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By admin April 15, 2011

A growing number of dentists are now
providing botulinum toxin, otherwise known as BoNT-A (Botox® and
Dysport®), treatment for their patients for both oral and maxillofacial
cosmetic and therapeutic use.  It has been estimated that up to 20% of
North American dentists now use BoNT-A in their practices for esthetic
and therapeutic uses .  While the use of BoNT-A for cosmetic purposes
has gotten a lot of attention in a number of dental journal articles;
BoNT-A products are excellent products to use for dental therapeutic
uses in a number of areas.

BoNT-A works by inhibiting the release of acetylcholine at the
neuromuscular junction.  Acetylcholine, as you well may remember,
depolarizes the motor end plate of the muscle and will cause a muscle
contraction.  By inhibiting the release of acetylcholine, BoNT-A
effectively will either reduce the intensity of the contraction of the
muscle or will eliminate the contraction altogether, depending on the
dosage used.  Essentially, BoNT-A neurotoxin interrupts the contraction
process of the muscles and causes a temporary muscle paralysis.  This
can last usually anywhere up to three months as the muscle initiates new
acetylcholine receptors and the growth of branches from the neurons to
form new synaptic contacts.  Gradually the muscle returns to its full
function and with no side effects whatsoever .

When you think about this clearly, and when one learns how to use
BoNT-A  neurotoxin properly, it can be used for a number of dental
therapeutic procedures that can relieve pain and can retrain muscles
which can certainly enhance dental treatment plans as well as help some
serious disorders that have been frustrating to the dental practitioner
for many years.  


I have personally treated patients for temporomandibular joint disorder
in my practice for the past 30 years.  It almost seems as if
temporomandibular joint disorder is some kind of fad in dentistry that
has gone in and out of style during my career.  We have been told that
80% of patients have some sort of TMD and need treatment, then it is
something that you just don’t hear about for awhile.  TMD is almost like
a black box that sits somewhere in the middle of medical and dental
healthcare professionals with neither profession having a decent
treatment plan for relieving its symptoms.  Often, TMD is just a
clinical label for any pain of the jaw and facial muscles, which can be
associated with headaches, earaches, cervical spine disorders, and
general facial pain.

Often, with TMD cases, there may be one or multiple trigger points in
muscles that a patient points to.  Palpating these areas immediately
sends a cascading pain along muscle or neuronal tracks that radiate from
the trigger point outward.  Many agents have been used and injected
directly into these trigger points to treat these areas, including
sterile saline and local anesthetic.  The theory of trigger point
injections is that the disruption of the trigger point may be enough to
bring some relief, either short term or long term.  The success of these
treatments have been limited, primarily because the effect of sterile
saline or local anesthetic lasts from a few minutes to a few hours.  

Other treatments have been used for TMD disorders over the years which
include psychological therapy, maxillary or mandibular repositioning,
orthotic devices, neuromuscular therapy, drug treatments such as
anti-inflammatory agents, non-narcotic and narcotic pain medications,
muscle relaxants, chiropractic therapy, massage, acupuncture, and even

There are many schools of thought in dentistry that an orthognathic
approach will work the best with occlusal equilibrations and full mouth
reconstructions, which will absolutely relieve facial pain.  

The use of BoNT-A therapy for TMD symptoms has been in use for many
years.  For trigger point injections, it makes much more sense to use
BoNT-A products because the effects will last for three months and you
are actually helping relieve the intensity of the contraction of the
muscle, which is usually in spasm.  Many times we, as dentists, have
developed tunnel vision and believe that just by fixing the dentition
that it will solve all of the other problems.  Many dentists completely
ignore the fact that the muscles themselves may be in spasms and need
the relief in order to allow us to achieve the right occlusal
equilibration and end-point for our full mouth reconstruction.  In other
words, what I would like you to think about is this progression – let’s
treat the muscle spasm symptoms first and then build our occlusion to
the relieved muscles so that the facial pain will be eliminated. 
Studies clearly show the relief of painful symptoms in facial muscles
with BoNT-A of up to 90% of patients who had not responded to
traditional treatments .  

For facial pain and TMD cases, BoNT-A neurotoxins can be generally
applied to a number of muscles of facial expression and mastication, 
including the masseter, temporalis, frontalis, procerus, corrugator,
orbicularis oris, orbicularis oculi, mentalis, depressor anguli oris and
pterygoid muscles .  

The use of BoNT-A products in TMD therapy can give us a totally new
insight as to helping these patients who have had a lot of trouble
getting relief before.


Excessive saliva production or the inability to hold saliva in the mouth
can result in sialorrhea or commonly know as drooling.  There are a
number of causes for sialorrhea which may include a number of medical
disorders, Parkinson’s Disease would be one of the more common disorders
that cause this.  Occasionally, pharmaceuticals such as scopolamine
could be used to treat this disorder but there are obviously adverse
side effects that go along with this kind of pharmaceutical.  Behavioral
and occupational therapy have been used in the past as well to try to
treat these procedures.  Botox has been used to try sialorrhea by being
injected into the parotid and sub maxillary salivary glands to try to
inhibit the stimulation of the cholingeric receptors .  This use of
Botox is not in treating any muscles, but it is trying to result in the
reduction of the amount of the saliva produced.  This has to be
carefully as if too much Botox is used then it will result in chewing
difficulties, dysphagia and xerostomia.


Bruxism is the general term that refers to both clenching and grinding
of the teeth.  There have been numerous theories as to why this occurs
and certainly most bruxism will manifest itself nocturnally.  Certainly,
there are components of psychological stress that may cause it.  No
matter what the theory is that causes bruxism, there is no question that
it leads to the destruction of otherwise healthy dentition, exacerbates
periodontal disease, either causes TMD and is the cause of headaches
and facial pain.  Traditionally, intraoral appliances have been the
treatment of choice for bruxism with good success as to relieving some
or all of the symptoms.  

We use BoNT-A products routinely in helping patients with bruxism.  Here
is where proper training in the use of BoNT-A neurotoxins is really
essential.  We would typically treat bruxism and TMD patients with
bilateral injections of BoNT-A into the masseter and temporalis
muscles.  A practicing clinician must have a good feel as to what the
proper dosage is because too much of the BoNT-A will paralyze the
muscles of mastication and interfere with the patient’s ability and
confidence in chewing and talking.  Too small of a dosage will not have
any effect at all.  Using the right amount of BoNT-A will reduce the
intensity of contractions of these muscles of mastication as well as
give your patient full competence for chewing, eating properly, and
speaking.  The relief afforded to patients by BoNT-A neurotoxins can
help eliminate facial pain, grossly reduce their TMD symptoms and can
significantly help the other associated treatments of periodontal
disease by removing the bruxism element.  

As an example of BoNT-A treatment for both TMJ and bruxism, figure 1
shows a patient who has experienced facial pain and has significant
bruxism, so much so that she has had to have significant dentistry
repeated because of restoration breakage.   You can see just be looking
at this patient that her masseter muscles are in spasm even at rest and
gives her a very square look to her face.  This is not skeletal but is
purely a result of masseter hypertrophy.  Figure 2 is a close up view of
the masseter muscle in spasm.  You can see the result of BoNT-A therapy
two weeks later in figure 3 – the masseter muscles are no longer in
spasm and the patient’s face is much more rounded at the corners of the
mandible.  We were not interested in the cosmetic effects of this
treatment even though the patient was thrilled.  Her facial pain had
disappeared and she subsequently has had successful long term dental
treatment with BoNT-A injections repeated approximately every 4-6 months
to maintain her comfort.


Oromandibular dystonia is some kind of muscle dysfunction and pathology
that involves the massecatory and lower facial muscles.  It can cause
unintentional opening and closing of the mouth and vertical, lateral,
and protrusive directions.  Many times this will also result in
voluntarily chewing of the soft tissue inside the mouth and will often
also interfere with regular chewing and speaking.

Botox has been used for oromandibular dystonia as well as pletharo spasm
which are often related conditions.  Masseter injections of Botox have
been reported to resolve some of these muscle dysfunctions.  It has
turned out to be a very effective treatment for oromandibular dystonia
and certainly pletharo spasm in which it has been used for years.
Pletharo spasm is excessive and voluntary closure of the eyelids which
is often caused by spasms of the orbicularis oculi.


While the role of the facial muscles in determining placement of the
teeth is fairly well known, many times it seems that dental
practitioners forget about the muscles once the teeth are set after
orthodontic therapy has taken place.  Relapse has been a continual
problem for many general and orthodontic dental practitioners and there
are a number of theories as to why this happens.  There are so many
patients where you can see on their faces just by gross observation that
they have a hyperactive mentalis muscle that may be disrupting the
alignment of the teeth.  Other muscles in spasm can usually be observed
as well with proper training.  

When you look back at some of the previous paragraphs of this article
and you come to the realization that BoNT-A neurotoxins can go ahead and
reduce the muscle contraction intensity, over time it is very possible
that muscles can be trained to work normally.  Anyone who has treated
the muscles of facial expression for cosmetic purposes with BoNT-A sees
this routinely where the cosmetic results will last for longer periods
of time for patients who have kept up a schedule of receiving BoNT-A 
neurotoxins on a regular basis.  This idea could revolutionize how we
deal with orthodontic relapse as dental practitioners become more
familiar with the use of BoNT-A neurotoxins.  


The same idea described in the previous paragraph directly can be
applied to those patients who have trouble getting used to removable
prosthodontics in their mouths.  While it is true that more and more
patients everyday are receiving implant treatment to help stabilize
dentures, there will always be patients who can either not afford
implant therapy or because of underlying challenges such as medical
history or bone resorption, just are not candidates for implant
therapy.  Many of these patients have hyperactive muscles, which then
creates a huge challenge of having them retain the dentures in their
mouths.  If you study the facial muscles carefully in patients, you will
often times see a hypertrophic masseter and can even feel strong
lateral and medial pterygoid muscles that cause this situation.  Muscle
training via BoNT-A neurotoxins may someday provide relief as dentists
become more familiar with their use.

The use of BoNT-A in the oral and maxillofacial areas is really nothing
new and one can even find literature dating back almost two decades in
this arena .  As dentists are now accepting and treating patients with
these products for soft tissue cosmetic use to enhance the dental
esthetics, BoNT-A neurotoxins are getting much more attention in
dentistry than ever before.  Certainly, if dentists are going to use
these therapies, training is absolutely essential and required both
ethically and by state dental boards.  Research has certainly shown that
BoNT-A products, such as Botox® and Dysport®, is a viable treatment for
many facial, TMD, and oral dysfunctions, when they are based in the

BoNT-A products are a conservative, minimally invasive, and relatively
painless therapeutic approaches to dental, facial, and head and neck
areas that have frustrated many dentists over the past 30 years.  The
safety of these products is well known because of their temporary nature
and the fact that they are totally reversible over time with generally
no lasting effects.  The other advantages are that it gives the patient
and the dental practitioner the option to stop a therapy at any time and
return to the previous state with no ill effects.


There are many causes for facial asymmetries.  Facial asymmetries may be
a result of genetics, some kind of physical trauma, previous facial
surgeries, uneven skeletal growth of the facial bones, nerve injury, or
muscle hypertrophy, which may cause one side of the face to look smaller
or larger than the contra lateral muscles on the other side of the face

Botox can be used in certain and select muscles which may be causing
some of the asymmetry in order to try to balance the facial muscles and
create a more asymmetrical appearance.  


Masseteric hypertrophy literally means enlargement of the masseter
muscles.  Most often, this is associated with clenching and bruxism,
even when it is mild to moderate.  

A common treatment for masseteric hypertrophy is Botox being injected
into the belly of the masseter muscle .  This will cause a slenderizing
of the face in addition to reducing the intensity of contractions of the
masseter muscles and like all other Botox treatments, repeat injections
are required every few months.

Dr. Louis Malcmacher is a practicing general
dentist and an internationally known lecturer, author, and dental
consultant known for his comprehensive and entertaining style.  An
evaluator for Clinicians Reports, Dr. Malcmacher is the president of the
American Academy of Facial Esthetics.  You can contact him at 440
892-1810 or email  His website is where you can find information about his
lecture schedule, botox and dermal filler hands-on live patient
training, audio cd’s, download his resource list, and and sign up for a
free monthly e-newsletter.

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