Masseter BTX for Bruxism and Jaw Tension — the Muscle Test

Why the Assessment Comes Before the Injection

A wide or square lower face is not one problem but at least three that look alike in a mirror: an enlarged masseter muscle, a broad mandibular angle (bone), and buccal or jowl fat. Botulinum toxin acts on the first and does nothing to the other two, which is why the width of the lower face is sorted before any injection is planned.

The treatment is commonly searched for as “masseter botox” or “jaw botox”. Here it is called masseter BTX, or botulinum toxin, because the medicine is the active ingredient rather than a brand. Several botulinum toxin type A products are HSA-registered in Singapore; all are prescription-only medicines administered by a registered doctor. This article is the educational companion to the jaw BTX and face slimming treatment page.

Key Facts

What the Masseter Is

The masseter is the thick, rectangular muscle felt at the angle of the jaw on clenching. It runs from the zygomatic arch to the outer surface of the mandibular ramus and angle, in superficial, middle and deep layers, and it closes the jaw. Like any skeletal muscle it enlarges with work: clenching, night-time grinding, chewing gum, tough food, or a one-sided chewing habit that grows one side more than the other. Because it sits directly under the skin at the angle, its size sets the outline of the lower face.

Muscle, Bone or Fat: the Clench Test

Three structures can make the lower face wide, and they are sorted at consultation:

• Masseter hypertrophy. Clench hard and the angle of the jaw bulges and firms under the fingers; relax and it softens. This is what botulinum toxin acts on.
• Mandibular angle bone. The angle is broad or flared by skeletal shape. It feels hard whether clenched or relaxed, and no injection changes it. A bone-dominant jaw is a square jaw question with a different answer.
• Buccal or jowl fat. Softness in front of the masseter or along the jawline that does not firm on clenching. Fat is a volume question, addressed by buccal fat approaches for the round face or, under the jaw, by submental fat treatment.

Most faces are a mix. The clench test shows how much of the width is muscle, and when the muscle contributes little, the honest advice is that this treatment is not the right one.

“Toxin weakens a muscle. It does nothing to bone and nothing to fat — so the first question is never the dose, but which of the three is making the jaw wide.”

Dr Sin YongOn assessing a wide lower face

How Botulinum Toxin Type A Works

A nerve tells a muscle to contract by releasing acetylcholine at the neuromuscular junction, from vesicles that fuse with the nerve terminal using the SNARE proteins. Botulinum toxin type A is taken up into the terminal, and its light chain, a zinc-dependent enzyme, cleaves one of those proteins, SNAP-25. Without intact SNAP-25 the vesicles cannot fuse, acetylcholine is not released, and the muscle fibres are no longer told to contract.

The slimming follows from that. A muscle that is not working undergoes atrophy of disuse, the way a limb thins inside a cast; the masseter loses bulk because it is resting, not because anything has been removed. The block is reversible: the terminal rebuilds its release machinery, function returns, and the muscle can rebuild if the clenching habit continues, which is why the plan is individual and reviewed over time.

Who It Suits, and Who It Does Not

Masseter BTX is directed at adults whose lower-face width is driven mainly by masseter hypertrophy on examination, and at people whose masseters are overworked by bruxism or habitual clenching, whether or not they also want a slimmer outline.

It is not the right treatment when the width is bone-dominant, when the softness is jowl or buccal fat, or when the cheeks are already hollow and a smaller masseter would leave the face gaunt. It is not given during pregnancy or breastfeeding. It is assessed with particular care, and often declined, in neuromuscular disorders such as myasthenia gravis, in anyone taking aminoglycoside antibiotics or other medicines that affect neuromuscular transmission, and where there is infection at the site or hypersensitivity to a botulinum toxin product.

Bruxism and Jaw Tension: the Medical Indication

Bruxism is the grinding or clenching of the teeth, often at night and often unnoticed until a partner hears it or a dentist sees the wear. The masseter does most of that work, and its overuse is linked to jaw ache on waking, tension-type headache, tooth wear and strain on the temporomandibular joint. Chronic clenching is also one of the commonest routes to masseter hypertrophy, which is why the medical and aesthetic questions so often arrive together.

Botulinum toxin reduces the force the masseter can generate, and so the load that grinding places on the teeth and the joint. It does not treat the cause of bruxism, which may be stress, sleep disturbance, airway problems or medication, and it does not replace a night guard. Where bruxism is the indication, dental review sits alongside the plan and the aim is comfort and load rather than appearance.

The Assessment

The consultation begins with the clench test, the masseter palpated on each side at rest and under maximal clench so that thickness, where the bulk sits, and any asymmetry are recorded. The anterior border of the masseter is located, because the smile muscles lie in front of it. The mandibular angle, chin, fat and skin are examined too, since a jaw sometimes reads as wide because the chin is short, in which case chin enhancement is the more relevant discussion. Medical, medication, dental and jaw-joint history is taken.

What the Appointment Involves

Injection points are marked within a zone bounded above by a line from the tragus of the ear to the corner of the mouth, below by the mandibular border, and in front by the anterior border of the masseter. Below the tragus–commissure line the needle stays clear of the parotid duct, which crosses the upper part of the muscle; behind the anterior border it stays clear of the risorius and zygomaticus, which lift the corner of the mouth. The toxin is placed intramuscularly into the belly of the muscle, at more than one point and depth so that deep and superficial layers are both reached, with the dose divided between sides according to the examination.

Recovery

Recovery varies. A mild ache in the muscle, small bruises at the injection points and a heaviness when chewing tough food are normal in the early period. Massaging the area is avoided so that toxin is not pushed toward the smile muscles or the parotid. Symptoms that warrant review rather than waiting are a lopsided smile, difficulty swallowing or speaking, a new dry mouth, or a bulge at the angle of the jaw on chewing. A review is planned so that asymmetry can be assessed and, where appropriate, addressed.

Risks Stated Plainly

• Smile asymmetry. Toxin that reaches the risorius or zygomaticus lifts the corner of the mouth less on that side; this is why the anterior border of the masseter is respected.
• Chewing fatigue. Hard or chewy food is more tiring while the effect is present; over-dosing makes this pronounced.
• Paradoxical bulging. If the deep fibres are weakened but the superficial layer is not, the superficial fibres bunch on clenching and the angle looks bigger; it is addressed by treating the layer that was missed.
• Sunken cheeks. In a thin face, over-treatment removes support under the skin at the angle and the lower cheek can look hollow; a reason to decline or plan conservatively.
• Dry mouth. Toxin in the parotid gland or its duct reduces saliva on that side.
• Bruising, tenderness, headache and, rarely, flu-like symptoms. Very rarely toxin spreads beyond the injected area; this is why it is a prescription medicine given by a registered doctor.

How It Differs From the Adjacent Options

These are different mechanisms for different questions, not competing versions of one treatment:

• Chin filler adds structure: a hyaluronic acid gel lengthens or projects the chin so the lower face reads as a taper. It puts volume in where masseter BTX takes muscle work out; the V-shape combination is covered in the guide to chin fillers and the V-shape.
• Buccal fat removal is surgical: the buccal fat pad is removed through an incision inside the mouth. It changes the fat in front of the masseter and does nothing to the muscle.
• Jawline filler adds definition along the mandibular border. It is about the edge of the jaw rather than its width, and in a masseter-dominant face it can make the jaw look heavier.
• HIFU delivers focused ultrasound to fixed depths of 1.5, 3.0 and 4.5 mm to heat the dermis and SMAS. It is directed at skin laxity along the jawline, not at muscle.
• BTX elsewhere on the face uses the same molecule to relax the muscles that fold skin into lines; see the wrinkle-prevention BTX page.

For an overview of the jaw treatment itself, see the jaw BTX Singapore guide.

What Determines the Cost

Cost is set out at consultation, once the examination has answered the questions above. The factors are the thickness of the masseter on each side, since the dose follows the muscle; whether the sides differ; whether the indication is bruxism, slimming or both; the formulation used; whether chin enhancement or another treatment is combined; and how the plan is staged and reviewed. Treatment on the jaw BTX and face slimming page is planned individually, and no figure is quoted before the assessment.

Related Pages

• Jaw BTX and face slimming — the treatment page
• Square jaw and the masseter
• Chin enhancement
• Buccal fat and the round face
• Double chin treatment
• Wrinkle-prevention BTX
• HIFU
• Jaw BTX Singapore guide
• Chin fillers and the V-shape