BOTOX TRAINING FOR DENTISTS

Treating patients with

Tension headaches and TMDs
Created and Presented by:
Sky Naslenas
Case – Daphne
 25 year old female,
healthy

 C/C:
 Clicking, popping,
painful TMJ, headaches
 open bite
 tongue thrust
 Occlusion is ONE of the contributing
factors in TMD
• Canine protected
• Mutually protected or Group Function
• Occlusal tripod
 Today’s Adult Orthodontics
 Aesthetics reconciled with function

 More adults seeking orthodontics for functional

reasons, i.e. TMJ discomfort, pre-prosthetic work up

 People expect straight teeth and TMD symptom

improvement
 “Gnathological” Orthodontics
Invisalign

 Great diagnostic tool

 acts as a night guard, clenching
force is ameliorated by plastic
aligners
 aligners act as a deprogramming
splint and a semi soft night guard
 “Gnathological” Orthodontics
Lingual Braces with bite pads

 Control tongue habit

 Bite pads disclude the teeth –
“shock absorbers”
Bite pads
12 months into treatment…
18 months into treatment…
18 months into treatment…
24 months Treatment Completed
Perfect Occlusion, Still suffering
from headaches…
 Definition of Myo-facial Pain
 characterized by chronic and, in some cases, severe pain

 associated primarily with "trigger points", localized in painful

lumps or nodules in any of the FACIAL muscles or connective
tissue known as fascia

 May include symptoms of referred pain, restricted head and

neck movement, and sleep disturbances

S. Naslenas
Botulinum (BotN) toxin is a polypeptide
produced by the gram-positive
anaerobic bacterium Clostridium
botulinum
 OVERVIEW
Part 1 – Intro to Botox (Theory)

 Legalities of Usage
 History, Development
 Structure and Mechanism of Action
 Types of headaches
 TMD overview

Flash Coffee Break

 OVERVIEW
Part 2 – Treatment with Botox
(Clinical Aspects)

 Handling of Botox
 Review of applied facial anatomy
 Pain management Injection sites
 Aesthetic injection sites
 Adverse effects

Flash Lunch Break

 OVERVIEW
Part 3 – Patient Injections

 Practice injections - mannequins

 Botox preparation
 Patient Injections

Leisurely Wrap up – Questions and

Feedback
Part 1 – Intro to Botox (Theory)
 The College’s view that Ontario dentists are not permitted to carry
out the injection of Botox™, or any other agent material, into the
extra-oral/facial tissues of a patient for cosmetic procedures

 One possible exception would be the use of Botox™ for temporo-

mandibular disorders, as the management of such conditions
clearly falls within the scope of the practice of dentistry

 However, such use of this agent is currently considered off-label

and experimental and should only be employed by highly-trained
and very experienced practitioners, usually in a hospital-based
multidisciplinary clinic.

2009
Botox approved to treat migraines in
Canada

Health Canada has given doctors the green light to

use Botox injections in adults who suffer from
migraines 15 or more days a month.

Nov. 14, 2011

Diagnostic Criteria for treatment with
BOTOX injections

 history of migraine

 15 days or more per month

 eight headache days being migraine

(CNW Group/Allergan Inc.)

 Chronology of Development
1700s – 1800s 1944 1950s - 1960s 1968
Identified as E. Schantz, et al Type A 900 kD* Medical use
cause of began purifying Complex evaluation
botulism by botulinum purification
Clostridium toxin type A optimization
botulinum

1997 1989 1970s – 1980s

Current BTX-A Original BTX-A First clinical
(allergan) (allergan) development:
FDA approval; FDA approval; begin blepharospasm &
neurotoxin complex clinical strabismus
protein only 5 ng* development for
per 100 units cervical dystonia
and other uses
Summary of BOTOX development

 Justinus Kerner - clinical symptoms of

food-borne botulism from 1817-1822

 1980 Human Testing

 1989 FDA approval therapeutic

Oculinum

 2011 FDA approval for Migraine

treatment
 BOTOX – Applied Clinical Uses
 According to the World Health Organization, living with daily
migraines can be more disabling than blindness, paraplegia or
rheumatoid arthritis.

 A burden in the workplace – lost revenue for sick days

 In two clinical trials funded by Allergan, patients who received

Botox reported a total cumulative reduction in headache hours by
107 and 134 hours at 24 weeks, compared with 70 and 95 hours in
patients treated with placebo.
 Why Botox is Different

 Non-systemic – Botox®
 Administered directly into the desired site of
action
 Focal therapy
 No unwanted side effects:
No GI upset
No fatigue
No confusion
No depression
No liver toxicity
 Why you should have confidence in
Botox

 Botox® has been proven as a safe and effective therapy, and has
been widely used for more than 25 years.

 Over the past 30 years, Botox® has been evaluated in more than
200 studies specific to approved indications in the US, Canada and
Europe
Botulinum Toxin Type A in the Prophylactic Treatment of Chronic Tension-Type
Headache: A Multicentre, Double-Blind, Randomized, Placebo-Controlled, Parallel-
Group Study
SD Silberstein1, H Göbel2, R Jensen3, AH Elkind4R DeGryse5, JMCM Walcott5 and C
Turkel5
Cephalalgia Volume 26, Issue 7,ps 790–800, July 2006

 N=300 (62.3% female; mean age 42.6 years)

 All patients had ≥50% decrease in tension headache

days vs. placebo (P ≤ 0.024)

 Most treatment-related adverse events were mild or

moderate, and transient
 Testimonials
”It was a life-changing experience for me being able to wake
up, go throughout my day and go to bed without headaches,
which in return for me means enjoying being a wife and a mom
... without missing a beat. Best of all no more medicines,” says
Jade Battah.

”It is an immediate relief from these agonizing headaches that

systemic migraine medications wouldn’t even touch at times,”
says Dr. Vi Maievschi.

Daphne’s testimonial.
Botox for Head Pain, Largest Study Yet. A report from the American
Headache Society Annual Scientific Meeting
Updated: July 9, 2006

80% (217) said their head pain episodes were less frequent,
less intense or both.

60.5% (164) reported good to excellent pain relief

19.5% (53) reported some pain relief.

20% (54) reported no relief

Botulinum A Molecular Structure
1950s - 1960s
Type A 900 kD*
Complex
purification
Optimization**
 Chronology of Development
1700s – 1800s 1944 1950s - 1960s 1968
Identified as E. Schantz, et al Type A 900 kD* Medical use
cause of began purifying Complex evaluation
botulism by botulinum purification
Clostridium toxin type A optimization
botulinum

1997 1989 1970s – 1980s

Current BTX-A Original BTX-A First clinical
(allergan) (allergan) development:
FDA approval; FDA approval; begin blepharospasm &
neurotoxin complex clinical strabismus
protein only 5 ng* development for
per 100 units cervical dystonia
and other uses
 Mechanism of Action: 4 key steps

1. Toxin bonds to specific receptors on the surface of the presynaptic cell

surface.
30 minutes.

Normally functioning synapse The binding step

 Mechanism of Action: 4 key steps

2. The toxin-receptor complex is internalized inside the nerve terminal.

Internalization/Engulfing step
 Mechanism of Action: 4 key steps

3. Translocation – the light chain of the toxin molecule is released into the cytoplasm
of the nerve terminal. 2-4 hours

The translocation step

 Mechanism of Action: 4 key steps
4. The light chain of serotypes A and E inhibits acetylcholine release by cleaving
a cytoplasmic protein (SNAP-25) required for the docking of acetylcholine
vesicles on the inner side of the nerve terminal plasma membrane. 3-12
days for maximum blockade to occur.

The bockade-the neurotransmitter not

released and the nerve is paralyzed
Mechanism of Recovery: 2 key steps
1. After an injection of BOTOX®, the axon terminal
proliferates external collateral sprouts. This occurs 3-4months
after the initial injection.

Sprouting of collateral axons

 Mechanism of Recovery: 2 key steps
2. Sprouts subsequently retract and are eliminated; parent terminal is
re-established. (Bendetto AV, 1999) ** Clinical Significance -
Resistance Vs. Immunity

Development of a new neuromuscular junction

 Types of Headaches
Neurovascular pathway Muscular pathway
(Migraines) (Tension Headaches)
Muscle Tension Headaches

 the most common of all headache types

 afflicts 75% of all headache sufferers

 90% of all adults have had at least one

tension headache per week

American Council for Headaches

 Muscle Tension Headaches –
Symptoms
 kind of steady ache (as opposed to
a throb)

 forms a tight band around the

forehead, affecting both sides of
the head

 usually occur in the front of the

head, radiating to the top of the
skull, the back of the skull, neck
and shoulders
 Dual Role of BotN in pain moderation
– NEW EVIDENCE
MUSCLE TENSION NEUROVASCULAR

BotN inhibits the release of the Even so, the reduction of pain often
neurotransmitter, acetylcholine, at occurs before the decrease in muscle
the neuromuscular junction contractions..
thereby inhibiting striated muscle
contractions.
Tension headache AND Migraine
relief???
Can ALL headaches be helped???
Proposed mechanism of Migraine
Control
Pathophysiology of a migraine attack.
Substance P (neuropeptide) moderates
pain

Botulinum toxins are being used OFF label for

neuropathic pain. In this case, the toxin is felt to work by
preventing the release of Substance P and CGRP from the
pain terminals. The botulinum toxins can reach this area
because there is no myelin around the pain nerve fibers.

COMBO effect on Migraines?

 Muscle Tension and TMD relationship

 Many times people under stress will clench or grind their

teeth, which frequently (but not always) is the result of a
misaligned bite or is exacerbated by occlusal interferences

 Chronic grinding and clenching exacerbates migraines

 Tension headaches are almost always accompanied by spasms

of the muscles which help to open and close the jaw = TMD
 Combo Therapy?
Neurovascular pathway Muscular pathway
(Migraines) (Tension Headaches)
 SYMPTOMS OF TMD
Tension Headaches

 Migraines

 Tooth pain

 Limited jaw opening

 Grinding of teeth

 Neck ache

 Back ache “TMJ is subject to most complex vector forces arising

from parafunction”
Dr. Goodheart
Simplified Classification of TMJ
Disorders

 Muscle Disorders

 Joint Sounds

 Joint Locking

 Arthritis
 Muscle Disorders

• Myalgia -------------------> Localized muscle

tenderness to
• Myofascial Pain palpation with no
referral to remote
• Spasm/Trismus sites.


• Myositis
 Muscle Disorders

• Myalgia
Muscle tenderness to
• Myofascial Pain -----------------> palpation with referral
to remote sites.
• Spasm/Trismus

• Myositis

 Muscle Disorders

• Myalgia

• Myofascial Pain

• Spasm/Trismus -------------> Painful inhibition of

muscle activity
• Myositis


 Muscle Disorders

• Myalgia

• Myofascial Pain

• Spasm/Trismus A sterile, systematic

or bacterially induced
• Myositis ---------------->


inflammatory muscle
disorder
Current Long-Term Management of
Myogenic conditions
• Orthoses / Splints

• Orthognathic surgery

• Coronoplasty/Equilibration

• Removable Overlay Partials

• Reconstruction (Crowns/overlays over existing

teeth regardless of condition)

• Orthodontics (Braces)
Over-estimated treatment success:
Misinterpretation of clinical observations
Raphel K Marbach JJ: JADA 1997 128:73-80

• Spontaneous remission

• Placebo effect of treatment

• Failure to consider treatment

dropout

• Poor treatment compliance

Muscle relaxant drug protocol

Low Dose tricyclic antidepressant therapy

Effective at 20-30 % of regularly prescribed doseage

• Amitriptaline (Elavil) – 10-25 mg per day

• Nortriptyline (Pamelar)
• Doxepin (Sinequan)
• Desipramine (Norpramin)

***Multiple Side- EFFECTS

 BoNT NOT first line of treatment
ALL CONVENTIONAL REVERSIBLE
THERAPEUTIC OPTIONS HAVE
BEEN EXHAUSTED

PATIENT DOES NOT DESIRE

CONVENTIONAL TREATMENT
OPTIONS

First OTC analgesics, self physio – massage, exercise, warmth

BOTOX® for TMD and clenching

• Decrease in pain
• Decrease in teeth sensitivity
• Decrease in clenching intensity (force)
• Decrease in clenching duration (time)
• Decrease in number of episodes

NO LIMITATION OF CHEWING FUNCTION

 New Paradigm for Dentistry

Prevent PRE-TMD CLENCHING

WITH A PHARMACEUTICAL SPLINT
vs. TREATING THE SYMPTOMS
Flash Coffee Break

Part 2 – Treatment with Botox (Clinical Aspects)

 Types of Botox
• used to smooth away
wrinkles
Cosmetic
• ideal for individuals
Botox ages of 18 to 65

• used to treat excessive

sweating, upper limb
Therapeutic spasticity, muscular eye
issues
Botox • tension and
migraine(?)headaches
 AUTHENTIC BOTOX
 Look for the hologram “Allergan”

 Authentic BotN should effervesce

upon dilution

 Pricing - too good to be true

 Excessive dilution of the product

 BOTOX® Packaging and Storage

 Botox® is shipped by Allergan frozen, on dry ice. Unopened

Botox® should be stored at a refrigeration level of 0-8°C or at
≤ -5°C.

 The Expiration date is typically 2 years from shipment date.

 Botulinum Toxin Type A (Botox®) is considered a relatively

fragile and easily denatured toxin. Do not store in refrigerator
door.

 Store reconstituted product at 2°C to 8°C in refrigerator.

BOTOX® Packaging and Storage

 BOTOX® Cosmetic should be clear, colorless and free of

particulate matter.

 Botox® should be reconstituted just prior to use. Allergan

continues to recommend non-preserved 0.9%Saline to dilute
the toxin

 If non-preserved is used, Botox® should be used in 24 hours

– the official Allergan position

 Most practitioners are using preserved bacteriostatic saline

and with proper storage, it can be used up to 4 weeks
 Preparation of Botox solution
Supplies needed:

1) 20 gauge 2”needle Reconstitution

2) 5ml syringe
3) 30 ½ gauge 5/16 needle on a Aesthetic/Tender
1ml tuberculin syringe Areas
4) 30 gauge ½” needle
Large/deep
5) 1ml syringe Muscles
Preparation of Botox solution

DRAW 4 ML OF PRESERVED SALINE INTO A

5CC SYRINGE WITH A 2 INCH 21 GAUGE
NEEDLE

DATE AND SAVE THE REST OF THE 10ML JAR

FOR UP TO 10 DAYS
 Preparation of Botox solution

• INJECT BOTOX VIAL DEAD CENTER OF

DIAPHRAGM

• VACUUM PULLS SALINE INTO VIAL

• SOLUTION EFFERVESCES UNTIL VACUUM

RELEASED
Preparation of Botox solution

FRAGILE MOLECULES

GENTLY ROTATE VIAL

DO NOT SHAKE VIAL

Preparation of Botox solution

 USE SAME 2 INCH NEEDLE TO FILL ALL 1cc

SYRINGES. These will be used for Injections of
Large/Bulky Muscles

 REMOVE THE RUBBER CAP AND FILL

TUBERCULIN SYRINGES DIRECTLY FROM THE
VIAL. These will be used in cosmetically
sensitive areas. (Optional)
Preparation of Botox solution

 ATTACH .30 GAUGE ½ INCH NEEDLES

ONTO FILLED 1cc s SYRINGES
 The greater the dilution the greater the
perfusion

100 U in 1 cc: 3-4 mm 100 U in 2.5 cc: 1.0 cm 100 U in 4 cc: 1.5 cm spread –
spread (focal pain) spread about the width
of a quarter

Use this rule for all injections

 The greater the dilution the greater
the perfusion

100 U in 2.5 cc: 1.0 cm 100 U in 3cc: 1.2 cm 100 U in 4 cc: 1.5 cm
spread (dime) spread – about the spread – about the
width of a nickel width of a quarter

Allergan recommends 2.5 mL dilution = 4u/0.1 mL

This course used 3.0 ml dilution= 3.3u/0.1 ml**

 Botox® Dilution Chart
Saline Volume to Dilute Units Per ml Units Per .1ml
Botox® (after reconstitution, units
/ 1 ml)
2.0ml 50 units 5 units

2.5ml 40 units 4 units

3.0ml 33 units 3.3 units

4.0ml 25 units 2.5 units

Allergan recommended
Applied Anatomy lesson-
Facial muscles
Applied Anatomy - Facial muscles
Frontalis
Inner Frontalis

Outer Frontalis • Origin

– Galea aponeurotica
above the hairline
• Insertion
– Skin near eyebrows
• Function
– Draws forehead up
• Supply
– CN VII (temporal)
– Superficial temporal a.
Applied Anatomy - Facial muscles
Depressor supercilli
Depressor supercilli
• Origin
– Root of the nose
• Insertion
– Medial eyebrow
• Function
– Lowers inner eyebrow
• Supply
– CN VII
– Facial a.
Applied Anatomy - Facial muscles
Procerus
Procerus
(Depressor Glabellae, • Origin
Pyramidalis nasi)
– Nasal bone / upper nasal
cartilage
• Insertion
– Forehead skin
• Function
– Lowers central forehead
• Supply
– CN VII (temporal, lower
zygomatic, buccal)
– Facial a.
Applied Anatomy - Facial muscles
Corrugator
Corrugator • Origin
– Medial orbit near radix
• Insertion
– Skin above eyebrow
• Function
– Pulls eyebrows
down/medially
• Supply
– CN VII (temporal,
zygomatic)
– Superficial temporal a.
Applied Anatomy - Facial muscles
Orbicularis oculi (orbital)
• Origin
Orbicularis oculi – Medial orbit
(orbital)
• Insertion
Orbicularis oculi – Palpebral ligament
(palpebral)
Orbicularis oculi • Function
(lacrimal) – Narrow eye opening, close the eye
– Eye protection, moistening
• Supply
– CN VII (temporal, zygomatic)
– Superficial temporal a.
Applied Anatomy - Facial muscles
Levator labii superioris (nasal)

• Origin
Levator labii superioris – zygoma
• Insertion
– Skin of the nose and lip lateral
to the nasal wing
• Function
– Raises the upper lip, stretches
nasal wing, wrinkles the nose
• Supply
– Zygomatic, buccal CN VII
– Facial artery
Applied Anatomy - Facial muscles
Orbicularis oris
• Origin
– Corner of the mouth
• Insertion
– Opposite corner, opposite
philtrum
• Function
– Lip positions for speech
• Supply
– Zygomatic, buccal,
mandibular
– Facial artery

Orbicularis oris
Applied Anatomy - Facial muscles
Masseter
• Origin
– Zygomatic arch
• Insertion
– Angle of the
mandible
• Function
– Chew food
• Supply
– Masseteric CN V
– Superficial temporal,
maxillary, facial
arteries
Masseter
Applied Anatomy - Facial muscles
Mentalis
• Origin
– Mandible just beneath
the teeth
• Insertion
– Skin of the chin
• Function
– Pulls up the chin skin
pushing up the lower lip
• Supply
– Zygomatic branch
– Facial artery
Mentalis
Applied Anatomy - Facial muscles
Depressor anguli oris (Triangularis)
• Origin
– Mandible and
platysma
• Insertion
– Corner of mouth,
orbicularis oris
• Function
– Pulls down the
corners of the mouth
• Supply
– Mandibular, buccal
Triangularis
branch
– Facial artery
 BOTOX® Consumer Language

Purified Protein --------------------> Not a microorganism that

causes Botulism

Natural Muscle relaxant--------------------> Describes how

Botox works

Local effect--------------------> Does not effect the rest of the

body

For 3 months-------------------->Comforts patients, helping

the realize that the treatment is
reversible
 BOTOX® Consumer Language

Minimal Discomfort--------------------> Eases concerns that

treatment may be too painful. “Like
squeezing a pimple”

Don’t touch for 3 hours--------------------> Avoid side-effects

caused by moving material o
another location: shoes, pets,
showering

Full effect in 2 weeks --------------------> Avoid concern that

there is no immediate effect
Botox action – clinical timeline
• It takes the toxin approximately 1 ½ - 2 hours
to bind to the nerve

• Because of its intracellular site of action,

BoNTa takes between 2-10 days from
injection to exert its clinical effect

• Most commonly, re-treatment is between 3-

6 months with a small percentage going
considerably longer

• It is not recommended to retreat a patient

before 3 months
Botox action – clinical timeline
 Patient Consultation Session
Pre - Treatment Instructions
• Avoid alcoholic beverages at least 24 hours prior to treatment

• Avoid anti-inflammatory/blood thinning medications ideally for a

period for two (2) weeks before treatment.

• Medications and supplements such as Aspirin, vitamin E, Gingo Biloba,

St, John’s Wort, Ibuprofen, Motrin, Advil, Aleve, and other NSAIDS are
all blood thinning

• All can increase the risk of bruising/swelling after injections

 Patient Consultation Session
Post-Treatment Instructions
• Strictly avoid manipulation of are for 3-4 hours following treatment

• This includes not doing a massage, facial, peel, or microdermabrasion

for a few days

• Stay out of the sun

• It takes 3-5 days for most patients to begin to lose muscle strength and
10-14 to realize the full effects
 Side Effects
• Ecchymosis – Bruising
• Occasional heaviness sensation of the forehead
• Transient headache, flu-like symptoms, dry mouth
• Discomfort, swelling, redness
• Weakness of the lacrimal pump or dry eye
• Possible bacterial or fungal skin infection
• Redness, swelling, mild pain, bruising, numbness, infection, flu-like
syndrome, temporary muscle aching, as well as paralysis of a nearby
muscle
• Seek immediate medical attention with breathing, swallowing, and speech
problems
.
 Recognizing Botulism
Classic triad:
I. Acute, symmetric, descending flaccid paralysis
II. No fever
III. Small muscles then large muscles

Death- from airway obstruction and respiratory muscle

paralysis

Or
Ventilator support (for 3 months)

CLINICAL MARGIN OF ERROR

30 VIALS ($18000) = BOTULISM SYMPTOMS
 Contraindications

Pre-existing Neuromuscular Disorders

 Amyotrophic lateral sclerosis (ALS)
 Mo tor neuropathy
 Neuromuscular junctional disorders (e.g., myasthenia
gravis or Lambert-Eaton syndrome)
 Contraindications

Drug Interactions: agents interfering with neuromuscular

transmission potentiate effect aminoglycosides
 Streptomycin
 Neomycin
 Gentamycin curare-like compounds
 Contraindications
OTHERS

 Pregnant or lactating women

 Hypersensitivity to any ingredient including Albumin 9 Human
Blood Product
 Flu or cold symptoms
 Infection or dermatitis in areas being treated
 Unrealistic patient expectations
 Add to ALL Consent Forms

 In the event of any frivolous claims made against

the treating doctor, I agree to cover the costs of all
legal fees including but not limited to the defending
doctor’s attorney’s and court fees.

 I further agree that should any claim against the

treating doctor be perceived as frivolous, the
attorneys for the treating doctor will be entitled to
the maximum damages against me and my
attorneys.
 Evaluation
• Have patient remove all make up

• Seat patient in chair – do not lie down

• Cleanse the treatment area

• Aim light on patients face – blood vessels

• Stretch skin with fingers to see blood vessels

• Have patient assess face with hand mirror

• Demonstrate lesions and asymmetries

• Pre treatment photos – front and side

• Inject upright
 Immunity/Resistance to protein in Botox® serum – Neutralizing
Antibodies
Approximately 0.5-3% of patients
• After multiple injections
• Protein eliminated in 2002, reduced formation of
AB
• Antibodies may resolve over time

Risk Factors
• Injections > 200 units
• “Booster” injections within 1 month

Management
• Use the lowest possible effective dose
• Slightly alter the site of injections, if possible
• If resistance develops, Myoblock (BoNTb) may
be used (not in Ontario)
• - attempt injections again after a period of time
Potential pitfalls: BoNTa complications
Complications Prevention Treatment
Brow ptosis Avoid over-treating the frontalis Treat brow depressors; ptosis
(which elevates the brow) or improves as BoNTa wears off and
injecting too low on the frontalis frontalis regains strength

Eyelid ptosis Proper injection technique avoid Iopidine drops 0.5% or

(migration of BoNTa to levator deep placement; keep volume naphazoline such as Vasocon-A,
palpebri superioris) low; avoid manipulation of area maphcon-A, Opcon-A – 1 drop to
after injection; tell patients not to affected eye Q4-6 hrs PRN.
touch their face Resolves in 1-2 weeks
Headache Avoid injection under periosteum NSAIDs, ibuprofen
 Major Injection Sites

• Frontal
• Temporal
• Masseteric
• Occipital/Suboccipital/
Cervical
 Injection Paradigms

Three General Paradigms

Fixed-Site Follow-the-Pain Combination

Predetermined Injections given in Fixed-Site and

injection sites regions where patients Follow-the-Pain
report pain or
interictal tenderness
Major Injection Sites
Injection Sites: Frontal Region

3 Major Muscles in the Complex:

 Frontalis

 Procerus

 Corrugators
 Injection Sites: Frontal Region
Have patient move the forehead and
knit the brows to assess muscle
tension
Frontalis

 Frontalis 2.5 u x 10 = 25 u

 Procerus 5 u x 2each

 Corrugators 5 u x 2 each

Total units: 30-45 u

The Forehead – Aesthetic implications

Have patient move the

forehead and knit the brows
to assess muscle action
Assess the muscle in its
dynamic state
Insert needle into contracted
muscle and inject into
relaxed muscle
The Forehead – Aesthetic implications

Reduction of forehead wrinkles may be achieved by weakening the

frontalis muscle with Botox® injections while care must be taken to
avoid brow ptosis.

SMALL Vs. LARGE MALE VS. FEMALE

Normal Forehead (<12cm), 4 injection Females tend to have more arched

sites, 2-4 units per injection site. eyebrows – desirable to maintain

Broad Forehead (>12cm) 5 injection Assess arch shape by the orbital rim
sites 2-4 units per injection. bony anatomy not the hair strands
 The Forehead – Arch Shape

(1) Botulinum toxin dose used to treat glabellar frown lines in an individual
with an arched brow. The arch represents the bony rim, not the eyebrow. (2)
Botulinum toxin dose used to treat glabellar frown lines in a woman with a
more horizontal-type brow.
All Sites have therapeutic and cosmetic
effects
 Forehead Injection Sites
- All Sites have therapeutic and
cosmetic effects
 Avoid injection near levator palpebrae superioris - may reduce the
complication of ptosis. The brow ptosis which will last 2-3 months
and is not a desirable cosmetic result.

 Keep your injections 1cm above the supra orbital ridge to avoid
droopy forehead and lowering of the eyebrows. The lower one third
of the frontalis muscle is used to elevate the eyebrow and therefore
injection into this area should be avoided

 Treatment of the medial frontalis leaving the lateral frontalis

untreated in patients with wider foreheads, can cause the “spock
brow”.
 Forehead Injection Sites
-All Sites have therapeutic and
cosmetic effects

Inadvertant migration to
levator palpebrae superioris
will end up in a droopy
eyelid
 Adverse Effects – “Ptosis”
(A) A 28-year-old woman with mild ptosis presents for Botox of crow's feet.
(B) Thirteen days after 20 U of Botox. Botox (16 U) was placed to the
lateral orbital obicularis close to the canthal angle to widen the palpebral
fissure and 4 U of Botox injected to the right upper lid pretarsal nasal and
lateral obicularis, which further elevates the right upper eyelid.
Adverse Effects – “Ptosis”
Balanced Botox Chemodenervation of the Upper
Face: Symmetry in Motion
Jane J. OlsonFrom:
Semin Plast Surg. 2007 February; 21(1): 47–53.

(A) A 53-year-old woman with right facial weakness since 1969 following jaw
surgery later developed aberrant regeneration of the seventh cranial nerve. (B)
Post–lower eyelid blepharoplasty and 43 U of Botox. Botox (30 U)was placed in the
glabella bilaterally, using a lower position and higher dose to the left brow
depressors. Botox (13 U) was placed to the frontalis muscle, more inferiorly on the
right than the left.
Balanced Botox Chemodenervation of the Upper
Face: Symmetry in Motion

(A) A 46-year-old woman referred for left eyelid ptosis. She has left eye amblyopia
resulting in a lower left eyebrow and lid fold position, yet normal eyelid margin
position. The right eyebrow is higher due to incentive for the brain to stimulate
right frontalis muscle contraction, which raises the right eyebrow and lid fold
above the normal nonamblyopic eye. (B) Managed with 50 U of Botox, with larger
doses to the left brow depressors and left lateral orbicularis muscle. The left
eyebrow relaxes upward and raises the left eyelid skin fold.
 Adverse Effects – “Mr. Spock”

(A) Patient was seen post-Botox elsewhere with excessive lateral brow
elevation and head of brow separation due to heavy glabellar and medial
frontalis muscle treatment and omission of lateral frontalis treatment.
Botox (7 U) was added to the lateral frontalis at this visit to drop the
lateral brow. (B) Subsequently, the patient underwent upper eyelid
blepharoplasty and was managed with 50 U of Botox to the brow
depressors and lateral orbicularis without frontalis muscle treatment.
 Desirable Reconciliation of
Functional and Aesthetic results
 Desirable Reconciliation of
Functional and Aesthetic results
Injection Sites: Temporal Area
Muscles to Inject: Temporalis

 Having the patient clench

his/her teeth will produce a
palpable anterior bulge to the
temporalis muscle, directing
the anterior injection site
Injection Sites: Temporal Area
Muscles to Inject: Temporalis

 4-5 U per site ( 20 units)

with additional 2 optional
sites on the symptomatic
side depending on the
patient’s self report of pain
or tenderness

Total units: 40 – 60u

Injection Sites: Temporal Area

 Patients may specifically have pain

around the temporal artery

 Relieve muscle compression with the

injection

 Nerve decompression may alleviate

migraine type pain

 Nerve decompression some surgery aims for

an even higher rate of pain reduction by
relieving pressure on nerves caused by
surrounding tissue.
 Injection Sites: Temporal Area

 This nerve decompression procedure,

an operation that relieves pressure on the
nerves behind the eyes believed to cause
migraine pain, was first developed 12
years ago by Dr. Guyuronthis.

 Botox is used as a test, and surgery as

a treatment.”
All Sites have therapeutic and cosmetic
effects
Balanced Botox Chemodenervation of the Upper Face:
Symmetry in Motion

(A) A 55-year-old woman presented for “drooped lid.”

She developed Bell's palsy in 1978 followed by
aberrant regeneration of the seventh cranial nerve,
stimulating left palpebral fissure narrowing (not
ptosis) upon jaw movements and asymmetry of
eyebrows.

(A) Left palpebral fissure narrows with jaw movements.

(A) Managed with Botox 50 U. Her right frontalis muscle

is treated more inferiorly and her left frontalis more
superiorly. A higher dose is delivered to her left
brow depressors than her right to raise and control
the abnormal shape of the left eyebrow.
Microdosing to the left pretarsal and lateral orbital
orbicularis oculi muscles widen the left palpebral
fissure.
 Bell’s Palsy –
Facial Nerve Palsy

Bells palsy pre- Botox Bells palsy post- Botox

Treatment: Intentionally weaken unaffected side to create esthetic symmetry
Lateral Orbicularis Oculi M.
& Tendon of Temporalis M.

 Always inject OUTSIDE the

orbital rim
 (finger width away from
epicanthus)

 Patient is asked to squint

and smile maximally

 Safe zone is between the

upper and lower borders of
the crow’s feet

 Avoid injecting directly

above eyebrow – lacrimal
gland
Injection Sites: Masseter Region

 Overdose - will paralyze the

muscles of mastication, chewing
and talking

 Underdose - will not have any

effect at all

 Correct dose of BoNT-A - will

reduce muscle contractions
 Masseter - Referred pain
 Teeth- “Endo –type” pain

 Sinuses – thin sinus floor, the roots

get sensitized from the pressure

 Earache

 Parotid and submandibular gland

areas
 Injection Sites: Masseter Region
 Localize the muscle by asking the
patient to clench

 Determine anterior and posterior

borders of the masseter

 The number of injection sites will

vary with size

 15-25 per side

Total units: 30 -50u

Injection Sites: Masseter Region
Protective Masticatory
Function of lateral
Pterygoid muscles

The instant teeth occlude:

 Temporalis and masseter relax
 Swallowing initiated
 The LP attempts to disclude the teeth

LP acts as an air brake and rudder

LATERAL PTERYGOID NOT INJECTED

All Sites have therapeutic and cosmetic effects
The Masseters – Aesthetic implications
Daphne post Botox…

Before After
Injection Sites: Occipital/Suboccipital
and Cervical Regions

Muscles to inject (patient

guided):

Occipitalis, suboccipital
muscles, and trapezius

Nuchal ridge
Injection Sites: Occipital/Suboccipital and
Cervical Regions
Muscles of the Suboccipital Region

Nuchal ridge
Injection Sites: Occipital/Suboccipital
and Cervical Regions

Occipitalis 2.5-5 units

Cervical paraspinals 2.5 -5

units each

Trapezius and Trapezius

muscles 5 units each

Total units: 40 – 60u

The Role of Botox as Aids in multiple
aspects

 Cosmetic dentistry
 Perio
 Ortho
 Oral Surgery
Less clenching (Masseter Injections) = Less load on
implants = better osseo-integration = improved
prognosis

Multiple immediately loaded implants

Added benefit: Tolerance of rapid vertical change

with prosthesis
Reduced implant failure
Maxillary Vertical Excess - Gummy
Smile
Muscles to be injected:

Levator labii superioris (nasal)

INJECTING BETWEEN ZYGOMATIC

ARCH AND LABIAL COMMISSURE
CAUSES ORAL PTOSIS – desirable
in gummy smile treatment

Injecting levator labii superioris

alaque nasii with 1.25U per visit,
up to 2.5 -3 units
Maxillary Vertical Excess - Gummy
Smile

Alternative to orthognathic surgery

May alieviate dryness from lip

incompetance
Maxillary Vertical Excess - Gummy
Smile

(Scholtes et al, 2008, Franco, 2007, and Polo, 2008)

Maxillary Vertical Excess - Gummy
Smile

(Scholtes et al, 2008, Franco, 2007, and Polo, 2008)

 Depressor anguli oris (Triangularis)
- INJECTIONS
DAO produces a frown in the
mouth.

Triangularis is innervated by
mandibular and buccal branches
of the facial nerve (VII)

 Blood supply by the facial

artery.

 3.5 - 5 units per side

Triangularis
Depressor anguli oris (Triangularis)
Angular Cheilitis

Poor Aesthetics –
previous Facial
Nerve Paralysis
 Increased tolerance of functional
orthotics that cause instant postural
change Masseter and DAO inejctions
Post Periodontal Surgery – Limit pull of
depressor anguli oris muscles
Ann Med Health Sci Res. 2013 Jan-Mar; 3(1): 131.
Role of Botox in Efficient Muscle Relaxation and Treatment Outcome: An Overview
P Kumar, A Khattar,1 R Goel,2 and A Kumar3
Author information ► Copyright and License information ►
 ORTHODONTIC IMPLICATIONS
Tongue Thrust

Tongue Thrust - Genioglossus 5units maximum dose

HIGHER DOSES MAY RESULT
IN DYSPHAGIA
 ORTHODONTIC IMPLICATIONS
Deep Overbite, Stability over time?
Masseteric Hypertrophy: An Orthodontic Perspective
G Sreejith Kumar,
Babukkuttan Pilla
The Journal of Indian Orthodontic Society, October-December 2012;46(4):233-237

Depression of the molars during

chewing or swallowing.

Decision for premolar extraction is

influenced – potential for reduced
face height and bite deepening when
premolars are extracted.
 Hypertonic Lips:
Orbicularis Oris (Sphincter) Control

Tardive dyskinesia -
repetitive, involuntary,
purposeless movements

Tremors

Hemifacial spasms

Difficulty correcting and

maintaining orthodontic
alignment in Class II division II
patients with Hypertonic lips
 Hypertonic Lips:
Orbicularis Oris (Sphincter) Control

Multiple Sites for injections

Doses = 4x 1.25U
PRECAUTIONS for Orbicularis Oris
• UNPREDICTIBLE
• PUCKERING
• LIP BITING
• P AND V SOUNDS

Asymmetric lip line (pucker test for muscle function)

Weak side unable to pout as much as strong side

 Mentalis
• Origin = The incisive fossa of the
mandible

• Insertion = Skin of the chin

.
• Action = Raises and protrudes the
lower lip

• Considerations: Injection site should

be kept at the point of the chin to
prevent compromise of the lip
depressors

Injection Techniques 5-10 units per

injection site
Mentalis

Among the Causes of Gingival

Recession is:

Muscle Attachments (Frenum)

pulling on the gum tissue. The
case to the left shows a frenal pull
with gum recession.

In place of mentalis repositioning

surgery, temporary paralysis with
Botox is less invasive.
 Mentalis
Int J Periodontics Restorative Dent. 2011 Apr;31(2):165-73.
Treatment of gingival recession in the anterior mandible using the tunnel technique and a
combination epithelialized-subepithelial connective tissue graft-a case series.
Stimmelmayr M, Allen EP, Gernet W, Edelhoff D, Beuer F, Schlee M, Iglhaut G.
Source

Office of Oral Surgery, Cham, Germany. [email protected]

Abstract

Covering exposed roots becomes more and more difficult as the gingiva becomes thinner
and the vestibule becomes more shallow. Also, the outcome becomes less predictable. In
addition, where there is high frenal attachment or muscle pull, such as the mentalis
muscle in the mandibular anterior region, secondary retraction of a coronally advanced
flap will likely occur.
 Mentalis

Tonic contraction of the mentalis can create a horizontal

crease in the skin of the upper chin or an accentuation of
the dermal attachments causing mentalis chin
irregularity. Treatment with Botox® can correct both of
these defects.
Sialorrhea

• 21G 2” needle inserted

at the mid-point
between the tragus and
the mandibular angle.

• Needle advanced until

the anterior border of
masseter muscle.

• 50 units per gland, 25

units X 2 injection sites
0.1 mL
 Sialorrhea

Arch Otolaryngol Head Neck Surg. 2011 Apr;137(4):339-44. doi:

10.1001/archoto.2010.240. Epub 2011 Jan 17.
Botulinum toxin A for treatment of sialorrhea in children: an effective,
minimally invasive approach.
Khan WU, Campisi P, Nadarajah S, Shakur YA, Khan N, Semenuk D, McCann
C, Roske L, McConney-Ellis S, Joseph M, Parra D, Amaral J, John P, Temple M,
Connolly B.
Source

Faculty of Medicine, University of Toronto, Ontario, Canada.

Review of PAIN INJECTION PROTOCOL
Muscle Number of Units per Not to exceed
Injection injection site units per side
Sites

Frontalis 6-8 2.5 20

Temporalis 1 10 10
Anterior
Temporalis Mid 1 5 5
Temporalis 1 2.5 - 5 5
Posterior
Masseter 2 5 - 12.5 25-30
Occipitalis 1 5 5
Suboccipital 1-3 2.5 7.5
Muscles
Trapezius 1-3 2.5 7.5
 Review of Perioral Injection Sites

Muscle Number of Units per Not to exceed

Injection Sites injection site units per side

Lavator Palpabrae 1 2.5 2.5

Superioris
Lavator Labii 1 5 7.5
Superioris
Depressor Anguli Oris 1 5 -7.5 7.5
Mentalis 1 -2 2.5 - 5 5
Orbicularis Oris 2–4 2.5 8
Parotid glad 2-4 10 -25 50
Angles and Depth of Needle
¼ needle superficial at 10˚ to skin
surface a fingerbreadth away from the
epicanthi. Watch bleb!

Entire length of needle at 30˚ to skin.

Linear thread – Inject as you withdraw
for Corrugators (parallel to eyebrows)

Entire length of needle at 45˚ to skin.

Insert into clenched muscle; Inject a
bolus into relaxed muscle belly

Entire length of needle at 90˚ to skin.

Insert into clenched muscle; Inject a
bolus into relaxed muscle belly

Half the length of needle at 30˚ to skin

(bleb rises under the skin)

½ needle 5-6 mm at 90˚ to skin

 Review Of Safety Zones:
Treatment of Eyelid ptosis - Least desirable

Rx: lopidine (eye-ope n-d-ing) eyedrops with epinephrine

1-2 drops 2-3 times per day (contracts Muller’s muscle 2-3mm)
Or
Botox 1.25 units below eyebrow
 Review Of Safety Zones:
Treatment of Eyebrow ptosis

Have to wait it out…

Massaging the area may help Botox break down
 Superficial blood vessels
LOOK FOR THEM!
To prevent bruising:

 do NOT inject in recumbent position

Avoid alcohol and aspirin for 24 hrs before and after

Tx: ice, Arnica, Traumeel gel

Masking of Bruises: Dermablend/Laura Mercier

Chart Entry:
 Use a diagram or a table

 Therapeutic Botox for e.g.

diagnosis, prevention &
treatment of TMD

Patient informed reason for

injecting is to limit
parafunctional clenching,
migraines, etc.
Let’s help our patients!
 Diffusion of Innovation
 Everett Rogers 1962

 Rogers defines an innovation as "an idea, practice, or object

that is perceived as new by an individual or other unit of
adoption”.

 Rogers categorizes the five stages (steps) as: awareness,

interest, evaluation, trial, and adoption.
Diffusion Decision
Innovation – Diffusion

Early adopters

Innovators

Late adopters Laggards

Time
Congratulations on acquiring a set of
new skills in Patient Care!

Allergan (Ontario and Quebec) 1800 668 6427

THANK YOU!