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Dr. Barry Eppley

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Surgeon Dr. Barry Eppley

Posts Tagged ‘botox for clenching’

Botox Injections Into The Masseter (Jaw) Muscle

Saturday, August 20th, 2011

Botulinum toxin, most commonly known as Botox, has a wide range of uses of which not all are FDA-approved. One of these yet-to-be-approved but growing uses is in injection into the masseter muscle. Being the second largest muscle in the face (the temporalis is the largest), it also differs from the other facial muscles being injected since it is not a muscle of facial expression. It is a masticatory or jaw moving and chewing muscle. There are two primary reasons to use Botox injections into the masseter muscle, one being for aesthetic facial contouring and the other for the relief of jaw-related facial pain.

Some patients with a very square face may have a significantmasseter muscle thickening or hypertrophy. The contribution of the masseter muscle thickness to the width of the face can be determined by having the patient bite down and looking and feeling the size of the muscle. Extreme flaring or bulging is a sign of a significant contribution to facial width. Masseter muscle reduction is a commonly requested procedure in Asian ethnicities, particularly Korean, due to their inherently wider facial shapes. Compared to surgical thinning of the masseter muscle which is a very traumatic procedure with a long recovery, Botox injections offer an equal result without any of the surgical side effects.

Botox injections can shrink the masseter muscle very effectively but is highly dose and location dependent. A dose of 25 units per masseter muscle is a good starting point and always produces a result. Less of a dose may also work but it is based on the size of the target. The equivalent dose of Dysport would be 50 to 75 units. It is important to inject only into the prominent bulges of the muscle on biting down. Placing it into normal muscle is a waste of injectate and may risk a cheek indentation, particularly at the anterior border of the muscle. It is also important to not inject above an imaginary line that runs between the tragus of the ear and the corner of the mouth. Going above that line places the buccal branch of the facial nerve at risk for months of temporary paralysis of the upper lip.

For this cosmetic facial shaping use, the effect becomes apparent relatively quickly within a month or two. The effects will last about 6 months and repeat injections are needed to sustain the narrowing effect. It is unknown if there is a point when the effect is sustained without further treatments.

For those who suffer from facial pain due to bruxism or excessive clenching, Botox has a similar beneficial effect. It not only stops the amount of muscle spasm and clenching but it can also cause a muscle thinning effect. The injection technique is the same but slightly higher doses may be needed. While I always start with 25 units of Botox per side, optimal pain relief may require a higher dose. But start at 25 units and see what happens. Also, because the temporalis muscle may be a contributor to the clenching, injection into it with 10 units may be needed. The injection point is determined by where the patient points to a temporalis location, but it is often into the muscle just above the zygomatic arch at the anterior edge of the hairline. The duration of these masseter muscle injections approximates that of its upper facial cosmetic effects of around 4 months. Despite this shorter duration, the pain relief can be dramatic.

Dr. Barry Eppley

Indianapolis, Indiana

Botox as an Injection Therapy for Excessive Clenching

Saturday, November 20th, 2010

Teeth clenching, otherwise known as bruxism, is a common phenomenon amongst  many people.  To some degree, almost everybody clenches his or her teeth. The issue lies in the intensity of the  teeth clenching is. A person with severe bruxism will often clench their teeth with not only excessive force but with great repetition, often occurring during sleep. Patients awake with tooth and jaw muscle soreness. At pressures on the teeth that can be up to greater than 500 pounds per square inch, it is not wonder that tooth damage can occur.


Why clenching occurs in anyone is largely unknown. Theories usually point to stress or habits  but the problem is no doubt from many causes that collectively creates masseter muscles that are overactive. Besides excessive tooth wear, the hallmark of clenching is sore jaw muscles either near and around the angle of the jaw in front of the ear and in the temple area.                                                                                           


Currently, the most common treatment for clenching is a custom-made mouth-guard that is worn during sleep to prevent tooth damage and, in theory, to stop the muscles from overactivity.The effectiveness of dental appliances covering the tooth surfaces is unchallenged. But the muscle problem is a different story. This is evidenced by the array of other available muscle treatments including drugs, transcutaneous nerve stimulation, thermal therapies and biofeedback, to name a few of the most prominent. For some these work, but for many others the results are less than needed or simply don’t work at all.


One direct muscle treatment for the masseter muscles of clenching is Botox injections. As a well known cosmetic wrinkle treatment for much smaller muscles that cause facial expressions, it can similarly be injected into any other muscle. The intent into the masseter muscles is not paralysis but to control its hyperactivity and break the cycle of spasm and pain. Good candidates are those that have significant masseter muscle flaring or bunching while clenching with palpable pain of those areas.


Injection into the masseter muscles is a very simple and near painless treatment, The key is to stay in the lower half of the muscle near the jaw angle. Using an imaginary line drawn from the corner of the mouth to the lower end of the tragus of the ear, the injection points should stay south of this near horizontal line. Injecting above this line may create weakness of the buccal branch of the facial nerve which would be evident by paralysis of the upper lip during smiling. By having the patient clench, the bulging areas of the muscle are injected. I use 25 units of Botox per side as a baseline dose. Some patients may require more but this is a good economical place to start.


If there is any temporalis muscle tenderness, it can be injected as well. This is best done just above the level of the zygomatic arch at the junction of the scalp and the non-hair bearing temporal skin. This is also the area beneath the temporalis fascia where the zygomaticofrontal nerve branch comes upward from the deeper muscle belly. This sensory nerve branch of the maxillary nerve has been implicated in migraines of the temple region. About 8 to 10 additional units can be injected into each side of the temporal area.


One effective technique is to add Marcaine (with epinephrine), a longer acting local anesthetic, into the Botox solution. This provides immediate relief of pain within minutes of being injected as Botox will take days to exert its beneficial effects. The ratio I find effective is 0.3cc per 1cc syringe of Botox. (0.7cc volume = 28 units of Botox or 4 units of Botox per .1cc) Each masseter or side then receives almost 1cc of Botox/Marcaine solution.


As a direct muscle treatment, Botox works very well for clenching problems. For some patients, it is eliminated completely. For others the relief is significant but not complete. It should be expected to last around 3 to 4 months.


Dr. Barry Eppley

Indianapolis, Indiana

Dr. Barry EppleyDr. Barry Eppley

Dr. Barry Eppley is an extensively trained plastic and cosmetic surgeon with more than 20 years of surgical experience. He is both a licensed physician and dentist as well as double board-certified in both Plastic and Reconstructive Surgery and Oral and Maxillofacial Surgery. This training allows him to perform the most complex surgical procedures from cosmetic changes to the face and body to craniofacial surgery. Dr. Eppley has made extensive contributions to plastic surgery starting with the development of several advanced surgical techniques. He is a revered author, lecturer and educator in the field of plastic and cosmetic surgery.

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