mice central located nuclei could primarily be found in the treated masseter muscle with a portion of 2.7%, and this portion decreased after six weeks, whereas in mdx mice a decrease could also be seen in the non-injected muscles. In contrast, in wild type mice necrosis was not apparent at any time and in all muscles investigated. CONCLUSION: From our results it can be concluded that in mdx mice masticatory muscles de- and regeneration processes were extended, triggered by a selective BTX-A injection, or mdx mice at this age, independently of BTX-A treatment, went through another cycle of de- and regeneration as a characteristic of this disease.

Tratamiento del bruxismo con toxina botulínica tipo A. Estudio clínico prospectivo / Bruxism treatment with botulinum toxin type A. Prospective clinical study

Introducción y objetivo: El bruxismo (BRX) se define como rechinar y/o apretar los dientes, involuntaria e intensamente, debido a hipertrofia y/o contracción reiterada de los músculos masticatorios, especialmente los maseteros. Puede suceder durante el sueño o de día indistintamente. Los tratamientos empleados tienen la finalidad de limitar el daño sobre diferentes estructuras biológicas, especialmente la articulación témporo-mandibular (ATM), y oscilan desde oclusión irreversible, interposición de férulas, tratamiento farmacológico y/o terapias cognitivas, así como el empleo de toxina botulínica tipo A (TB-A). El objetivo de nuestro estudio fue investigar el efecto de relajación inducido por la inyección de TB-A en los maseteros y su relación con el alivio de los síntomas referidos por los pacientes con BRX. Material y método. Estudio clínico, prospectivo y longitudinal en 25 pacientes, mujeres, de 24 a 67 años (37.2 ± 10.7), desde setiembre de 2018 a marzo de 2019.Los controles de evaluación se realizaron antes, 2 semanas y 4 meses después del tratamiento con TB-A. Se tomaron fotografías digitales, se valoró el índice de desgaste dental de Smith-Knigth y se realizó ortopantomografía. Algunas pacientes aportaron resonancia magnética nuclear. Se tomaron medidas del diámetro bigonial mediante calibre digital y se valoró el grosor de los maseteros en reposo y contracción, por medición ecográfica. Resultados: Después del tratamiento con TB-A, el 24% de las pacientes se vieron libres de BRX y el 76% restante obtuvo gran mejoría; hubo escasos y transitorios efectos adversos. Conclusiones: La TB-A protege las estructuras orofaciales (dientes, músculos mandibulares, ATM) del daño inducido por el BRX, al tiempo que alivia el dolor y los síntomas relacionados con la excesiva contracción muscular

Background and objective: Bruxism (BRX) is defined as grinding or clenching of teeth, involuntarily and intensely, due to hypertrophy and/or contraction of muscles related to chewing, with particular involvement of masseters. It can happen during sleep or wakefulness indistinctly. Treatments are intended to limit destructive effects of BRX on different biological structures, especially the temporomandibular joint; are variable and range from irreversible occlusion, interposition of splints, pharmacological therapies, cognitive-behavioral approaches and the use of botulinum toxin type A (BoNT-A). The aim of this study was to investigate the relaxation effect of BoNT-A injection in masseter muscles and its relation to relief of symptoms in patients with BRX. Methods: This study is a clinical, prospective and longitudinal trial on 25 adult female patients between age ranges 24 to 67 (3.,2 ± 10.7), carried out from September 2018 to March 2019.Evaluation controls were done before, 2 weeks and 4 months after treatment with BoNT-A. Examination protocol in the trial included digital photography, Smith and Knight tooth wear index, orthopantomogra- phy and magnetic resonance imaging. Measurements of bigonial diameters were taken by calliper, at rest and during contraction, and the thickness of each masseter muscle was also evaluated in the same conditions, by ultrasound at every control. Results.As a result, after BoNT-A treatment, 24% of the patients were free of BRX, while the remaining 76% obtained a significant improvement, with few and transient adverse effects. Conclusions: BoNT-A can be used to protect oral-facial structures (such as teeth, jaw muscles, temporomandibular joint), from excessive forces and harmful damage caused by BRX, and to relieve accompanying pain and related complaints by decreasing the muscle forces exerted during contraction

The pro-algesic effect of γ-aminobutyric acid (GABA) injection into the masseter muscle of healthy men and women.

Background and aims Preclinical studies have reported that activation of peripheral γ-aminobutyric acid A (GABAA) receptors may result in analgesia. The current study was conducted in young healthy men (n = 30) and women (n = 28) to determine whether injections of GABA into the masseter muscle reduce pain in a sex-related manner. Methods The effect of injection of GABA alone, or in combination with the non-inflammatory algogen glutamate, was assessed in two separate studies. Lorazepam, a positive allosteric modulator of the GABAA-receptor, was co-injected with GABA in both studies to explore the role of this receptor in muscle pain responses of healthy human volunteers. Masticatory muscle mechanical pain intensity was recorded on an electronic visual analogue scale (VAS) while muscle pain sensitivity was assessed by determining the pressure pain threshold (PPT), tolerance and maximal jaw opening (MJO) of the subjects prior to, and again after the various intramuscular injections. Results Intramuscular injection of GABA alone was reported to be significantly more painful, in a concentration related manner, than saline control injections, and this pain was further increased by co-injection of lorazepam with GABA. Co-injection of GABA with glutamate was found to significantly increase glutamate-evoked masseter muscle pain in men, but not in women. There was no effect of injections of either GABA alone, or GABA with glutamate, on PPT, tolerance or maximum jaw opening. Conclusions Injection of GABA into the human masseter muscle appears to excite nociceptors to produce muscle pain without a longer term effect on mechanical pain sensitivity in the muscle. The findings suggest that GABA-mediated pain in humans is produced through peripheral GABAA receptor activation. The mechanism underlying the sex-related difference in the effect of GABA on glutamate-evoked muscle pain was speculated to be due to a methodological artifact. Implications This study was designed to detect analgesic rather than algesic effects of peripherally administered GABA, and as a result, the concentration of glutamate chosen for injection was close to the maximal pain response for healthy women, based on previously determined pain-concentration response relationships for glutamate. This may explain the finding of greater pain in men than women, when GABA and glutamate were co-injected. Overall, the findings suggest that activation of peripheral GABAA receptors in human masticatory muscle produces pain, possibly due to depolarization of the masticatory muscle afferent fibers.

The effects on the mandibular condyle of Botox injection into the masseter are not transient.

OBJECTIVES: To evaluate whether the effects on the mandibular condylar cartilage (MCC) and subchondral bone are transient of botulinum neurotoxin (Botox) injection into the masseter muscle. METHODS: Botox (0.3 U) was injected into the right masseter of 6-week-old female mice (C57BL/6; n = 16). In addition, 16 mice were used as control and received no injections. Experimental and matching control mice were killed 4 or 8 weeks after the single Botox injection. Mandibles and mandibular condyles were analyzed by means of microscopic computed tomography (microCT) and histology. Sagittal sections of condyles were stained for tartrate-resistant acid phosphatase (TRAP), toluidine blue, 5-ethynyl-2'-deoxyuridine (EdU), and terminal deoxynucleotide transferase-mediated dUTP nick-end labeling. RESULTS: Bone volume fraction was significantly decreased on the subchondral bone of the Botox-injected side, compared with the control side and control mice, 4 and 8 weeks after injection. Furthermore, histologic analysis revealed decrease in mineralization, cartilage thickness, TRAP activity, and EdU-positive cells in the MCC of the Botox-injected side 4 and 8 weeks after injection. CONCLUSIONS: The effects on the MCC and subchondral bone of Botox injection into the masseter muscle persisted for 8 weeks after injection and were not considered to be transient.

Masseter corticomotor excitability is decreased after intramuscular administration of nerve growth factor.

BACKGROUND: Quantification of motor-evoked potentials (MEPs) can contribute to better elucidate the central modulation of motor pathways in response to nociceptive inputs. The primary aim of this study was to assess the modulatory effects of nerve growth factor (NGF) injection on masseter corticomotor excitability. METHODS: The healthy participants of this randomized, double blind placebo-controlled experiment were assigned to have injected into the right masseter muscle either NGF (n = 25) or isotonic saline (IS, n = 17). The following variables were assessed at baseline and 48 hr after the injection: right masseter MEP amplitude and corticomotor mapping and clinical assessment of jaw pain intensity and function. Repeated Measures ANOVA was applied to the data. RESULTS: NGF caused jaw pain and increased jaw functional disability after the injection (p < 0.050). Also, the participants in the NGF group decreased the MEP amplitude (p < 0.001) but the IS group did not present any significant modulation after the injection (p > 0.050). Likewise, the participants in the NGF group reduced corticomotor map area and volume (p < 0.001), but the IS group did not show any significant corticomotor mapping changes after the injection (p > 0.050). Finally, there was a significant correlation between the magnitude of decreased corticomotor excitability and jaw pain intensity on chewing 48 hr after the NGF injection (r = -0.51, p = 0.009). CONCLUSION: NGF-induced masseter muscle soreness can significantly reduce jaw muscle corticomotor excitability, which in turn is associated with lower jaw pain intensity and substantiates the occurrence of central changes that most likely aim to protect the musculoskeletal orofacial structures. SIGNIFICANCE: Intramuscular administration of nerve growth factor into masseter muscle causes inhibitory corticomotor plasticity, which likely occurs to prevent further damage and seems associated with lower pain intensity on function.

Botulinum Toxin Injections for Masseter Reduction in East Asians.

BACKGROUND: Cultural ideals for a slimmer face have led to an upsurge in interest in facial contouring among East Asians. Although surgical resection has traditionally been the main treatment option, botulinum toxin injection is becoming a popular, noninvasive alternative. OBJECTIVE: To describe the use of botulinum toxin injection for masseter reduction in East Asians. METHODS: An electronic search of the PubMed database was performed for studies published from 2000 to 2017 that meet the word combination of botulinum toxin, masseter, hypertrophy, and/or lower face contouring. Only the studies conducted in East Asian countries were analyzed in this review, exception of one study from Thailand. RESULTS: A total of 12 publications were identified. Each study was reviewed to extract relevant information on patient selection, injection techniques, efficacy, dosage, frequency, and main side effects of treating masseters with botulinum toxin. CONCLUSION: Botulinum toxin injection for masseter reduction in East Asians is efficacious and generally considered safe with no significant side effects. Future areas for investigation include defining the criteria for benign masseteric hypertrophy, minimum effective dosage of botulinum toxin, and the potential long-term effects of the injection.

Consensus Statement of the Malignant Hyperthermia Association of the United States on Unresolved Clinical Questions Concerning the Management of Patients With Malignant Hyperthermia.

At a recent consensus conference, the Malignant Hyperthermia Association of the United States addressed 6 important and unresolved clinical questions concerning the optimal management of patients with malignant hyperthermia (MH) susceptibility or acute MH. They include: (1) How much dantrolene should be available in facilities where volatile agents are not available or administered, and succinylcholine is only stocked on site for emergency purposes? (2) What defines masseter muscle rigidity? What is its relationship to MH, and how should it be managed when it occurs? (3) What is the relationship between MH susceptibility and heat- or exercise-related rhabdomyolysis? (4) What evidence-based interventions should be recommended to alleviate hyperthermia associated with MH? (5) After treatment of acute MH, how much dantrolene should be administered and for how long? What criteria should be used to determine stopping treatment with dantrolene? (6) Can patients with a suspected personal or family history of MH be safely anesthetized before diagnostic testing? This report describes the consensus process and the outcomes for each of the foregoing unanswered clinical questions.

The Masseter Muscle and Its Role in Facial Contouring, Aging, and Quality of Life: A Literature Review.

BACKGROUND: Masseter muscle hypertrophy manifests itself as enlargement of the masseter muscle. It can be associated with a square-angled lower face, pain, dental attrition, maxillary and mandibular bone resorption, and accelerated aging process of the lower face. The objective of this study was to assess the efficacy and safety of botulinum toxin type A in contouring the masseter and its impact on quality of life and the aging process of the lower face, and its role in full face rejuvenation. METHODS: A PubMed search was conducted for articles on masseter treatment with botulinum toxin type A, masseter muscle hypertrophy, and the aging process of the lower face. Key studies are reviewed and findings are summarized. RESULTS: Botulinum toxin type A can be injected into the lower posterior aspect of the masseter muscle. Treatment decreases muscle bulk and reshapes the lower face. Furthermore, patient quality-of-life measures, including pain and symptoms of grinding and clenching, are improved. Treatment can decrease shear stress on maxillary and mandibular bones and can possibly prevent tooth loss and progressive bone resorption of the lower face. Adverse effects are minimal and short lasting. CONCLUSIONS: Botulinum toxin type A is a safe and effective treatment of masseter hypertrophy. The treatment results in improvement of functionality and cosmesis, and restoration of facial harmony.

Masseter Muscle Volume Changes Evaluated by 3-Dimensional Computed Tomography After Repeated Botulinum Toxin A Injections in Patients With Square Facial Morphology.

INTRODUCTION: Botulinum neurotoxin A (BoNT-A) is a minimally invasive and technically straightforward treatment of masseter muscle (MM) volume reduction and facial contouring, but the literature on its long-term effect on MM volume remains unclear. OBJECTIVE: This study aimed to assess quantitatively for progressive volume changes of lower facial contour after 3 BoNT-A injections in patients with bilateral MM hypertrophy causing square facial morphology using 3-dimensional computed tomographic scans. MATERIALS AND METHODS: Ten female patients with square facial morphology due to bilateral MM hypertrophy were recruited to, and 6 completed, this clinical study. Each received 24 U of BoNT-A into the inferior portion of each MM on both sides, repeated 6 monthly to complete 3 treatments. Masseter muscle volume changes were assessed using 3-dimensional computed tomography at pretreatment (before injections) and posttreatment (1 year after the third injection). RESULTS: Mean MM volume significantly reduced from 26.39 ± 4.18 cm before treatment to 23.26 ± 4.31 cm 1 year after treatment (P = 0.002). CONCLUSION: Three consecutive 6-monthly BoNT-A injections into the MMs reduced their volume by 12% when assessed 1 year after completion of treatment.

Characteristics of Glutamate-Evoked Pain in the Masseter Region: Differences Between Targeted Injections in Subcutaneous, Muscle, and Bone Tissues.

AIMS: To investigate whether glutamate-evoked pain in the masseter region differs between three different depths of injection, targeting subcutaneous, muscle, and bone tissues. METHODS: A total of 16 healthy volunteers participated and, in a randomized order, received injections of glutamate (1.0 M, 0.2 mL) and isotonic saline (0.9%, 0.2 mL) in the masseter region that targeted subcutaneous, intramuscular, and bone surface tissues. Following injection, pain intensity was measured using electronic visual analog scale (eVAS) and numeric rating scale (NRS) scores of unpleasantness, tiredness, tension, soreness, and stiffness. Pressure pain sensitivity (PPS), pain drawing areas, and McGill Pain Questionnaire (MPQ) scores were also assessed. Repeated-measures analysis of variance, McNemar test, and Tukey post hoc tests were used for statistical analyses. P < .05 was considered statistically significant. RESULTS: Overall, subcutaneous injections induced significantly more unpleasantness and pain than intramuscular injections, and PPS scores evoked after glutamate injection at the surface of the bone were significantly higher than after intramuscular glutamate injection. Subcutaneous glutamate injections were more often described as "sharp" and "pinching." CONCLUSION: The subcutaneous injection was more painful and unpleasant than the intramuscular injection. The glutamate injection at the surface of the bone sensitized the deep pain tissues to pressure stimulation. Clinically, it may be difficult to differentiate between the source or site of pain originating from the masseter region, but the specific quality and word descriptors could assist in differential diagnosis.