Int. J. Oral Maxillofac. Surg.

2009; 38: 316–320

doi:10.1016/j.ijom.2009.01.008, available online at http://www.sciencedirect.com

Clinical Paper
Aesthetic Surgery

Effect of botulinum toxin type A J. S. Kwon1, S. T. Kim1,

Y. M. Jeon, J. H. Choi
TMJ and Orofacial Pain Clinic, Department of

injection into human masseter

Oral Diagnosis & Oral Medicine, College of
Dentistry, Yonsei University, Seoul, Korea

muscle on stimulated parotid

saliva flow rate
J. S. Kwon, S. T. Kim, Y. M. Jeon, J. H. Choi: Effect of botulinum toxin type A
injection into human masseter muscle on stimulated parotid saliva flow rate. Int. J.
Oral Maxillofac. Surg. 2009; 38: 316–320. # 2009 International Association of Oral
and Maxillofacial Surgeons. Published by Elsevier Ltd. All rights reserved.

Abstract. Botulinum toxin type A (BTX-A) injection into the masseter muscles is
used to treat masseteric hypertrophy. No serious side effects of BTX-A have been
reported, but patients sometimes complain of xerostomia. The aim of this study was
to evaluate the effect of injecting BTX-A into the masseter for the treatment of
masseteric hypertrophy on the flow of saliva from the parotid gland. 34 volunteers
enrolled in this study. A total of 25 units of BTX-A was injected into each side
bilaterally at two points at the center of the lower third of the masseter muscle.
Saliva was collected from the parotid gland over a period of 10 min to determine the
flow rate for 18 weeks after injection. The flow rate was calculated by dividing the
amount in milliliters by the collection time in minutes. There were no significant
Keywords: botulinum toxin type A; BTX-A;
changes in the stimulated parotid saliva flow at 4, 8, 12 or 18 weeks compared with masseter muscle; stimulated parotid saliva.
the baseline. Within this limited study, it can be concluded that BTX-A injection
into the masseter does not cause any significant decrease in the production of saliva Accepted for publication 16 January 2009
from the parotid gland. Available online 23 February 2009

Botulinum toxin produced by Clostridium
botulinum induces muscle paresis and atro-
phy by blocking acetylcholine secretion in
the neuromuscular junctions.3,4 The US
Food and Drug Administration (FDA)
has approved the use of botulinum toxin
type A (BTX-A)16 for the treatment of
strabismus, blepharospasm, seventh cranial
nerve disorders (hemifacial spasm), cervi-
cal dystonia, glabellar wrinkles for cos-
metic uses and hyperhidrosis.10 Besides
the FDA-approved uses, BTX-A has a
variety of clinical applications.15
In oral and maxillofacial surgery, the
use of BTX-A for treating bilateral mas-
seteric hypertrophy was introduced in
1994.11,14 The conventional treatment of
masseteric hypertrophy consists of surgi-
cal reduction, such as a masseteric resec-
tion.2 The postoperative complications
and the patients’ reluctance to undergo
surgery have led to the need for reversible
and conservative treatments. Many con-
servative treatments including occlusal
adjustment, splint therapy, relaxation ther-
apy, spasmolytics, tranquillizers and anti-
depressants have been advocated; these
are almost always unsuccessful. Since
the 1990 s, BTX-A injections to the mass-
1
The authors contributed equally to this
study.

0901-5027/040316 + 05 $36.00/0 # 2009 International Association of Oral and Maxillofacial Surgeons. Published by Elsevier Ltd. All rights reserved.
 BTX-A and Parotid Saliva 317

eter muscles have been commonly used to

treat masseteric hypertrophy.
No serious side effects of BTX-A have
been reported, and those that have occurred
have been minor, such as local bruising, a
painful injection site, or the unwanted
spread of action to the adjacent muscles
such as facial muscle weakness. Some-
times, patients complain of xerostomia
after a BTX-A injection into the masseter
muscle. There are no reports of a relation-
ship between parotid salivary flow and a
BTX-A injection into the masseter muscle.
The aim of this study was to evaluate the
effect of injecting BTX-A into the masseter
muscle for the treatment of masseteric
hypertrophy on the flow of saliva from
the parotid gland.

Materials and Methods

This study was performed in accordance
with the 1975 Declaration of Helsinki. The
study population consisted of volunteers
recruited from dental students and staff at
the College of Dentistry, Yonsei Univer-
sity, Seoul, Korea in 2004 who had com-
plained of a bulky masseter muscle. After
screening by digital palpation, panoramic
view, and posteroanterior view, volunteers
who did not have a bony protuberance of
the mandibular angle but had masseteric
hypertrophy were enrolled in this study.
Before admission to the study, the nature
and the established use of BTX-A as well as
its potential side effects were explained,
and signed, informed consent was obtained
from each volunteer. The volunteers were
free to withdraw from the treatment at any
time.
After screening for temporomandibular
joint (TMJ) and orofacial pain, a total of
34 volunteers, aged 22–35 years (mean
age 26.1 years; 14 males and 18 females)
were enrolled in the study. The exclusion
criteria included pregnancy, a history of
drug allergy or any other serious medical
illnesses. All the subjects were healthy.
None was taking any prescription or non-
prescription medication.
Botulinum toxin injection
The BTX-A (BTXA1, Lanzhou Institute
of Biological Products, Lanzhou, China)
was supplied as a freeze-dried powder of
100 U, and was reconstituted with 2 ml of
sterile saline to a concentration of 5 U/
0.1 ml. The reconstituted drug was used
immediately. A total of 25 U of BTX-A
was injected into each side bilaterally
using a 1 ml-syringe with a 29-gauge,
and a half-inch needle. It was injected into
two points at the center of the lower third
Fig. 1. Injection point for BTX-A in the hypertrophic masseter muscles.
of the masseter muscle, which were
located 1 cm from each other (Fig. 1).
The clinical effect of BTX-A was eval-
uated by electromyography (EMG) and
clinical photographs 4, 8, 12 and 18 weeks
after injection. Subjects were also inter-
viewed about adverse reactions.
Collection of parotid saliva
The subjects were asked not to drink
alcohol or perform hard physical exercise
the day before collection. They were asked
not to eat, drink, smoke, brush their teeth,
or perform oral hygiene for a minimum of
1 hour before saliva collection. All the
samples were taken at the same time of
the day (between 5 and 7 p.m.)
The subjects were instructed to sit com-
fortably with their eyes open and head tilted
slightly forward, and were asked to mini-
mize their orofacial movements. Parotid
saliva flow was stimulated with 2% citric
acid placed on the dorsal lateral surface of
the tongue for 5 s at 30 s intervals. After a
2 min equilibration period, a modified
Curby cup (Fig. 2) was used to collect
the saliva over a period of 10 min to deter-
mine the flow rate. The collector consists of
a plastic cup with an inner and outer cham-
ber. The inner chamber was attached to
plastic tubing that carried saliva to the
collection vessel. The outer chamber was
attached to a suction-inducing device via
plastic tubing and the cup was placed over
the orifice of Stensen’s duct (Fig. 3).
The flow rate was calculated by divid-
ing the amount in milliliters by the collec-
tion time in minutes. The flow rate of
stimulated parotid saliva was taken before
injection and 4, 8, 12 and 18 weeks after
injection.
EMG data
EMG was performed using a BioPak sys-
tem (BioResearch, Inc., Milwaukee, Wis.,
USA) before injection and 4, 8, 12 and 18
weeks after injection. The data were taken
from the masseter muscle during maxi-
mum voluntary clenching.
318 Kwon et al.
Fig. 2. The modifed Curby cup.
Fig. 3. Positioning the modified Curby cup over the orifice of Stensen’s duct.
Statistical analysis
The flow rates at 4, 8, 12 and 18 weeks
post-injection were compared with those
at pre-injection using a paired t-test.
SAS1 Version 8.1 Windows Statistics
Program (SAS Institute, USA) was used
for statistical analyses. A P value <0.01
was considered statistically significant.
Results
All subjects reported significant clinical
improvement 12 weeks after injection.
swelling and pain in the area of the injec-
tion were reported.
After injecting the BTX-A, the EMG
activity of the masseter muscles showed a
significant decrease at 4 and 8 weeks
compared with the baseline. There were
no significant changes in the stimulated
parotid saliva flow at 4, 8, 12 and 18 weeks
compared with the baseline (Table 1,
Fig. 4).
Discussion
BTX-A injection is beneficial in many
conditions, such as overactivity of the
muscles and the hypersecretion of glands.12
The toxin is commonly used to treat mas-
seteric hypertrophy because the paresis
induced by BTX-A injection causes muscle
atrophy, which decreases the diameter of
the target muscle8.
There have been some reports of side
effects following injection of BTX-A into
the hypertrophic masseter muscles. Kim
et al reported a change in facial smiling as
well as a sunken cheek after a BTX-A
injection.8 In the authors’ previous stu-
dies, several mild side effects such as
swelling, bruise or pain in the area of
the injection, headache, muscle weakness,
discomfort in mastication and a dry mouth
have been reported occasionally but these
side effects were all temporary and loca-
lized.1,9 In other studies, patients have
complained of xerostomia.
After injection, the toxin may diffuse
into nearby muscles and other tissues,
such as the parotid glands, via the local
vasculature or by gravity influenced che-
mical diffusion.6 The toxin may affect the
parotid glands through systemic distribu-
tion via blood flow or by retrograde axonal
transport.7,16 A BTX-A injection into the
masseter muscles can affect the salivary
flow rate from the parotid glands and
cause xerostomia. In patients with cervical
dystonia, the use of botulinum toxin type
B (BTX-B) caused a significant decrease
in saliva production, as measured by the
Schirmer’s test, compared with BTX-A.16
There were no major local or systemic The salivary flow rate is affected by
complications associated with BTX-A many factors including the degree of
injection. Several mild side effects were hydration, body positioning, seasonal
observed, all of which were temporary and and diurnal factors, medical status and
localized. Muscle weakness, headache, medications, and the nature and duration
Table 1.
Time point Mean Standard deviation (ml/min) p-value
Preinjection 0.4363 0.5848
4 weeks 0.4067 0.3200 0.7620
8 weeks 0.4313 0.3642 0.9389
12 weeks 0.4748 0.3152 0.7247
18 weeks 0.4437 0.2192 0.9375

Fig. 4. Electromyographic activity of the masseter muscles and stimulated parotid saliva flow during 18 weeks after the BTX-A injection into the
masseter muscles.
of the stimulus.13 In this study, many
factors affecting the salivary flow rate
were controlled. Saliva can be collected
under unstimulated or stimulated condi-
tions and as whole saliva or from indivi-
dual glands. In this study, the stimulated
parotid saliva secretion was measured
owing to the close anatomic relationship
between the masseter muscle and the par-
otid gland.
The flow rate of the stimulated parotid
saliva did not show any significant
changes. From the results of this study,
it can be concluded that BTX-A does not
cause any significant decrease in saliva
production of the parotid gland when the
authors’ modified method of injection is
used for hypertrophic masseter muscles.
From the results of other studies5,7, it is
thought that BTX-A has no significant
systemic effects on the parotid gland. It is
thought that BTX-A does not cause auto-
nomic side effects, such as xerostomia,
unless it is injected into the masseter near
the parotid glands, because of the lower
affinity to the cholinergic terminals of
the salivary glands and lower systemic
effect. It is thought that the authors’
modified injection method causes fewer
autonomic side effects. None of the sub-
jects in this study complained of xeros-
tomia.
A limitation of this study was that the
unstimulated whole saliva rate was not
measured to determine the relationship
with xerostomia more closely. This may
be related to the systemic effect of BTX-
A. Further study to determine the unsti-
mulated whole saliva flow rate in patients
who complain of xerostomia after BTX-A
injection will be needed.
Funding
This study was supported by grants from
Han All Pharmaceutical Co., Seoul,
Korea.
BTX-A and Parotid Saliva 319
Competing interests
None of the authors has any financial
interest in the products, devices, or drugs
mentioned in this article.
Ethical approval
Not required.
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Address:
Jong-Hoon Choi
TMJ and Orofacial Pain Clinic
Department of Oral Diagnosis
& Oral Medicine
College of Dentistry
Yonsei University
134 Shinchon-dong
Seodaemun-gu
Seoul 120-752
Korea
Tel: +82 2 2228 3113x8880
Fax: +82 2 393 5673
E-mail: jhchoij@yuhs.ac