Caring for Face Pain and Sleep Apnea
Rich Hirschinger, DDS, MBA
Diplomate American Board of Orofacial Pain
9615 Brighton Way, Suite 323
Beverly Hills, CA 90210
888.981.8981
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Botox Treatment for TMJ Myofascial Muscle Pain

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For those potential patient that do not know me yet, please know that I really dislike the term "TMJ." Why? Because it is an anatomical part of everyone's anatomy and it is not a diagnosis. A doctor telling you that you have "TMJ" is like a doctor telling you that you have "knee." TMJ stands for temporomandibular joint, which is the joint that attaches the jaw bone called the mandible to the skull. So, if TMJ is not a diagnosis, then what is the diagnosis for people that suffer a lot of pain in the jaw? The pain is usually due to myalgia, which is a fancy way of saying muscle pain. What is a good treatment for muscle pain? I like to start with trigger point injections, which involves injecting plain lidocaine into the painful muscles to see if that provides a benefit. If it does but it doesn't last long, the procedure can be repeated. If it doesn't last longer with the second treatment, then Botox is the next treatment option. 

There are four main muscles that close the jaw, which are the superficial masseter, deep masseter, temporalis, and the medial pterygoid. The medial pterygoid does not always contribute to the pain patients feel so it does not always need to be injected with Botox. If it does not need to be injected, then I follow the protocol shown in the image to the right. Each yellow dot represents 5 units of Botox. Four locations of the temporalis muscle, and six locations between the superficial masseter and the deep masseter are injected. The total is ten locations of 5 units each, which is 50 units of Botox. Since Botox should be injected symmetrically, a 100 units of Botox is needed, and is standard when treating pain from myalgia. 

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If the medial pterygoid is involved in causing pain, then I follow the protocol shown in the double image ​to the right. As you can see, there are only three yellow dots in the temporalis, which is above the ear, and 5 yellow dots in the superficial masseter and deep masseter muscles, which are along the jawline. This means that there is 10 units more available to use in the medial pterygoid muscle, which is inside the jaw. The path of the Botox injection is shown in the green line, and the target of the Botox is shown by the yellow dot on the far right image. Each yellow dot represents 5 units of Botox. ​Using this protocol, three locations of the temporalis muscle, five locations between the superficial masseter and the deep masseter, and two locations of the medial pterygoid are injected with Botox The total is still ten locations of 5 units each, which is 50 units of Botox per side but using this protocol allows all four muscles that close the jaw to be treated with Botox.