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The trouble with the Masseter

The good, the bad, and the ugly truth behind botulinum toxin treatment for bruxism.

The good:

Masseter botulinum toxin injections first started being prescribed by dentists for a condition called bruxism (teeth grinding that would destroy the teeth during sleep). This was a condition caused by the strongest muscle in our body (the chewing muscle).

The masseter, mastication muscle is responsible for elevation of the mandible and some of the protraction but it is mostly dictating the strength that the teeth clench together.

With time, some people develop this condition called bruxism where the this strongest muscle in the body (masseter muscle) contracts unconsciously almost all of the time. This causes the jaw to clamp and teeth to grind together, destroying the teeth and causing a few other health and aesthetic issues.

Funnily enough, one would think that evolutionarily speaking, the strongest muscle would lie in our extremities for lifting purposes or lifting ourselves out of danger, but no! Evolution of man from eating grass and wild plants to developing teeth to grind down highly nutritious grains and raw meat through chewing, lead to enlarged masseter muscles. The discovery and control of fire 2mil years ago has since spared us the extra chewing and grinding. Evidence suggests that humans have existed for at least 6 million years. So I guess the presence of this condition that is still found in humans to this day could prove that It takes a long time to break a habit evolutionarily speaking.

The bad:

The masseter bruxism condition also has an aesthetic concern. The main reason is that it increases the jaw width and makes the face more square shaped. Only recently did people have this treatment done regardless of if they suffer with bruxism or not. This is in order to slim the face and make it more ‘V’ shaped.

Muscle mass increases the more you use it, the same way you exercise your biceps at the gym so that it gets bigger.

The same concept can be used when discussing the masseter muscle. The muscle is being used excessively, unconsciously and even in one’s sleep. The consensus of the aetiology of the excessive use is due to a subconscious psychological tick that stems from different reasons.

This overuse of the mastication muscle also destroys the teeth with time because of the sheer pressure stress the teeth are put under continuously, and over time, there will be shortening of the teeth involved and even cracks if not treated.

Most aesthetic medicine trainers are now teaching and endorsing the aesthetic treatment of all patients because of their perceived benefits that they are absolutely convinced of. They are teaching injectors to give botulinum toxin masseter treatments to patients who do not suffer from major issues with the jaw for ‘anti-aging’ benefits. They teach of clinical studies that show the results that the jawbone loss was GREATER in the ones that had NO treatment of the masseter muscle vs. the ones that HAD botulinum treatment of the masseter muscle.

What does that even mean, you ask yourself?

Well, the facial structures are held together by the jaw bone and with time, we normally lose minerals from the bones and the aging face loses its scaffolding structure. Where would the soft tissue such as muscle, fat and skin go? The soft tissues will go wherever gravity dictates and fall to the centre of the face. What most call a ‘saggy face’ is a result of a domino effect starting from the bone loss to the movement of the tissues towards the centre of the face, to the collagen loss and other soft tissue laxities. It would make sense right?  [i]

Well, if you look at actual studies there isn’t much research in terms of masseter botulinum toxin and bone loss. Now there are published medical journal articles that compare patients who have had treatments of the masseter muscle versus the ones that have not.

Following treatments for years, they took scans of the jaw later to find out how the bone loss is. Shockingly, many studies are showing the opposite results that the jawbone loss was greater in the ones that treated the masseter muscle vs. the ones that hadn’t treated it. However, there aren’t enough studies to conclude the efficacy and bone loss. The discussion is, what if muscle loss (atrophy) will also result in bone demineralisation?

Let’s get back to Bruxism though. Another issue the bruxism condition causes is recurrent migraines and constant headaches that are debilitating when it is grave.

If we start getting sentimental about it, all these issues have a simple 5 minute solution by an injection every 6 months with botulinum toxin.

From this point of view, personally, I have changed lives in my aesthetic medicine practice and brought women and men confidence they thought they would never have to look at themselves in the mirror and be able to say ‘I got this!’. This went further than the confidence in a bar when trying to catch someone’s eye, but I am talking about people who have pursued careers they had not been able to due to psychological obstacles they put themselves and all it took was a small injection in the jaw that took 5 minutes to do at my clinic.

I really still scratch my head thinking about the unbelievable change in their lives after a procedure that has nothing to do with their intellectual capability or physical aptitudes could have in the way they unleash their prospective.

The ugly:

Not everyone suffers from bruxism, although aesthetic medicine has taken it to a whole new level. We all know by now the gravity of pseudoscience that has been infesting social media, magazines, shops, clinics, even scientific journals and this causes a never before seen utter confusion among the people who don’t attain a keen scientific nose. Therefore, it is so difficult to smell the stench of falsehood and one must attain a master’s degree in medicine and a specialty in pathology so that they can understand quite the extent.   

That is not to say the dermatologists have any idea what they are talking about most of the time. As a doctor with a master’s degree in Burns plastics and reconstructive surgery and surgery resident, I can tell you that most doctors have no idea what they are talking about most of the time. When taking a direction of suggesting and advising patients, we can assume this is the way forward after being satisfyingly convinced by a few randomised control trials (keep in mind most research has a degree of bias and errors too), and the fact that it is FDA approved and there are enough physical results and has been researched for complications for enough time to warrant it’s use in our clinics.

After FDA approval most clinics start offering treatments immediately as soon as it hits the pharmacies or a marketing rep walks into their clinic with a good offer to gain profit.

Concluding this erratic trail of thought, it is not well known what the botulinum toxin does long term, but it does help some people for the moment to relieve symptoms. Though I would be reluctant to inject patients who just want a slimmer face unless there is a great need and it affects a patient’s day to day life. I will wait for enough randomised control trials to assess mandible bone density following botulinum toxin injections.


de Maio, M. , Wu, W. T. , Goodman, G. J. & Monheit, G. (2017). Facial Assessment and Injection Guide for Botulinum Toxin and Injectable Hyaluronic Acid Fillers: Focus on the Lower Face. Plastic and Reconstructive Surgery, 140 (3), 393e-404e. doi: 10.1097/PRS.0000000000003646.

Raphael, Karen G et al. “Effect of multiple injections of botulinum toxin into painful masticatory muscles on bone density in the temporomandibular complex.” Journal of oral rehabilitation vol. 47,11 (2020): 1319-1329. doi:10.1111/joor.13087

Hong, Seok Woo, and Jeong-Hyun Kang. “Decreased mandibular cortical bone quality after botulinum toxin injections in masticatory muscles in female adults.” Scientific reports vol. 10,1 3623. 27 Feb. 2020, doi:10.1038/s41598-020-60554-w

Tsai CY, Shyr YM, Chiu WC, Lee CM. Bone changes in the mandible following botulinum neurotoxin injections. Eur J Orthod. 2011 Apr;33(2):132-8. doi: 10.1093/ejo/cjq029. Epub 2010 Sep 30. PMID: 20884720.

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