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The Effects of Masseter Muscle Paralysis on Facial Bone Growth1

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The Effects of Masseter Muscle Paralysis on Facial Bone Growth1 Journal of Surgical Research 139, 243–252 (2007) doi:10.1016/j.jss.2006.09.003 The Effects of Masseter Muscle Paralysis on Facial Bone Growth1 Damir B. Matic, M.D.,*,2 Arjang Yazdani, M.D.,* R. Glenn Wells, Ph.D.,† Ting Y. Lee, Ph.D.,† and Bing S. Gan, M.D.* *Division of Plastic and Reconstructive Surgery; and †Department of Medical Biophysics and Department of Diagnostic Radiology and Nuclear Medicine, University of Western Ontario, London, Canada Submitted for publication July 16, 2006 Key Words: facial growth; masseter; botulin toxin; Background. Understanding the effects of muscle muscle paralysis; rabbit; SPECT; cephalometrics; fa- function on facial bone growth may help us treat chil- cial anomalies. dren with facial anomalies. Facial bone growth is known to be a result of both genetic and epigenetic INTRODUCTION influences. One of the main epigenetic factors control- ling growth is thought to be muscle action. The pur- It has been shown that children born with congenital pose of this study was to establish a model of single facial anomalies have disturbed facial growth and de- facial muscle paralysis and to identify the effects mas- velopment [1]. Surgery is done early in these patients seter muscle paralysis has on mandible and zygoma growth. in an attempt to restore normal function and facial Methods. Twenty New Zealand white rabbits were appearance and to allow for normal psychological de- divided into control, paralysis, and sham groups. Mas- velopment [2, 3]. However, surgical correction can seter muscle paralysis was achieved with botulinum cause additional growth disturbances, does not pro- toxin A (BTX). Computed tomographic and single- mote growth, and can worsen the overall outcome for photon emission computed tomography (SPECT) these patients [4–6]. A better understanding of the scans and cephalometric measurements were per- mechanisms involved in controlling and regulating fa- formed. Masseter weights and mandible and zygoma cial growth may help to develop novel approaches, im- volumes, shapes, and metabolism were measured. proving current surgical interventions. Results. Eighteen animals completed the study. Sig- It is known that craniofacial bone growth is influ- nificant decreases in zygoma and mandible volumes enced by both genetic and epigenetic factors [7–14]. with minimal changes in shape were seen on the par- Moss and others have noted that muscle function is one alyzed sides. SPECT showed a decrease in bone pro- of the most important epigenetic factors involved in duction in both zygomas and mandibles on the para- guiding facial bone growth [7, 13, 15]. The notion that lyzed sides. muscle action influences facial growth may have arisen Conclusions. An animal model has been created in from clinical observations of facial characteristics of which the effects of single muscle paralysis on bone people with abnormal occlusion. Patients who are pri- growth can be studied. Masseter muscle function may marily mouth breathers develop long faces; tongue- be responsible in maintaining mandible and zygoma thrust habits result in anterior open bites, and patients volume by controlling bone production. Masseter that have an increased bite force and hypertrophy of function alone has less influence on mandible and zy- their masseter muscles develop a more acute gonial goma shape. © 2007 Elsevier Inc. All rights reserved. angle (square jaw), relatively shorter face, and a larger 1 Presented in June 2004 at the 49th annual Plastic Surgery mandible [16–18]. Research Council meeting in Ann Arbor, MI, and in September 2003 Animal models were created in an attempt to delin- at the 10th meeting of the International Society of Craniofacial eate the influence muscle has on facial bone growth. Surgery in Monterey, CA. Animal research can be divided into scar- and non- 2 To whom correspondence and reprint requests should be ad- dressed at London Health Sciences Center–Westminster Campus, scar-forming studies. Scar-forming studies generally 800 Commissioners Road, London, ON, N6A 4G5, Canada. E-mail: involve either removal of bone or bone sutures, and/or [email protected]. excision, transection, or change in the position of var- 243 0022-4804/07 $32.00 © 2007 Elsevier Inc. All rights reserved. 244 JOURNAL OF SURGICAL RESEARCH: VOL. 139, NO. 2, MAY 15, 2007 METHODS Experimental Design Prior to the start of the experiment, full protocol approval was obtained through the Council of Animal Care at the University of Western Ontario (London, Ontario, Canada). Twenty New Zealand white rabbits (Oryctolagus cuniculus) were used for the study. All animals were female to limit sexual dimorphism. All animals were enrolled after weaning, at 6 weeks of age. Each animal was housed in a separate cage in the same room (Lawson Research Institute, Lon- don, Ontario, Canada) under climate-controlled conditions with 12-h light and dark lighting schedules. All were fed a standard diet of hard pellets (Lab Diet No. 5326; Purina Mills Inc., Richmond, IN) and water ad libitum. The animals were weighed at time 0, 4, 8, and 12 weeks. Animals were divided randomly as follows. Control group (n ϭ 5). All rabbits had facial imaging at time 0, 4, 8, and 12 weeks of the study to document bone growth and metabo- lism. Imaging instrumentation included computed tomography (CT) FIG. 1. Rabbit skull showing the approximate positions of the and single-photon emission computed tomography (SPECT). superficial and deep masseter muscle bellies as they attach to both the zygoma and the mandible. The dots represent the injection sites Botulinum toxin A (BTX) group (n ϭ 10). All animals had both for both botulinum toxin A in the BTX group and saline in the Sham mandibular regions shaved for clinical land marking, allowing direct group. visualization of the masseter muscle injection sites. All rabbits had an intramuscular injection of 25 mouse units (mu), 2.5 mL of volume, ious facial muscles. Removal of a muscle or bone de- of BTX (Allergan Inc., Irvine, CA) into one randomly chosen super- ficial masseter muscle belly, at the time of the first scan date (time ϭ creases the blood supply, changes the loading of the 0) (Fig. 1). All animals were injected on the same day. Injection was entire skeleton, introduces another biomechanical performed into three separate points (2.5 mL divided into 0.8 mL, 0.8 force (scar), and often causes the animals to eat a soft mL, and 0.9 mL) within the substance of the masseter. Five days diet, which further alters the biomechanical environ- after injection, paralysis was assessed by clinical palpation of both ment [19]. Given these variables, the results of such masseters at rest and during mastication. The examiner was blinded to the side of injection. Imaging was performed as for the Control studies become difficult to interpret. group. Research to date has been performed on models in Sham group (n ϭ 5). All animals had both mandibular regions which more than one muscle’s function is altered. It is shaved. All rabbits had an intramuscular injection of 2.5 ml of sterile difficult therefore to determine a single muscle’s influ- saline (0.9% sodium chloride) into one randomly chosen superficial ence on adjacent bone growth. A non-scarring type of masseter muscle belly at the time of the first scan date (time ϭ 0). animal model in which only one muscle’s action is Injection was performed into three separate points (2.5 mL volume removed has not yet been created. The purpose of this divided into 0.8 mL, 0.8 mL, and 0.9 mL) within the substance of the masseter (Fig. 1). CT scans were performed at the same time points pilot study, therefore, is to develop a model of individ- as for the other groups. SPECT scans were not performed in this ual muscle paralysis while minimizing the variables group due to limited SPECT scanner availability. known to independently affect facial growth such as scar. This model will then be used to gather pilot data to answer the following questions: What are the effects Anesthesia of paralysis of the masseter muscle on the growth and shape of the bones onto which it attaches (mandible All animals received anesthesia during craniofacial imaging peri- ods and during intramuscular injections. A single dose of a cocktail and zygoma)? What are the effects of paralysis of the of 35 mg/kg of ketamine, 5 mg/kg of xylazine, and 0.75 mg/kg of masseter muscle on the metabolism of the bones onto acepromazine was injected intramuscularly to achieve initial anes- which it attaches? thesia on the imaging days and for accurate injections of BTX and ™™™™™™™™™™™™™™™™™™™™™™™™™™™™™™™™™™™™™™™™™™™™™™™™™™™™™™™™™™™™™™™™™™™™™™™™™™™™™™3 FIG. 2. (A) Inferior view of rabbit upper skull showing the anatomical landmarks and corresponding points used for cephalometric measurements. Point A, posterior alveolar margin of the posterior maxillary incisor; point B, anterior alveolar margin of the first maxillary molar; point C, most anterior projection of the spina masseterica; point N, most anterior projection of the palatine process of the maxilla; point Z, most posterior projection of zygomatic arch on process of squamosal temporal bone. (B) Lateral view of rabbit upper skull showing the anatomical landmarks and corresponding points used for cephalometric measurements. Point C, most anterior projection of the spina masseterica; point X, most anterior projection of zygomatic process of squamosal temporal bone; point Y, lateral aspect of supraorbital process of frontal bone; point Z, most posterior projection of zygomatic arch on process of squamosal temporal bone. (C) Lateral view of rabbit mandible showing the points used for cephalometric measurements. Point R, most anterior and inferior projection of angulus mandibulae; point S, posterior alveolar margin of posterior mandibular molar; point T, anterior alveolar margin of mandibular first molar; point U, most superior and posterior projection of angulus mandibulae; point V, most anterior projection of processus condyloideus; point W, posterior alveolar margin of mandibular incisor.
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