Mandibular Bone Loss after Masticatory Muscles Intervention with Botulinum Toxin: An Approach from Basic Research to Clinical Findings

Pioneering pain management with botulinum toxin type A: From anti-inflammation to regenerative therapies

In the present paper, a comprehensive review was conducted to evaluate the performance of botulinum toxin type A (BTX-A) in managing various types of pain, including myofascial, muscular temporomandibular joint pain, orofacial pain, chronic migraines, and more. Firstly, the mechanism of action and anti-inflammatory effects of BTX-A was introduced. Following this, recent advancements in BTX-A applications were discussed, with an emphasis on emerging combination therapies, regenerative medicine, and personalized treatment strategies. Unlike previous reviews, this study explored a broader spectrum of pain conditions and highlighted BTX-A's versatility and potential as a long-term, minimally invasive pain management option. Additionally, the importance of tailoring BTX-A treatment was emphasized through the integration of biomarkers, genetic factors, and optimized dosing regimens to enhance efficacy and minimize side effects. Novel combinations with regenerative therapies, such as stem cells and tissue engineering, were identified as promising avenues for joint and nerve repair, providing both symptomatic relief and tissue regeneration. Furthermore, digital health tools and artificial intelligence were suggested as innovative approaches to monitor treatment responses and optimize dosing protocols in real-time, advancing personalized pain management. Overall, this review underscores BTX-A's potential in comprehensive and patient-centered pain management and offers recommendations to guide future studies in optimizing BTX-A therapy.

Impact of botulinum toxin type A on tooth movement and bone remodeling in male Wistar rats

OBJECTIVE

We evaluated whether the use of botulinum neurotoxin type A (BTX-A) in masticatory muscles influences tooth movement and bone remodeling.

DESIGN

Seventy-seven male Wistar rats were allocated to the groups: S - Saline (n=20); SM - Saline with movement (n=20); BT - Botulinum toxin (n=18); BTM - Botulinum toxin with movement (n=19). On day 1, 0.02 mL of sterile 0.9 % saline was administered to groups S and SM and BTX-A (1 U in 0.02 mL of saline) to groups BT and BTM, in the masseter and temporal muscles laterally. On day 30, a nickel titanium spring was installed to move the first maxillary molar and euthanasia was performed on days 32 and 51. Tooth displacement, maxillary and mandibular bone volumes, collagen neoformation, bone and root resorptions, and masseter morphometry were assessed. Statistical analysis was conducted (p < 0.05).

RESULTS

A higher percentage of type I collagen was observed in the BT than in the S group on day 51 and lower mass, length, and diameter of the masseter fibers in BT and BTM (p < 0.05). Tooth displacement, bone volume, bone and root resorptions, hyaline area, and masseter height showed no difference among groups with and without BTX-A, regardless of tooth movement (p > 0.05).

CONCLUSIONS

BTX-A did not interfere with tooth displacement, bone volume, and dental and periodontal tissues related to tooth movement in rats; it increased mature collagen in animals without tooth movement; and it caused a decrease in the mass, length, and diameter of the masseter fibers.

Clinical benefit of botulinum toxin for treatment of persistent TMD-related myofascial pain: A randomized, placebo-controlled, cross-over trial

BACKGROUND

Injections of botulinum toxin type A (BoNT-A) have been proposed as an additional treatment modality for patients suffering chronic temporomandibular disorder (TMD)-related myofascial pain (MFP). BoNT-A impairs muscle function, along with its analgesic effect, and a minimal effective dose should be used. The objective of this randomized placebo-controlled crossover study was to evaluate the clinical benefit of a moderate dose (50 U) of BoNT-A.

METHODS

Sixty-six subjects were randomized into two groups, one which received BoNT-A first and a second which received a saline solution (SS) first. Follow-ups were performed 2, 11, and 16 weeks after the injections. Diagnostic criteria for temporomandibular disorders (DC/TMD) diagnostic algorithms were used to evaluate characteristic pain intensity (CPI) and pain-related disability based on the Graded Chronic Pain Scale (GCPS). Electromyographic and bite force were also evaluated.

RESULTS

The within-group analysis showed a significant improvement in pain intensity and pain-related disability after BoNT-A (p < 0.001, p = 0.005, p = 0.011) and SS (p = 0.003, p = 0.005, p = 0.046) injections up to week 16. The between-group analysis of pain-related variables revealed no differences between groups at any time. Nonetheless, BoNT-A, but not SS, caused a significant decline in muscle performance. The number needed to treat (NNT) regarding a clinically significant pain reduction (≥30%) was 6.3, 57.0, and 19.0 at 2, 11, and 16-week follow-ups favoring BoNT-A.

CONCLUSIONS

Injections of 50 U of BoNT-A might improve MFP symptoms, but the specific effect of the drug on pain compared to the placebo is not obvious.

Ultrasound-Guided Botulinum Toxin-A Injections into the Masseter Muscle for Both Medical and Aesthetic Purposes

With the increasing use of Botulinum toxin type A (BoNT-A) injections in the masseter muscles for both medical and aesthetic purposes, there is a constant need to continually enhance the efficacy of these treatments and reduce the risk of potential adverse events. This review provides an in-depth analysis of the masseter muscle's anatomical structure and essential landmarks and emphasizes the advantages of ultrasound (US) guidance in improving the precision of BoNT-A injections compared to conventional blind methods. The review is supplemented with comprehensive figures, including graphics, clinical images, and ultrasound visuals, to support the discussion. Potential complications such as paradoxical bulging, inadvertent injections into the risorius muscle or parotid gland, facial paralysis, and the risk of bone resorption are examined. Future research should aim at refining injection techniques and assessing the long-term effects of repeated treatments to ensure optimal patient care and safety.

Repeated unilateral injections of botulinum toxin in masticatory muscles in adult rats do not amplify condylar and alveolar bone loss nor modify the volume of the hypertrophic bone proliferation at enthesis

OBJECTIVES

Botulinum toxin is used in human in repeatedly masticatory muscles injections. A single BTX injection in animal induces mandibular bone loss with a muscle enthesis hypertrophic metaplasia. Our aim was to evaluate mandibular bone changes after unilateral repeated injections of BTX in adult rats.

STUDY DESIGN

Mature male rats were randomized into 3 groups: one, two or three injections. Each rat received injections in right masseter and temporalis muscles. The left side was the control side. Microcomputed tomography was used to perform 2D and 3D analyses.

RESULTS

Bone loss was evidenced on the right sides of alveolar and condylar bone. Alveolar bone volume increased in both control left side and injected right side whereas condylar bone volume remained constant in all groups, for both sides. Enthesis bone hypertrophic metaplasias were evidenced on the BTX injected sides without any modification with the number of injections.

CONCLUSION

BTX repeated injections in masticatory muscles lead to major mandibular condylar and alveolar bone loss that does not worsen. They lead to the occurrence of an enthesis bone proliferation that is not dependent on the number of injections. These results are an argument for the safety of BTX injections in masticatory muscles in human.

Electrical stimulation prevents condyle and subchondral degeneration following the masseter atrophy

OBJECTIVE

There is a strong relationship between masticatory muscle atrophy and condyle degeneration. Although electrical stimulation (ES) is an effective treatment for muscle atrophy, its influence on the underlying condyle is unclear. This study aimed to investigate whether ES can prevent condyle degradation during the stage of masseter muscle atrophy.

MATERIALS AND METHODS

Six-week-old rats were randomly divided into the control, botulinum toxin (BTX), or BTX + ES group. BTX was injected into the bilateral masseters of rats to induce masseter atrophy. The left-side masseters without ES treatment were served as BTX group, and the right-side masseters received ES with different parameters (5 mA/10 Hz, 5 mA/50 Hz, 6 mA/10 Hz, 6 mA/50 Hz, 7 mA/10 Hz, and 7 mA/50 Hz) were served as BTX + ES groups. After 4 weeks, micro-CT and qualitative or quantitative analysis of osteogenesis, chondrogenesis, and angiogenesis-related genes in condyles were conducted.

RESULTS

ES, especially at 7 mA/50 Hz, significantly attenuated masseter atrophy, condyle degeneration, and subchondral bone loss. Moreover, the upregulation of related proteins, including collagen 1, osteocalcin, bone morphogenetic protein 2, collagen 2a, and vascular endothelial growth factor were observed.

CONCLUSION

ES partly rescued condylar degeneration and subchondral bone loss following masseter atrophy.

Botulinum Toxin-A for the Treatment of Myogenous Temporomandibular Disorders: An Umbrella Review of Systematic Reviews

OBJECTIVE

Temporomandibular disorders (TMDs) encompass several conditions that cause pain and impair function of the masticatory muscles (M-TMDs) and temporomandibular joints. There is a large interest among clinicians and researchers in the use of botulinum toxin-A (BoNT-A) as a treatment for M-TMD. However, due to the lack of consistent evidence regarding the efficacy as well as adverse events of BoNT-A, clinical decision making is challenging. Therefore, this umbrella review aimed to systematically assess systematic reviews (SRs) evaluating BoNT-A treatment effects on pain intensity, mandibular movements, and adverse events in patients with M-TMDs.

METHOD

An electronic search was undertaken in the databases MEDLINE, EMBASE, CINAHL, Cochrane Central Registry of Controlled Trials (CENTRAL), Web of Science, Epistemonikos, ClinicalTrials.gov, and ICTRP to identify SRs investigating BoNT-A effects on M-TMDs, published from the inception of each database until 6 December 2023. The quality of evidence was rated according to the critical appraisal checklist developed by the umbrella review methodology working group. Only high-quality SRs were included.

RESULTS

In total, 18 SRs were included. BoNT-A was shown to be more effective than placebo to reduce pain intensity, but not compared to standard treatments. Additionally, BoNT-A was not superior to placebo or standard treatments regarding improvement of mandibular movements. BoNT-A was considered to have a higher risk for adverse events on muscle and bony tissue compared with other treatments.

CONCLUSION

The synthesis in this umbrella review provides the highest level of evidence present. Taken together, there are indications of effectiveness of BoNT-A for treatment of M-TMDs, supported by moderate evidence. However, considering the risk of causing serious adverse events, treatment with BoNT-A is recommended to be the last treatment alternative.

Adverse effect of botulinum toxin-A injections on mandibular bone: A systematic review and meta-analysis

INTRODUCTION

Botulinum toxin-A (BTX) is a potent neurotoxin that is emerging in the scope of dental practice for its ability to temporarily paralyse musculature and reduce hyperfunction. This may be desirable in diseases/disorders associated with hyperactive muscles such as the muscles of mastication, most implicated in painful temporomandibular disorders (TMDs). The use of BTX extends beyond its indications with off-label use in TMD's and other conditions, while potential adverse effects remain understudied. BTX is well-established hindlimb paralysis model in animals leading to significant bone loss with underlying mechanisms remaining unclear. The objective of this study is to systematically review the literature for articles investigating changes in mandibular bone following BTX injections and meta-analyse available data on reported bone outcomes.

METHODS

Comprehensive search of Medline, Embase and Web of Science retrieved 934 articles. Following the screening process, 36 articles in animals and humans were included for quantitative synthesis. Articles in human individuals (6) and three different animal species (14) presented mandibular bone outcomes that were included in the meta-analysis.

RESULTS

The masseter and temporalis muscles were frequently injected across all species. In humans, we observe a decrease of about 6% in cortical thickness of mandibular regions following BTX injection with no evident changes in either volume or density of bone structures. In animals, bone loss in the condylar region is significantly high in both cortical and trabecular compartments.

DISCUSSION

Our analysis supports the concept of BTX-induced bone-loss model in animal mandibles. Further, bone loss might be confined to the cortical compartments in humans. Most studies did not address the reality of repeated injections and excessive dosing, which occur due to the reversible action of BTX. More rigorous trials are needed to draw a full picture of potential long-term adverse effects on bone.

Clinical aspects of mastication myalgia-an overview

Mastication myalgia is the most common cause of non-odontogenic pain in the orofacial region and is often associated with a reduced quality of life. The purpose of this review is to provide an overview of the clinical aspects of myalgia based on available research. The review includes epidemiological, diagnostic, and etiological aspects. In addition, the potential risk factors related to the transition from acute to chronic myalgia are explored and treatment strategies are presented for its management. As a result, this review may increase clinical knowledge about mastication myalgia and clarify strategies regarding prevention, diagnostics, and management to improve prognosis and reduce patient suffering.

Does Botulinum Toxin Injection Exacerbate Sarcopenia and Bone Mass in Individuals With Cerebral Palsy?

BACKGROUND

Botulinum toxin (BoNT) causes sarcopenia and low bone mass in animal studies. Whether such effect exists in children and adolescents with spastic cerebral palsy (CP) is not clear yet. To investigate the influences of BoNT on grip strength (GS), skeletal muscle mass, and bone mineral density (BMD) in children and adolescents with spastic CP, we conducted this uncontrolled longitudinal study.

METHODS

The body composition of individuals with spastic CP were measured by dual-energy X-ray absorptiometry at preinjection and at 12 and 24 weeks after BoNT intervention. Sarcopenia was defined as meeting both decreased GS and low muscle mass. Twenty-five participants were enrolled (mean age 8.5 years).

RESULTS

Before BoNT intervention, four adolescents had sarcopenia and low bone mass. When the body composition was analyzed as four limbs, trunk, and head, the skeletal muscle mass of the injected limbs, appendicular skeletal muscle mass, and total body less head BMD increased significantly over 24-week follow-up period (P = 0.0117, 0.0032, 0.0229), whereas the GS remained unchanged. When the body composition was analyzed as segments derived from bilateral arms, forearms, hands, thighs, and lower legs, the skeletal muscle mass (P = 0.0113) but not BMD of the injected segments increased significantly over the 24 weeks. The prevalence of low muscle mass, decreased GS, sarcopenia, and low bone mass did not change over 24 weeks.

CONCLUSIONS

The present study showed that BoNT does not exacerbate sarcopenia and low bone mass in individuals with spastic CP.

Unilateral Hypofunction of the Masseter Leads to Molecular and 3D Morphometric Signs of Atrophy in Ipsilateral Agonist Masticatory Muscles in Adult Mice

Mice are commonly used to study mandibular dynamics due to their similarity in chewing cycle patterns with humans. Adult mice treated unilaterally with botulinum toxin type A (BoNTA) in the masseter exhibit atrophy of this muscle characterized by an increase in the gene expression of atrophy-related molecular markers, and a reduction in both muscle fiber diameter and muscle mass at 14d. However, the impact of this muscle imbalance on the non-treated masticatory muscles remains unexplored. Here, we hypothesize that the unilateral masseter hypofunction leads to molecular and 3D morphometric signs of atrophy of the masseter and its agonist masticatory muscles in adult mice. Twenty-three 8-week-old male BALB/c mice received a single injection of BoNTA in the right masseter, whereas the left masseter received the same volume of saline solution (control side). Animals were euthanized at 2d, 7d, and 14d, and the masticatory muscles were analyzed for mRNA expression. Five heads were harvested at 14d, fixed, stained with a contrast-enhanced agent, and scanned using X-ray microtomography. The three-dimensional morphometric parameters (the volume and thickness) from muscles in situ were obtained. Atrogin-1/MAFbx, MuRF-1, and Myogenin mRNA gene expression were significantly increased at 2 and 7d for both the masseter and temporalis from the BoNTA side. For medial pterygoid, increased mRNA gene expression was found at 7d for Atrogin-1/MAFbx and at 2d-7d for Myogenin. Both the volume and thickness of the masseter, temporalis, and medial pterygoid muscles from the BoNTA side were significantly reduced at 14d. In contrast, the lateral pterygoid from the BoNTA side showed a significant increase in volume at 14d. Therefore, the unilateral hypofunction of the masseter leads to molecular and morphological signs of atrophy in both the BoNTA-injected muscle and its agonistic non-injected masticatory muscles. The generalized effect on the mouse masticatory apparatus when one of its components is intervened suggests the need for more clinical studies to determine the safety of BoNTA usage in clinical dentistry.

Analysis of Cephalometric Points in Male and Female Mandibles: An Application to Gender-Affirming Facial Surgery

Gender-affirming facial surgery is a common intervention for transgender patients because of its ability to decrease the frequency of misgendering. Many anatomic targets can be addressed, but the mandible is the primary aspect of the lower third of the face that is manipulated during these procedures. This study's objective is to quantify the differences in cephalometric measurements between male and female mandibles on maxillofacial imaging, with the goal of identifying surgical targets for gender affirmation. A nonrandomized, retrospective, single-institution, case-control study of 387 patients who underwent maxillofacial computed tomography during 2017-2020 was performed. After excluding patients with imaging that did not capture the entire head or had deforming pathology of the face, a total of 113 patients were included. Cephalometric measurements that corresponded to areas reported by patients as sources of dysphoria were selected for analysis. These included mandibular width, ramus height, lateral flare, masseter volume, total face height, and the values of the mandibular angles in degrees. The relationship of masseter volume to the other measurements was also characterized. Significantly greater masseter volume was seen in males compared with females, and a greater masseter thickness was also seen in males. The mandibular angle was more acute in males than females. Aggregate analysis of muscle volume and thickness was positively correlated with ramus height, lateral flare, and mandibular width. Ramus, mental, and total facial height correlated directly with patient height in males but not in females. These data provide a normative baseline for planning lower facial gender-affirming surgery.

Botulinum Toxin, a Drug with Potential Interest for Dentists—An Introduction

The review is an introduction to medical, non-cosmetic treatments with botulinum neurotoxin (BoNT) in the orofacial region. It focuses on the current most common, best-documented and safest indications of interest for dentists in terms of dystonia and sialorrhea. These conditions are recommended to start with and suitable to gain better skill and experience with BoNT. The introduction also stresses the importance of correct diagnostics based on interdisciplinary cooperation, precise targeting of the injections, measurements of treatment effect, and control of the oral health with regard to side effects.

Effect of Botulinum Toxin Injection on EMG Activity and Bite Force in Masticatory Muscle Disorder: A Randomized Clinical Trial

Botulinum toxin type A (BoNT-A) is increasingly used in treating masticatory muscle pain disorder; however, safe doses and reinjection intervals still need to be established. The purpose of this randomized clinical trial was to evaluate the degree and duration of the impairment of masticatory muscle performance. Fifty-seven subjects were randomly divided into two groups: one of which received BoNT-A first (n = 28) while the other received saline first (n = 29), with the cross-over being in week 16, and a total follow-up period of 32 weeks. A total dose of 50 U of BoNT-A was injected in the masseter and temporal muscles bilaterally. Electromyographic (EMG) activity and bite forces were assessed. A significant reduction in EMG activity was observed up to week 18 (p ≤ 001), with total recovery at week 33. A significant reduction in maximum bite force was observed up to week 11 (p ≤ 005), with total recovery at week 25. In conclusion, when treating masticatory muscle pain disorder with 50 U of BoNT-A, a reinjection interval of 33 weeks can be considered safe since the recovery of muscle function occurs by that time.

Botulinum toxin A in dentistry and orofacial surgery: an evidence-based review - part 2: cosmetic applications

Objective An evidence-based review on the role of botulinum toxin type A (BoNTA) on diverse cosmetic applications of interest to dental practitioners and allied specialities. In this context, to identify the cosmetic treatments that have an evidence-based rationale against areas requiring further research, with a view to assess the safety and efficacy of BoNTA.Data source and selection A comprehensive search was conducted using Cochrane Library of Systematic Reviews, Cochrane Central Register of Controlled Trials, and PubMed (Medline) electronic databases. Thirty-nine studies of variable quality were included. The Best Evidence Topics (BETs) Critical Appraisal Tool was used to facilitate the quality assessment of relevant studies.Data extraction Based on current level II evidence, BoNTA was safe and effective to improve facial contour, reduce volume and thickness of bilateral hypertrophic masseter. Conservative doses using a combined approach of BoNTA and hyaluronic acid was recommended as a safe and effective treatment for perioral enhancement supported by level II evidence. There was limited evidence, not higher than level III, to support BoNTA effectiveness for gummy smile associated to perioral musculature hyperactivity, while jawline sculpting targeting the platysma muscle had lower level IV evidence up to this date.Conclusion BoNTA has been widely used off-label for the investigated cosmetic orofacial conditions, with reports of 'good patient and practitioner satisfaction'. However, there is limited high-quality evidence to support the long-term safety and effectiveness of repetitive BoNTA injections. Additionally, no studies were found that provided a cost-effectiveness evaluation of BoNTA formulations against other current cosmetic interventions. Well-designed clinical trials, including long-term follow-up, would help to provide robust evidence-based recommendations for clinical practice, supporting BoNTA popularity, independently or in a combined approach.

Relationship Between Masticatory Muscle Size and Bone Regeneration After Mandibular Angle Osteotomy

ABSTRACT

Mandibular angle osteotomy with outer cortex grinding has become the preferred cosmetic procedure for correcting square faces. After surgery, bone hyperplasia at the mandibular angle affects the operation result. This study evaluated the effect of the masticatory muscles on bone repair. From January 2016 to January 2019, patients who underwent mandibular angle osteotomy with outer cortex grinding were retrospectively reviewed. Computed tomography data of these patients were collected, and the bone volume of the mandibular angle changes and its correlation with masticatory muscle morphology were analyzed. Computed tomography data measurement results showed that a large amount of bone in the mandibular angle area was removed by the operation; however, the long-term follow-up results showed that there was bone hyperplasia in the mandibular angle areas. Compared with the immediate postoperative bone volume, the difference was statistically significant (P < 0.01). The thickness and cross-sectional area of the masseter muscle were significantly related to bone regeneration (P < 0.01). This study suggests that mandibular angle osteotomy with outer cortex grinding could ablate the symptoms of a prominent mandibular angle; however, muscle-related bone hyperplasia in the mandibular angle area after surgery was a non-negligible event, which may significantly compromise surgical outcomes.

Lagomorpha as a Model Morphological System

Due to their global distribution, invasive history, and unique characteristics, European rabbits are recognizable almost anywhere on our planet. Although they are members of a much larger group of living and extinct mammals [Mammalia, Lagomorpha (rabbits, hares, and pikas)], the group is often characterized by several well-known genera (e.g., Oryctolagus, Sylvilagus, Lepus, and Ochotona). This representation does not capture the extraordinary diversity of behavior and form found throughout the order. Model organisms are commonly used as exemplars for biological research, but there are a limited number of model clades or lineages that have been used to study evolutionary morphology in a more explicitly comparative way. We present this review paper to show that lagomorphs are a strong system in which to study macro- and micro-scale patterns of morphological change within a clade that offers underappreciated levels of diversity. To this end, we offer a summary of the status of relevant aspects of lagomorph biology.

Computational biomechanical modelling of the rabbit cranium during mastication

Although a functional relationship between bone structure and mastication has been shown in some regions of the rabbit skull, the biomechanics of the whole cranium during mastication have yet to be fully explored. In terms of cranial biomechanics, the rabbit is a particularly interesting species due to its uniquely fenestrated rostrum, the mechanical function of which is debated. In addition, the rabbit processes food through incisor and molar biting within a single bite cycle, and the potential influence of these bite modes on skull biomechanics remains unknown. This study combined the in silico methods of multi-body dynamics and finite element analysis to compute musculoskeletal forces associated with a range of incisor and molar biting, and to predict the associated strains. The results show that the majority of the cranium, including the fenestrated rostrum, transmits masticatory strains. The peak strains generated over all bites were found to be attributed to both incisor and molar biting. This could be a consequence of a skull shape adapted to promote an even strain distribution for a combination of infrequent incisor bites and cyclic molar bites. However, some regions, such as the supraorbital process, experienced low peak strain for all masticatory loads considered, suggesting such regions are not designed to resist masticatory forces.

Botulinum toxin type A and acupuncture for masticatory myofascial pain: a randomized clinical trial

BoNT-A has been widely used for TMD therapy. However, the potential benefits compared to dry needling techniques are not clear.

Preoperative and postoperative assessment of temporal and masseter muscle size with magnetic resonance imaging in patients undergoing unilateral temporomandibular joint surgery

The aim of this study was to assess any change between the preoperative and postoperative sizes of temporal and masseter muscles with magnetic resonance imaging (MRI) in patients undergoing unilateral temporomandibular joint surgery. This study was designed and implemented retrospectively. For clinical evaluation, a visual analog scale (VAS) and maximum mouth opening (MMO) were used. In order to make a preoperative diagnosis and perform a 6-month control, muscle size was measured in millimeters (mm) on T1 axial sections in MRI. Statistical analyses were performed using the SPSS 23.0 software package. Numeric variables were compared between two dependent groups using the Wilcoxon signed rank test. Statistical significance was set at p < 0.05. Twelve patients who underwent unilateral discectomy plus dermis-fat grafting, with classical preauricular inverse L incision, were included in the study, and data for eleven female patients were evaluated. The difference in size between the operated and non-operated sides was found to be statistically insignificant at the preoperative stage for both masseter muscle (operated side m^M: 13.264 ± 1.822 mm; non-operated side m^M: 13.264 ± 2.315 mm; p^M = 0.929) and temporal muscle (operated side m^T: 20.345 ± 2.609 mm; non-operated side m^T: 20.582 ± 2.366 mm; p^T = 0.594). There was a significant size reduction in the masseter muscle on the operated side in the postoperative period (preop m^M: 13.264 ± 1.822 mm; postop m^M: 12.036 ± 1.728 mm; p^M = 0.018). Although there was also a size reduction in the operated side of the temporal muscle in the postoperative period, that difference did not reach statistical significance (preop m^T: 20.345 ± 2.609 mm; postop m^T: 19.445 ± 1.603 mm; p^T = 0.182). On the non-operated side, there were no significant postoperative changes in the sizes of either the masseter muscle (preop m^M: 13.264 ± 2.315 mm; postop m^M: 12.682 ± 2.059 mm; p^M = 0.248) or the temporal muscle (preop m^T: 20.582 ± 2.366; postop m^T: 19.891 ± 3.487 mm; p^T = 0.625). Considering the study findings as a whole, a size reduction was observed in the operated side of the masseter muscle after TMJ surgery. The etiology of this change may be surgical trauma to the temporal and masseter muscles, skeletal alteration resulting from condylar change secondary to discectomy, and patients restraining themselves from application of maximum bite force as a result of a self-protection mechanism due to postoperative pain.

Is There Association Between Stress and Bruxism? A Systematic Review and Meta-Analysis

This systematic review and meta-analysis aimed to investigate a possible association between stress and bruxism in humans. This study was conducted according to Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines under the code CRD42020188862, and the searches were performed on the following databases: PubMed, Scopus, Web of Science, Cochrane, LILACS, OpenGrey, and Google Scholar. This systematic review evaluated observational studies in adult humans with and without stress to verify the association between bruxism and the presence of stress. The risk of bias was evaluated through the Joanna Briggs Institute Critical Appraisal Tools for Analytical Cross-Sectional Studies. In quantitative analysis, the Odds Ratio (OR) and their 95% confidence interval (CI) were calculated through a fixed-effect model. Furthermore, a summary of the overall strength of evidence was presented using the Grading of Recommendations, Assessment, Development, and Evaluation (GRADE). A total of 1,458 studies were identified, and six were included in this systematic review. Two studies included were classified with a low risk of bias, and the others were classified with a moderate risk of bias. In three articles, a meta-analysis was performed and showed an association between these two factors (OR 2.07 [1.51, 2.83], p < 0.00001, I ² = 45%). Besides that, a low certainty of the evidence was detected among this association. Stressed individuals show a higher chance of presenting bruxism when compared to healthy individuals. Despite the low heterogeneity found in the quantitative analysis among the articles reporting an association between stress and bruxism, further studies with similar methods are necessary to understand this relationship better.

Evaluation of jaw bone density and morphology in bruxers using panoramic radiography

Background/purpose

Bruxism affects the stomatognathic system and causes tissue damage by the excessive jaw movements. The purpose of this study was to evaluate the effects of sleep bruxism on jaw bone density, mineralisation and morphology by comparing bruxers and non-bruxers.

Materials and methods

60 bruxers and 60 non-bruxers (control) patients were included in the analysis. Cortical width at the gonion (GI), at the mental foramen (MI), at the antegonion (AI), the panoramic mandibular index (PMI), the mandibular cortical index (MCI) and antegonial notch depth (AND) were measured bilaterally on 120 panoramic radiographs. The measurements were evaluated for repeatability, correlation with age, gender and correlation between the variables.

Results

A significant association was observed between cortical shape (MCI) and bruxism status (p = 0.012). The MI was significantly different between the bruxers and non-bruxers (p = 0.006). There was a significant but weak correlation between the MI value and age in bruxers and the control (p = 0.003, p = 0.04). The AI was not associated with bruxism status and did not vary by age or gender (p > 0.05). The AND was higher in bruxers than non-bruxers (p = 0.001). Male bruxers had a significantly higher AND value than female bruxers (p = 0.001). The GI was higher in male bruxers (p = 0.001).

Conclusion

Defects in the endosteal margin of the cortex and cortical thickening in the mental region were detected in bruxer patients. Furthermore, AND was increased in bruxers. Tiny bone peaks accompanied the cortical thickening seen in the gonial region. Male bruxer patients had higher GI and AND values than female bruxers.

Effect of multiple injections of botulinum toxin into painful masticatory muscles on bone density in the temporomandibular complex

Background

Adverse effects of masticatory muscle injections of Botulinum Toxin (Btx) have been noted in animal and, less dramatically, human studies.

Objective

Among women treated in multiple community‐based private practices, to compare TMJ bone density and mandibular condylar volume between patients with myofascial TMJD receiving multiple masticatory muscle Btx treatments and similarly diagnosed women not receiving such treatment.

Methods

Cohorts consisted of women whose treatment charts indicated a diagnosis of myofascial TMJD: 35 received at least 2 Btx treatment cycles; 44 received none. Bone density at pre‐specified regions of interest (ROI) was defined by grey scale values from Cone Beam CT, adjusting for a fixed density phantom included in each scan. Mean bone density and mandibular condyle volume were compared between groups. Dose‐response effects were tested within the Btx‐exposed group.

Results

The mean density of primary and secondary ROIs was similar between exposure groups, as was condylar volume. Among Btx‐exposed women, increasing dose of Btx to the temporalis muscle was inversely proportional to the density of the trabecular area of the mandible body. Many Btx‐exposed women received smaller doses of Btx to the masseter muscles than in most TMJD Btx clinical trials.

Conclusion

Masticatory muscle injections of Btx failed to produce clinically significant TMJ bone‐related changes. Should Btx receive regulatory approval for treatment of myofascial TMJD, a phase IV study is recommended to evaluate potential adverse effects of Btx on bone and muscle when administered at higher doses and/or for more treatment cycles.

Clinical outcomes of botulinum toxin type A injections in the management of primary bruxism in adults: A systematic review

STATEMENT OF PROBLEM

Botulinum toxin has been used for various therapeutic and esthetic purposes for nearly 4 decades and has shown positive outcomes in patients with bruxism. However, the effectiveness of botulinum toxin injections as an alternative to traditional therapies in the management of primary bruxism is still unclear.

PURPOSE

The purpose of this systematic review was to analyze the clinical outcomes of the use of botulinum toxin type A injections in the management of primary bruxism in adults.

MATERIAL AND METHODS

Databases such as PubMed, Web of Science, Scopus, LILIACS, Cochrane Library, and Open Grey Literature were searched without language or date restrictions until October 6, 2019. Using Mendeley Desktop software to organize the references, 2 independent researchers selected the published clinical studies (Study type) on the improvement of symptoms (Outcome) in human adults with primary bruxism (Participants/Population) who received botulinum toxin type A injections (Intervention), placebo injections, saline injections, no injections, or other treatments (Comparator(s)/Control) for the management of bruxism.

RESULTS

A total of 601 references were initially obtained from the 6 databases. Six randomized clinical trials and 4 case series were selected and critically appraised according to the Fowkes and Fulton guidelines. Heterogeneity among the studies did not allow for a meta-analysis. All studies supported the efficacy and safety of botulinum toxin injections in reducing the symptoms of primary bruxism.

CONCLUSIONS

Botulinum toxin type A injections are effective in the treatment of the symptoms of primary bruxism in adults. Randomized clinical trials are still needed to establish a protocol for using botulinum toxin as an alternative to traditional therapies in the management of primary bruxism.

Efficacy and Safety of Botulinum Toxin Type A on Persistent Myofascial Pain: A Randomized Clinical Trial

This study assessed the safety and efficacy of three different doses of BoNT-A for persistent myofascial pain (MFP). One hundred female subjects were randomly assigned into five groups (n = 20): oral appliance (OA), saline solution (SS) and three BoNT-A groups with different doses. Pain intensity and pressure pain threshold were evaluated up to 24 weeks after treatment. Adverse effects related to muscle contraction, masticatory performance, muscle thickness and mandibular bone volume were also assessed. Changes over time were compared within and between groups. The “nparLD” package and Wilcoxon signed-rank test were used to analyze the data. BoNT-A reduced pain intensity (p < 0.0001) and increased pressure pain threshold (p < 0.0001) for up to 24 weeks compared to the placebo. No differences were found between BoNT-A and OA at the last follow-up. A transient decline in masticatory performance (p < 0.05) and muscle contraction (p < 0.0001), and a decrease in muscle thickness (p < 0.05) and coronoid and condylar process bone volume (p < 0.05) were found as dose-related adverse effects of BoNT-A. Regardless of the dose, BoNT-A was as effective as OA on MFP. Notwithstanding, due to BoNT-A dose-related adverse effects, we suggest the use of low doses of BoNT-A in MFP patients that do not benefit from conservative treatments.

Internal architecture of the mandibular condyle of rabbits is related to dietary resistance during growth

Although there is considerable evidence that bone responds to the loading environment in which it develops, few analyses have examined phenotypic plasticity or bone functional adaptation in the masticatory apparatus. Prior work suggests that masticatory morphology is sensitive to differences in food mechanical properties during development; however, the importance of the timing/duration of loading and variation in naturalistic diets is less clear. Here, we examined microstructural and macrostructural differences in the mandibular condyle in four groups of white rabbits (Oryctolagus cuniculus) raised for a year on diets that varied in mechanical properties and timing of the introduction of mechanically challenging foods, simulating seasonal variation in diet. We employed sliding semilandmarks to locate multiple volumes of interest deep to the mandibular condyle articular surface, and compared bone volume fraction, trabecular thickness and spacing, and condylar size/shape among experimental groups. The results reveal a shared pattern of bony architecture across the articular surface of all treatment groups, while also demonstrating significant among-group differences. Rabbits raised on mechanically challenging diets have significantly increased bone volume fraction relative to controls fed a less challenging diet. The post-weaning timing of the introduction of mechanically challenging foods also influences architectural properties, suggesting that bone plasticity can extend well into adulthood and that bony responses to changes in loading may be rapid. These findings demonstrate that bony architecture of the mandibular condyle in rabbits responds to variation in mechanical loading during an organism's lifetime and has the potential to track dietary variation within and among species.

Morphological association between the muscles and bones in the craniofacial region

The strains of inbred laboratory mice are isogenic and homogeneous for over 98.6% of their genomes. However, geometric morphometric studies have demonstrated clear differences among the skull shapes of various mice strains. The question now arises: why are skull shapes different among the mice strains? Epigenetic processes, such as morphological interaction between the muscles and bones, may cause differences in the skull shapes among various mice strains. To test these predictions, the objective of this study is to examine the morphological association between a specific part of the skull and its adjacent muscle. We examined C57BL6J, BALB/cA, and ICR mice on embryonic days (E) 12.5 and 16.5 as well as on postnatal days (P) 0, 10, and 90. As a result, we found morphological differences between C57BL6J and BALB/cA mice with respect to the inferior spine of the hypophyseal cartilage or basisphenoid (SP) and the tensor veli palatini muscle (TVP) during the prenatal and postnatal periods. There was a morphological correlation between the SP and the TVP in the C57BL6J, BALB/cA, and ICR mice during E15 and P0. However, there were not correlation between the TVP and the SP during P10. After discectomy, bone deformation was associated with a change in the shape of the adjacent muscle. Therefore, epigenetic modifications linked to the interaction between the muscles and bones might occur easily during the prenatal period, and inflammation seems to allow epigenetic modifications between the two to occur.

Muscle-Bone Crosstalk in the Masticatory System: From Biomechanical to Molecular Interactions

The masticatory system is a complex and highly organized group of structures, including craniofacial bones (maxillae and mandible), muscles, teeth, joints, and neurovascular elements. While the musculoskeletal structures of the head and neck are known to have a different embryonic origin, morphology, biomechanical demands, and biochemical characteristics than the trunk and limbs, their particular molecular basis and cell biology have been much less explored. In the last decade, the concept of muscle-bone crosstalk has emerged, comprising both the loads generated during muscle contraction and a biochemical component through soluble molecules. Bone cells embedded in the mineralized tissue respond to the biomechanical input by releasing molecular factors that impact the homeostasis of the attaching skeletal muscle. In the same way, muscle-derived factors act as soluble signals that modulate the remodeling process of the underlying bones. This concept of muscle-bone crosstalk at a molecular level is particularly interesting in the mandible, due to its tight anatomical relationship with one of the biggest and strongest masticatory muscles, the masseter. However, despite the close physical and physiological interaction of both tissues for proper functioning, this topic has been poorly addressed. Here we present one of the most detailed reviews of the literature to date regarding the biomechanical and biochemical interaction between muscles and bones of the masticatory system, both during development and in physiological or pathological remodeling processes. Evidence related to how masticatory function shapes the craniofacial bones is discussed, and a proposal presented that the masticatory muscles and craniofacial bones serve as secretory tissues. We furthermore discuss our current findings of myokines-release from masseter muscle in physiological conditions, during functional adaptation or pathology, and their putative role as bone-modulators in the craniofacial system. Finally, we address the physiological implications of the crosstalk between muscles and bones in the masticatory system, analyzing pathologies or clinical procedures in which the alteration of one of them affects the homeostasis of the other. Unveiling the mechanisms of muscle-bone crosstalk in the masticatory system opens broad possibilities for understanding and treating temporomandibular disorders, which severely impair the quality of life, with a high cost for diagnosis and management.