Review Article

Applications of Botulinum Toxin in Dentistry - Literature Review

Filho RR*, Zimmermann GS and Gonçalves BM
Department of Dentistry, Federal University of Santa Catarina (UFSC), Brazil

*Corresponding author: Rubens Rodrigues Filho, Department of Dentistry, Federal University of Santa Catarina (UFSC), Florianópolis, SC, Brazil

Published: 14 Nov, 2016
Cite this article as: Filho RR, Zimmermann GS, Gonçalves BM. Applications of Botulinum Toxin in Dentistry - Literature Review. J Dent Oral Biol. 2016; 1(3): 1013.


The Botulinum Neurotoxins are produced by the anaerobic bacterium Clostridium botulinum and are considered the most potent toxins known and its application has become useful and significant in the treatment of oral and maxillofacial injuries. The aim of this study was to review the literature showing the possible therapeutic uses of botulinum toxin in dentistry. There were used articles, that describe the injection of botulinum toxin type A (BTX-A) in areas related to the oral cavity and face, excluding cosmetic purposes. The results show that a toxin is a viable treatment alternative, with beneficial effects in dentistry, but in some cases should be associated with other types of treatment. Although the literature confirm the effectiveness of the BTX-A, these studies should be interpreted cautiously, and more research is needed to confirm the safety and effectiveness of this treatment in larger, well-controlled clinical studies.
Keywords: Botulinum toxin type A; Dentistry


The application of botulinum toxin (BTX) has become a useful and significant tool in the control of oral and maxillofacial injuries. Its application began the aesthetic use but has been very effective in various other clinical or surgical medical specialties [1].
Botulinum neurotoxin is synthesized by the Gram-positive, anaerobic, bacterium Clostridium botulinum and is considered the most potent toxin known [2]. The neurotoxins produced are proteins, and seven different serological types have been identified (A, B, C1, D, E, F and G), but the most widely used is the Botulinum Type A Toxin (BTX-A) [3,4]. The United States was the first to produce BTX-A during World War II, but the development of Botulinum neurotoxin as drug began in 1981 with the description of the use of BTX-A for the treatment strabismus. In 1989, after thorough clinical and laboratory tests, the Food and Drug Administration (FDA) approved the therapeutic use of BTX-A, for treatment of strabismus, blepharospasm, and hemifacial spasm in patients over 12 years of age. In 2000 the FDA approved BTX for dystonia and in 2002 it was approved for the temporal management of glabellar lines [5,6].
Normally, the brain sends messages to the muscles to contract and to promote the movement. The message is transmitted through a substance called acetylcholine. Botulinum toxin blocks the presynaptic release of acetylcholine (Ach) into the end-plate of the neural junction by interfering with the activity of SNARE (soluble N-ethylmaleimide-sensitive factor attachment protein receptors) proteins [7] and as a result, the muscle does not receive the message to contract, but without any systemic effects [8,9]. BTX produces partial muscle chemical denervation, resulting in localized reduction of muscular activity and can be used as a single therapy or as an adjunct to another treatment [10].
It has been proposed that BTX reduces pain directly by producing molecular changes in nociceptive fibres function, blocking the release of neurotransmitters [11,12], and indirectly by reducing excess dysfunctional muscle activity has been reported to have analgesic effects independent of its action on muscle tone [7].
Clinical effects of BTX-A occur within approximately 24-48 h after administration, peaking at 2-3 weeks. Effects generally last about 4 months, then level off to a moderate plateau until eventually full nerve recovery occurs within 3 to 6 months [13,14].
In dentistry, the toxin is used as a form of control for temporomandibular disorders (TMD), headaches, trigeminal neuralgia, migrane, myofacial pain, gummy smile, asymmetrical smile, masseter hypertrophy, mandibular spasm, surgical procedures, and hemifacial spasm and also in sialorrhea. Its use is growing and appears to be quite varied, and you can use in patients with facial changes and those whose changes are related to oral health, with good results when compared to other forms of treatment [15].
The aim of this study was to review the literature showing the recent advances and possible therapeutic uses of botulinum toxin in dentistry.

Search Strategy

This study constitutes a Literature Review Narrative or Traditional, held between May and September 2016 and selected scientific articles through search using three electronic databases: Pubmed, Scielo, and Bireme. The main keywords used were Botulinum Toxin and Dentistry, adding-specific words for each type of change researched.

Literature Review

Temporomandibular Disorders (TMDs)
TMDs involve a set of craniofacial changes with nonodontogenic facial pain and multifactorial or biopsychosocial etiologies, which may involve the temporomandibular joint (TMJ), masticatory muscles, and the associated structures [16-20]. Due to its muscle activity reducing and pain relief effects, BTX-A has gained an emerging role as a potential therapy for TMDs [6,13,21-23], including TMJ dislocation, bruxism, orofacial dystonia and arthritis [13,24-30].
Headache, Migrane and Trigeminal Neuralgia
Headaches can be classified into primary and secondary types. Primary headaches occur without underlying organic diseases and can be further classified into migraine, tension-type headaches, and cluster headaches. Despite important advances in management of headache disorders, many patients remain treatment resistant. Such side effects of treatment are relatively rare BTX-A is emerging as a new therapeutic alternative in the preventative treatment of headaches [29,31,32]. Furthermore, there have been several studies supporting the safety and tolerability of BTX-A in the treatment of headache disorders [33,34]. Although additional large-scale studies are needed to clarify clinical predictors of response as well as optimal dosing, injection sites and mechanism of action [10,32].
Several studies have suggested that BTX-A injected into the hyperalgesic tissue may be helpful at reducing spontaneous and provoked pain of neurophatic origin. Furthermore, a few randomized clinical trials have also suggested that BTX-A may be helpful in the treatment of trigeminal neuralgia [35].
Myofacial Pain
Myofacial pain syndrome is a disorder caused by persistent acute or chronic muscle contraction, characterized identification of trigger points or fibrous bands that, when stimulated or pressed, transfer radiated pain to the distribution area of the affected muscle [36]. Such trigger points can result from direct trauma, strain, overuse, or repetitive micro-trauma [37]. Many treatment options have been used to arrest, stabilize, or reverse this muscle hyperactivity, although all have shown some degree of success, all have potential complications [38,39].
Several studies have investigated the use of BTX-A for the treatment of myofacial pain, with positive findings [22,40-43]. However, some studies have demonstrated that the sole use o BTX-A is not enough to relieve pain [44-47] and that, in addition to active treatment, physical therapy is fundamental [48]. Overall, insufficient prospective randomized clinical trials have been performed to prove the effectiveness of BTX-A to treat myofacial pain in the maxillofacial region [49].
Gummy Smile
Gummy smile is a term used to describe excessive display of gingival tissue in the maxilla upon smiling caused by hyper-functional muscles of the upper lip. Several surgical techniques have been reported for the correction of hyper-functional upper lip elevator muscles [31]. The BTX-A may be an effective treatment alternative for patients with excessive gum exposure caused by over activity of the lip elevator muscles [43,50-52], but should be used with caution. Muscles are injected close to the nasalis or orbicularis oculi, with some fibers intermeshing the elevator labii superioris, levator labii superioris alaeque nasi, levator anguli oris, and zygomaticus major and minor [53].
Hyper-salivation is the result of hyper-secretion of salivary glands, but it is commonly associated with the loss of neuromuscular control with impaired oral motor activity and increased saliva flow. It also occurs as a side effect of drugs that act in the secretomor pathway, resulting in hyper secretion [54]. There are several therapeutic approaches for treatment of sialorrhea and the application of BTX-A was first proposed in 1977 through intra-glandular injection, mainly to the parotid gland [55], because it is able to depress secretory activity of the salivary glands [56] and saliva production can be effectively reduced. However, some authors use BTX injection guided by ultrasound to improve the effectiveness and safety [57], although others have not found differences in effects associated with the method of drug application.
There are many clinical trials in the literature showing the efficacy of this drug, but more detailed studies are needed on its safety and effect on glandular tissue.
Hemifacial Spasm
Hemifacial spasm is is a chronic disorder characterized by repetitive synchronous contraction of facial nerve innervated muscles on one side of the face [58]. The use of BTX-A in hemifacial spasm was approved by the U.S. Food and Drug Administration in 1989 and since then, evidences supporting its efficacy in the treatment of this disorder [59,60], however only a small number of studies have described the long-term use.
Masseter Hypertrophy
Masseteric hypertrophy usually results from anatomical asymmetry of the jaw and may be unilateral or bilateral. The injection of BTX-A is a minimally invasive procedure and the results obtained with injections have been encouraging and satisfying to patients [61-63]. Many studies showed the effects of long-term treatment of BTX-A, analyzing the monitoring data of patients with hypertrophy of the masseter muscle. Excellent results were obtained with satisfactory regression of hypertrophied muscle after intramuscular injection of BTX [64,65].
Various side effects of a BTX-A injection for masseteric hypertrophy have been reported, including change in bite force, speech disturbance, muscle pain, facial asymmetry, and prominent zygoma [66-68]. The change in bite force is an inevitable side effect of muscle atrophy, although it is normally only temporary.
Mandibular Spasm (Trismus)
It is a motor disturbance of the trigeminal nerve when the mandibular musculature remains semi-contracted or in spasm, resulting in restricted mouth opening [69]. BTX-A is injected into each masseter muscle and temporalis muscle, improving function and mouth opening, and decrease pain and tenderness to palpation. BTX-A treatment to the masticatory musculature diminishes the effects of hyper-functional or spastic muscles [70].
Asymmetrical Smile
Facial asymmetry can result from different causes, which will determine whether or not it can be reversible. There are three basic types of facial asymmetries: asymmetry acquired, iatrogenic and idiosyncratic or familial. In the pilot study, five patients with idiosyncratic asymmetrical smiles were treated with injections of BTX-A, which produced a symmetrical, more balanced smile one week after treatment and lasted at least six months after [71].
Surgery Procedures
More recently, it has been reported the clinical use of BTX-A in implantology for prophylactic reduction of masseter and temporalis muscle strength after implantation immediate load protocols [72]. The failure in osseous integration can be impeded by excessive functional forces in patients with para-functional habits.
BTX-A can also be used as an adjunct in fracture maxillofacial repair such zygomatic fracture fixation surgery and surgical reduction of mandibular condyle [73]. The repair often requires multiple fixation sites and hardware to overcome the strong forces of masticatory musculature. Overloading of these muscles can prevent fracture callus formation [73-75].
In periodontal surgeries, BTX injection can reduce periodontal trauma due to excessive muscular function [31].

Contraindications and Drug Interactions

Few studies reveal systemic problems associated with the administration with plastic purpose. Contraindications to the use of BTX in pregnancy, breastfeeding, neuromuscular junction disorders, hypersensitivity and drug interactions with amino glycosides, antibiotics, quinidine, calcium channel blockers, magnesium sulfate, succinylcholine, and polymyxin [76,77].

Adverse Effects

The side effects of intramuscular injection of the BTX-A when in therapeutic applications were mostly local and relatively mild, however, may be present in some cases [76,77]. Normally, these effects are transient, disappearing a few weeks after the applications [21,22,78]. The effects of BTX in the body are related to the frequency and amount of dosage. It can be observed hypotension, nausea, dysphagia, impaired sphincter control, itching, and a flu-like symptoms, facial pain, pharyngitis, double or blurred vision, anaphylaxis, urticaria, erythema, difficulty in articulating words and lack of control salivation, transient weakness, fatigue at or near the site [79], etc.


From the literature, we conclude that BTX-A is a viable treatment alternative, with beneficial effects for dentistry, but in some cases should be associated with other types of treatment. BTX-A is a potent and specific muscle relaxant, it will promote relaxation of the masticatory muscles, reducing pain and allowing a proper jaw function. Side effects they are rare, and transient, not causing major problems for patients. Although the literature confirm the effectiveness of the BTX-A, these studies should be interpreted cautiously, and more research is needed to confirm the safety and effectiveness of this treatment in larger, well-controlled clinical studies.


  1. Khanna S, Jain S. Botox: the poison that heals. Int Dent J. 2006; 56: 356-358.
  2. Sposito MM de M. Botulinic Toxin Type A : action mechanism. Acta Fisiatr. 2009; 16: 25-37.
  3. Torres Huerta JC, Hernández Santos JR, Ortiz Ramírez y S EM, Villegas T. Toxina botulínica tipo A para el manejo del dolor en pacientes con síndrome de dolor miofascial crónico. Rev Iberoamericana del Dolor. 2010; 17: 32-40.
  4. Setler PE. Therapeutic use of botulinum toxins: backgroundand history. Clin J Pain. 2002; 18: 119-124.
  5. Royal MA. Botulinum toxins in pain management. Phys Med Rehabil Clin N Am. 2003;14: 805-820.
  6. Cheshire WP, Abashian SW, Mann JD. Botulinum toxin in the treatment of myofascial pain syndrome. Pain. 1994; 59: 65-69.
  7. Dolly JO, O’Connell MA. Neurotherapeutics to inhibit exocytosis from sensory neurons for the control of chronic pain. Curr Opin Pharmacol. 2012; 12: 100-108.
  8. Sellin LC, Thesleff S. Pre- and post-synaptic actions of botulinum toxin at the rat neuromus- cular junction. J Physiol. 1981; 317: 487-495.
  9. Brin MF. Botulinum Toxin Therapy: Basic Science and Overview of Other Therapeutic Applications. Management of Facial Lines and Wrinkles. Philadelphia: Lippincott, Williams and Wilkins. 2000; 39: 279-302.
  10. Martínez-Pérez D. Botulinum toxin and its use in oral and maxillofacial pathology. Rev Esp Cirug Oral y Maxillofac. 2004; 26:149-154.
  11. Clark GT, Stiles A, Lockerman LZ, Gross SG. A critical review of the use of botulinum toxin in orofacial pain disorders. Dent Clin North Am. 2007; 51: 245-261.
  12. Guo BL, Zheng CX, Sui BD, Li YQ, Wang YY, Yang YL. A closer look to botulinum neurotoxin type A-induced analgesia. Tox-icon. 2013; 71: 134-139.
  13. Bakke M, Møller E, Werdelin LM, Dalager T, Kitai N, Kreiborg S. Treatment of severe temporomandibular joint clicking with botulinum toxin in the lateral pterygoid muscle in two cases of anterior disc displacement. Oral Surgery Oral Med Oral Pathol Oral Radiol Endod. 2005; 100: 693-700.
  14. Muthane UB, Panikar JN. Botulinum toxins: pharmacology and its current therapeutic evidence for use. Neurol India. 2003; 51: 455-460.
  15. Hoque A, McAndrew M. Use of botulinum toxin in dentistry. N Y State Dent J. 2009 ; 75: 52-55.
  16. Keller EE, Baltali E, Liang X, Zhao K, Huebner M, An KN. Temporomandibular custom hemi joint replacement prosthesis, prospective clinical and kinematic study. J Oral Maxillofac Surg. 2012; 70: 276-288.
  17. Emara AS, Faramawey MI, Hassaan MA, Hakam MM. Botulinum toxin injection for management of temporomandibular joint clicking. Int J Oral Maxillofac Surg. 2013; 42: 759-764.
  18. Peck CC, Goulet JP, Lobbezoo F, Schiffman EL, Alstergren P, Anderson GC, et al. Expanding the taxonomy of the diagnostic criteria for temporomandibular disorders. J Oral Rehabil. 2014; 41: 2-23.
  19. Al-Jundi MA, John MT, Setz JM, Szentpe-tery A, Kuss O. Meta-analysis of treatment need for temporomandibular disorders in adult non patients. J Orofac Pain. 2008; 22: 97-107.
  20. Herpich CM, Amaral AP, Leal-Junior EC, de Tosato PJ, Gomes CA, Arruda EE, et al. Analysis of laser therapy and assessment methods in the rehabilitation of temporomandibular disorder: a systematic review of the literature. J Phys Ther Sci. 2015; 27: 295-301.
  21. Freund B, Schwartz M. The use of botulinum toxin for the treatment of temporomandibular disorder. Oral Health. 1998; 88: 32-37.
  22. Freund B, Schwartz M, Symington JM. The use of botulinum toxin for the treatment of temporomandibular disorders: preliminary findings. J Oral Maxillofac Surg. 1999; 57: 916-920.
  23. von Lindern JJ, Niederhagen B, Bergé S, Appel T. Type A botulinum toxin in the treatment of chronic facial pain associated with masticatory hyperactivity. J Oral Maxillofac Surg. 2003; 61: 774-778.
  24. Fu KY, Chen HM, Sun ZP, Zhang ZK, Ma XC. Long term efficacy of botulinum toxin type A for the treatment of habitual dislocation of the temporomandibular joint. Br J Oral Maxillofac Surg. 2010; 48: 281-284.
  25. Tan EK, Jankovic J. Treating severe bruxism with botulinum toxin. J Am Dent Assoc. 2000; 131: 211-216.
  26. Tintner R, Jankovic J. Botulinum Toxin Type A in the Management of Oromandibular Dystonia and Bruxism. Scientific and Therapeutic Aspects of Botulinum Toxin. Lippincott Williams & Wilkins, Philadelphia PA. 2002; 343-350.
  27. Anderson S, Krug H, Dorman C, McGarraugh P, Frizelle S, Mahowald M. Analgesic effects of intra-articular botulinum toxin Type B in a murine model of chronic degenerative knee arthritis pain. J Pain Res. 2010; 6: 161-168.
  28. Raphael KG, Tadinada A, Bradshaw JM, Janal MN, Sirois DA, Chan KC, Lurie AG. Osteopenic consequences of botulinum toxin injections in the masticatory muscles: a pilot study. J Oral Rehabil. 2014; 41: 555-563.
  29. Persaud R, Garas G, Silva S, Stamatoglou C, Chatrath P, Patel K. An evidence-based review of botulinum toxin (Botox) applications in non-cosmetic head and neck conditions. JRSM Short Rep. 2013; 4: 10.
  30. Shim YJ, Lee MK, Kato T, Park HU, Heo K, Kim ST. Effects of Botulinum Toxin on Jaw Motor Events during Sleep in Sleep Bruxism Patients: A Polysomnographic Evaluation. J Clin Sleep Med. 2014; 10: 291-298.
  31. Rao LB, Sangur R, Pradeep S. Application of Botulinum toxin type A: an arsenal in dentistry. Indian J Dent Res. 2011; 22: 440-445.
  32. Samton J, Mauskop A. Treatment of headaches with botulinum toxin. Expert Rev Neurother. 2006; 6: 313-322.
  33. Menezes C, Rodrigues B, Magalhães E, Melo A. Botulinum toxin type A in refractory chronic migraine: an open-label trial. Arq Neuropsiquiatr. 2007; 65: 596-598.
  34. Freund BJ, Schwartz M. Treatment of chronic cervical-associated headache with botulinum toxin A: a pilot study. Headache. 2000; 40: 231-236.
  35. Babiloni AH, Kapos FP, Nixdorf DR. Intraoral administration of botulinum toxin for trigeminal neuropathic pain. Oral Med Oral Pathol Oral Radiol. 2016; 121: e148-e153.
  36. Día RCR, Lotero MAA, Suarez MVA, Saldarriaga SE, Martínez SE. Botulinum toxin for the treatment of chronic pain. Review of the evidence. Colombian Journal of Anesthesiology. 2014; 42: 205-213.
  37. Smith HS, Audette J, Royal MA: Botulinum toxin in pain management of soft tissue syndromes. Clin J Pain. 2002; 18: S147-S154.
  38. Manns A, Miralles R, Santander H, Valdivia J. Influence of the vertical dimension in the treatment of myofascial pain-dysfunction syndrome. J Prosthet Dent. 1983; 50:700-709.
  39. Narita N, Funato M, Ishii T, Kamiya K, Matsumoto T. Effects of jaw clenching while wearing an occlusal splint on awareness of tiredness, bite force, and EEG power spectrum. J Prosthodont Res. 2009; 53: 120-125.
  40. Acquadro MA, Borodic GE. Treatment of myofascial pain with botulinum A toxin. Anesthesiology. 1994; 80: 705-706.
  41. Kong K-H, Neo JJ, Chua KS. A randomized controlled study of botulinum toxin A in the treatment of hemiplegic shoulder pain associated with spasticity. Clin Rehabil. 2007; 21: 28-35.
  42. Porta M. A comparative trial of botulinum toxin type A and methylprednisolone for the treatment of myofascial pain syndrome and pain from chronic muscle spasm. Pain. 2000; 85: 101-105.
  43. Huerta JCT, Santos JRH, Ramírez EMO, Villegas ST. Botulinum toxin type A for the management of pain in patients with chronic myofascial pain. Rev la Soc Esp Dolor. 2010; 17: 22-27.
  44. Nixdorf DR, Heo G, Major PW. Randomized controlled trial of botulinum toxin A for chronic myogenous orofacial pain. Pain. 2002; 99:465-473.
  45. Ernberg M, Hedenberg-Magnusson B, List T, Svensson P. Efficacy of botulinum toxin type A for treatment of persistent myofascial TMD pain, a randomized, controlled, double-blind multicenter study. Pain. 2011; 152: 1988-1996.
  46. Soares A, Andriolo RB, Atallah ÁN, da Silva EM. Botulinum toxin for myofascial pain syndromes in adults. Cochrane Database Syst Rev. 2012; 18: CD007533.
  47. Ho KY, Tan KH. Botulinum toxin A for myofascial trigger point injection: a qualitative systematic review. Eur J Pain. 2007; 11: 519-527.
  48. Wheeler A, Goolkasian P, Gretz SS. Botulinum toxin A for thetreatment of chronic neck pain. Pain. 2001; 94: 255-260.
  49. Linde M, Hagen K, Stovner LJ. Botulinum toxin treatment of secondary headaches and cranial neuralgias: A review of evidence. Acta Neurol Scand Suppl. 2011; 191: 50-55.
  50. Hwang WS, Hur MS, Hu KS, Song WC, Koh KS, Baik HS, et al. Surface anatomy of the lip elevator muscles for the treatment of gummy smile using botulinum toxin. Angle Orthod. 2009; 79: 70-77.
  51. Mazzuco R, Hexsel D. Gummy smile, and botulinum toxin: a new approach based on the gingival exposure area. J Am Acad Dermatol. 2010; 63: 1042-1051.
  52. Dinker S, Anitha A, Sorake A, Kumar K. Management of gummy smile with Botulinum Toxin Type-A: A case report. J Int Oral Heal. 2014; 6: 111-115.
  53. Polo M. Botulinums type A (BOTOX) for the neuromuscular correction of excessive gingival display on smiling (gummy smile). Am j Orthod Dentofacial Orthop. 2008; 133: 195-203.
  54. Jongerius PH, Rotteveel JJ, Van Den Hoogen F, Joosten F, Van Hulst K, Gabreels FJM. Botulinum toxin A: a new option for treatment of drooling in children with cerebral palsy. Presentation of a case serie. European Journal of Pediatrics. 2001; 160: 509-512.
  55. Bushara KO. Sialorrhea in amyotrophic lateral sclerosis: a hypothesis of a new treatment-botulinum toxin A injections of the parotid glands. Med Hypotheses. 1997; 48: 337-339.
  56. Ellies M, Gottstein U, Rohrbach-Volland S, Arglebe C, Laskawi R. Reduction of salivary flow with botulinum toxin: extended report on 33 patients with drooling, salivary fistulas, and sialadenitis. Laryngoscope. 2004: 114: 1856-1860.
  57. Costa CC, Ferreira JB. Injections of botulinum toxin into the salivary glands to the treatment of chronic sialorrhea. Rev. Bras. Cir. Cabeça Pescoço. 2008; 37: 28-31.
  58. Karp BI, Alter K. Botulinum Toxin Treatment of Blepharospasm, Orofacial/Oromandibular Dystonia, and Hemifacial Spasm. Semin Neurol. 2016; 36: 84-91.
  59. Streitová H, Bareš M. Long-term therapy of benign essential blepharospasm and facial hemi spasm with botulinum toxin A: retrospective assessment of the clinical and quality of life impact in patients treated for more than 15 years. Acta Neurol Belg. 2014; 114: 285-291.
  60. Ababneh OH, Cetinkaya A, Kulwin DR. Long-term efficacy, and safety of botulinum toxin A injections to treat blepharospasm and hemifacial spasm. Clin Exp Ophthalmol. 2014; 42: 254-261.
  61. Manisali M, Hunt NP, Hopper C. Morphological and functional-changes in masseter after administration of botulinum toxin for treatment of masseteric hypertrophy. J Dent Res. 1996; 75: 1164.
  62. Moore AP, Wood GD. The Medical Management of Masseteric Hypertrophy With Botulinum Toxin Type A. Br J Oral Maxillofac Surg. 1994; 32: 26-28.
  63. Rijsdijk BA. Botulinum toxin Type A treatment of cosmetically disturbing masseteric hypertrophy (DUT). Ned Tijdschr Geneeskd. 1998: 142: 529-532.
  64. Andrade NN, Deshpande GS. Use of Botulinum Toxin (Botox) in the Management of Masseter Muscle Hypertrophy: A Simplified Technique. Plast Reconstr Surg. 2011; 128: 24e-26e.
  65. Xie Y, Zhou J, Li H, Cheng C, Herrler T, Li Q. Classification of Masseter Hypertrophy for Tailored Botulinum Toxin Type A Treatment. Plast Reconstr Surg. 2014; 134: 209e-218e.
  66. Kim HJ, Yum KW, Lee SS, Heo MS, Seo K. Effects of botulinum toxin type A on bilateral masseteric hypertrophy evaluated with computed tomographic measurement. Dermatol Surg. 2003; 29: 484-489.
  67. Kim JH, Shin JH, Kim ST, Kim CY. Effects of two different units of botulinum toxin type a evaluated by computed tomography and electromyographic measurements of human masseter muscle. Plast Reconstr Surg. 2007; 119: 711-717.
  68. Oshima M, Middlebrook JL, Atassi MZ. Antibodies and T cells against synthetic peptides of the C-terminal domain (Hc) of botulinum neurotoxin type A and their cross-reaction with Hc. Immunol Lett. 1998; 60: 7-12.
  69. Andrade LA, Brucki SM. Botulinum toxin A for trismus in cephalic tetanus. Arq Neuropsiquiatr. 1994; 52: 410-413.
  70. Cersósimo MG, Bertoti A, Roca CU, Micheli F. Botulinum toxin in a case of hemimasticatory spasm with severe worsening during pregnancy. Clin Neuropharmacol. 2004; 27: 6-8.
  71. Benedetto AV. Asymmetrical smiles corrected by botulinum toxin serotype A. Dermatol Surg. 2007; 33: 32-36.
  72. Ihde SK, Konstantinovic VS. The therapeutic use of botulinum toxin in cervical and maxillofacial conditions: an evidence-based review. Oral Surg Oral Med Oral Pathol Oral Radiol Endod. 2007; 104: e1-e11.
  73. Kayikçioğlu A, Erk Y, Mavili E, Vargel I, Ozgür F. Botulinum toxin in the treatment of zygomatic fractures. Plast Reconstr Surg. 2003; 111: 341-346.
  74. Nishimura K, Itoh T, Takaki K, Hosokawa K, Naito T, Yakota M. Periodontal parameters of osseo integrated dental implants: A 4-year controlled follow-up study. Clin Oral Implants Res. 1997; 8: 272-278.
  75. Ihde KM. Prophylactic use of botulinum toxin in dental implantology. Cranio-maxillofacial Implant Dir. 2007; 2: 3-8.
  76. Amantéa DV, Novaes AP, Campolongo GD, de Barros TP. Using Type A Botulinum Toxin in Pain and Temporomandibular Joint Dysfunction. JBA. 2003; 3: 170-173.
  77. Majid OW. Clinical use of botulinum toxins in oral and maxillofacial surgery. Int J Oral Maxillofac Surg. 2010; 39: 197-207.
  78. Jankovic J, Orman J. Botulinum A toxin for cranial-cervical dystonia: a double-blind, placebo controlled study. Neurology. 1987; 37: 616-623.
  79. Dutton JJ. Botulinum-A toxin in the treatment of craniocervical muscle spasms: short and long-term, local and systemic effects. Surv Ophthalmol, Brookline. 1996; 41: 51-65.