A型肉毒毒素不同注射方式治疗单纯性咬肌肥大患者的疗效及对咬肌厚度的影响

摘要 目的：探讨A型肉毒毒素不同注射方式治疗单纯性咬肌肥大患者的疗效及对咬肌厚度的影响。方法：选择2014年6月-2016年6月在我院接受治疗的单纯性咬肌肥大患者84例,根据随机数字表法将患者均分为研究组和对照组,两组各42例,其中对照组进行单次注射A型肉毒毒素,研究组给予连续注射A型肉毒毒素。所有患者在治疗前、治疗后1个月、治疗后3个月、治疗后6个月、治疗后9个月、治疗后12个月,采用超声对进行咬肌厚度进行检测;在治疗后12个月调查两组患者对治疗效果的主观评价,同时邀请两名专家对患者的治疗效果进行评价。记录患者在治疗后出现的不良反应。结果：研究组在治疗后9个月、治疗后12个月的咬肌厚度显著低于对照组,差异有统计学意义（P<0.05）,对照组患者的咬肌厚度在治疗后1个月至治疗后6个月逐渐降低,治疗后6个月达到最低值,在治疗后9个月和治疗后12个月开始回升。研究组患者的咬肌厚度在治疗后一直呈下降的趋势,并在治疗后12个月达到最低值。两组治疗后的各个时间点的咬肌厚度均低于治疗前,差异有统计学意义（P<0.05）。研究组患者本人的主观评价和专家评价为A、B、C的比例均显著低于对照组,D、E的比例均显著高于对照组,差异有统计学意义（P<0.05）。两组患者不良反应发生情况无统计学差异（P>0.05）。结论：与单次注射相比,A型肉毒毒素连续注射能更好的降低咬肌厚度,同时患者对治疗效果的主观评价和专家的评价较好,且不良反应少,临床上治疗咬肌肥大时可选用连续注射A型肉毒毒素的方式。     

The use of botulinum toxin type A in aesthetic mandibular contouring

The lower third of Asian faces is wider than that of Caucasians and it is determined by the size and width of the mandibular bone and the thickness of muscles and subcutaneous fat tissues surrounding it. Efforts to create an aesthetically slim and smooth facial contour line in nonobese people have led the authors to focus on two approaches: surgical resection of the masseteric muscle and modeling ostectomy of the square-angled mandibular bone. Because these procedures present some problems, the authors adopted a nonsurgical concept that chemically denervates muscles and reduces the bulk of the muscle. The authors have conducted a total of 1021 clinical cases from March of 2001 through September of 2002, in which patients were treated with botulinum toxin type A (Dysport; Ipsen Ltd, Slough, United Kingdom) for remodeling the lower facial contour line; 383 of those cases were followed up for at least 3 months after the initial injection. A database was made by measuring the change in the thickness of the injected muscle with an ultrasonogram. Eleven patients underwent resection of the mandibular angle before injection. The preinjection ostectomy group was involved in the study as a result of their dissatisfaction with the surgical results; they had a rather thick masseter muscle and not a bone problem. Some had both bone problems and a thick masseter muscle. Three months after the botulinum toxin injection, the thickness of the muscle was reduced by 31 percent on average. The atrophic effect of injection was observed after 2 to 4 weeks for most patients. Seventy percent of the 383 patients tracked were greatly satisfied with the result, with another 23 percent generally satisfied. No long-term side effects were reported. Masseteric hypertrophy is frequent in Asians because of racial characteristics and dietary habits. Botulinum toxin type A has made a new epoch in facial contouring for Asians. Considering that Asians have a prominent malar and a prominent mandible angle, the reduction in the thickness of the masseter can provoke relative prominence of the malar and mandible angle. Therefore, precise indication and anatomy of the facial muscle should be thoroughly understood, which will decrease the incidence of side effects and problems. Botulinum toxin type A (Dysport) injection is simple in technique, has few side effects, and promises a rapid return to daily life. The authors conclude that the injection of botulinum toxin type A can replace surgical masseter resection.     

Temporal brow lift using botulinum toxin A

The objective of this study was to determine whether brow elevation occurs as a result of paralysis of brow depressors after botulinum toxin A injection. The study's design was a prospective case series with pretreatment and posttreatment outcome evaluation with statistical analysis at a university-based division of facial plastic surgery private clinic. Twenty-two patients of a consecutive sample desiring a cosmetic enhancement underwent injection of botulinum toxin A directed to brow depressors. Injections consisted of 7 to 10 units of botulinum toxin A (Botox, Allergan, Irvine, Calif.) into selected brow depressor muscle (lateral orbicularis oculi) bilaterally. No patients withdrew for adverse effects. All patients were evaluated 2 weeks after treatment. The outcomes were measured by change in brow elevation along vertical axis extending from both midpupil and lateral canthus to the caudal row of brow hairs with eyes at neutral gaze and the head at Frankfort plane. Preintervention and postintervention brow height was measured by the primary clinical investigator. The average brow elevation from the midpupil observed after selected injection of brow depressors with botulinum toxin A was 1.02 mm (p = 0.038). The average brow elevation from the lateral canthus observed after selected injection of brow depressors with botulinum toxin A was 4.83 mm (p<0.0001). Significant temporal brow elevation occurs as the result of paralysis of brow depressors by using botulinum toxin A injection. This procedure may be considered an alternative to surgical brow elevation.     

Botulinum A toxin for the treatment of adult-onset spasmodic torticollis

Thirty-five patients with adult-onset idiopathic torticollis were treated by local injections of botulinum A toxin into dystonic cervical muscles. Substantial improvement with respect to reduction and elimination of pain was found in 81 percent, improvement in posture deformity and involuntary spasms in 70 percent, increased range of motion of the neck in 78 percent, reduction in visible sternocleidomastoid hypertrophy in 86 percent, and improvement in tremor in 65 percent. The syndrome was divided into four subtypes based on pattern of dystonic muscle groups involved in the dystonia, head and shoulder posture, and sternocleidomastoid muscle hypertrophy. Injection strategy based on this subdivision is described.     

Contralateral injections of botulinum A toxin for the treatment of hemifacial spasm to achieve increased facial symmetry.

Six patients noted facial asymmetry after botulinum toxin injection for hemifacial spasm. Each patient was injected on the side contralateral to the spasms with 10 to 15 IU over the zygomatic major and minor muscles. Each patient noted improvement in facial symmetry in the resting position and dynamic facial movements. Five of the six patients desired this approach with subsequent injections. This injection method variation proved helpful in the managing of hemifacial weakness created by botulinum A toxin for this condition.     

An alternative in vivo method to refine the mouse bioassay for botulinum toxin detection

Botulism is a rare, life-threatening paralytic disease of both humans and animals that is caused by botulinum neurotoxins (BoNT). Botulism is confirmed in the laboratory by the detection of BoNT in clinical specimens, contaminated foods, and cultures. Despite efforts to develop an in vitro method for botulinum toxin detection, the mouse bioassay remains the standard test for laboratory confirmation of this disease. In this study, we evaluated the use of a nonlethal mouse toe-spread reflex model to detect BoNT spiked into buffer, serum, and milk samples. Samples spiked with toxin serotype A and nontoxin control samples were injected into the left and right extensor digitorum longus muscles, respectively. Digital photographs at 0,8, and 24 h were used to obtain objective measurements through effective paralysis scores, which were determined by comparing the width-to-length ratio between right and left feet. Both objective measurements and clinical observation could accurately identify over 80% of animals injected with 1 LD(50) (4.3 pg) BoNT type A within 24 h. Half of animals injected with 0.5 LD(50) BoNT type A and none injected with 0.25 LD(50) demonstrated localized paralysis. Preincubating the toxin with antitoxin prevented the development of positive effective paralysis scores, demonstrating that (1) the effect was specific for BoNT and (2) identification of toxin serotype could be achieved by using this method. These results suggest that the mouse toe-spread reflex model may be a more humane alternative to the current mouse bioassay for laboratory investigations of botulism.     

Botulinum toxin injections as a method for chemically denervating skeletal muscle to test functional hypotheses: a pilot study in Lepomis cyanellus

In this study, we demonstrate that botulinum toxin can be used to chemically denervate muscles to test functional hypotheses. We injected research-grade type A botulinum toxin complex into pectoral fin abductors (abductor superficialis) of green sunfish (Lepomis cyanellus) to determine whether chemical denervation would eliminate the ability of a particular muscle to contribute to overall pectoral fin movements. Reduction of target muscle activity occurred within 8 d of the injection, and paralysis was confirmed using electromyography. No paralysis was seen in the adjacent muscles (abductor profundus) or in positive controls (saline injections). Paralysis occurred more slowly and at lower doses than previously documented for mammals. However, botulinum toxin complex (500 kDa) was used here, whereas previous studies have used purified toxin (150 kDa). Therefore, differences in physiological responses between fish and mammals cannot yet be distinguished from differences caused by the toxin type. However, we note that the toxin complex is less likely to diffuse across muscle fascia (because it is large), which should minimize paralytic effects on adjacent muscles. We suggest that botulinum toxin holds great promise as a chemical denervation agent in functional studies of animal locomotion and feeding behaviors.     

A型肉毒毒素联合CO2点阵激光治疗眼周皱纹的近期疗效评估

目的:探讨A型肉毒毒素联合CO_2点阵激光治疗眼周皱纹的近期临床疗效。方法:选择2013年6月到2014年6月我院接收眼部皱纹改善手术的患者90例,随机分为激光组、肉毒毒素组及联合治疗组,各30例,分别给予CO_2点阵激光治疗、A型肉毒毒素注射和A型肉毒毒素注射联合CO_2点阵激光治疗。所有患者在治疗后7 d、1月及3月进行疗效随访评价,比较三组不良反应情况。结果:三组患者眼周皱纹均有所改善,治疗1个月时效果最为明显。激光组的静态皱纹治疗效果明显,对动态皱纹治疗效果不明显;肉毒毒素组对动态皱纹治疗效果明显,对静态皱纹治疗效果不明显;联合治疗组对静态皱纹和动态皱纹均有明显的改善,其满意度评价总分数明显高于其他两组。三组患者对CO_2点阵激光和注射A型肉毒毒素所引起疼痛均能耐受,安全性好。结论:A型肉毒毒素联合CO_2点阵激光对静态皱纹和动态皱纹均有明显的改善作用,且不良反应轻,安全性好。     

Arrangement of the Clostridium baratii F7 Toxin Gene Cluster with Identification of a σ Factor That Recognizes the Botulinum Toxin Gene Cluster Promoters

Botulinum neurotoxin (BoNT) is the most poisonous substances known and its eight toxin types (A to H) are distinguished by the inability of polyclonal antibodies that neutralize one toxin type to neutralize any of the other seven toxin types. Infant botulism, an intestinal toxemia orphan disease, is the most common form of human botulism in the United States. It results from swallowed spores of Clostridium botulinum (or rarely, neurotoxigenic Clostridium butyricum or Clostridium baratii) that germinate and temporarily colonize the lumen of the large intestine, where, as vegetative cells, they produce botulinum toxin. Botulinum neurotoxin is encoded by the bont gene that is part of a toxin gene cluster that includes several accessory genes. We sequenced for the first time the complete botulinum neurotoxin gene cluster of nonproteolytic C. baratii type F7. Like the type E and the nonproteolytic type F6 botulinum toxin gene clusters, the C. baratii type F7 had an orfX toxin gene cluster that lacked the regulatory botR gene which is found in proteolytic C. botulinum strains and codes for an alternative σ factor. In the absence of botR, we identified a putative alternative regulatory gene located upstream of the C. baratii type F7 toxin gene cluster. This putative regulatory gene codes for a predicted σ factor that contains DNA-binding-domain homologues to the DNA-binding domains both of BotR and of other members of the TcdR-related group 5 of the σ⁷⁰ family that are involved in the regulation of toxin gene expression in clostridia. We showed that this TcdR-related protein in association with RNA polymerase core enzyme specifically binds to the C. baratii type F7 botulinum toxin gene cluster promoters. This TcdR-related protein may therefore be involved in regulating the expression of the genes of the botulinum toxin gene cluster in neurotoxigenic C. baratii.     

Surface raw electromyography has a moderate discriminatory capacity for differentiating between healthy individuals and those with TMD: A diagnostic study

The use of surface electromyography (sEMG) to identify subjects with chronic temporomandibular disorders (TMD) is controversial. The main objective of this study is to determine the diagnostic accuracy of EMG to differentiate between healthy subjects and those with TMD.This study evaluated 53 individuals with TMD who were referred to the university service and who fulfilled the eligibility criteria during the period of the study. Thirty-eight dental students were also recruited satisfying same eligibility criteria but without TMD. The inclusion criteria were to be fully dentate, have normal occlusion, and be righthanded. The exclusion criteria were periodontal pathology, caries or damaged dental tissues, orthodontic therapy, maxillofacial disease, botulinum A toxin therapy, and psychological disorders.The means of the masseter muscles, right (RM) and left (LM), and temporalis muscles, right (RT) and left (LT), and intraindividual indexes during resting and during clenching were calculated. Raw sEMG activity was used to determine the cutoff points and calculate the diagnostic accuracy of sEMG. The diagnostic accuracy of these variables for a diagnosis of TMD was evaluated by using the Receiver Operating Characteristic (ROC) curve and the area under it (AUC). A new transformed diagnostic variable was obtained by using the Generalized Additive Models (GAM). Optimal cutoff points were obtained where the sensitivity and specificity were similar and by the Youden index. The highest estimated AUC was 0.660 (95% CI 0.605–0.871) corresponding to the rLT variable during rest. When rLT and rACTIVITY (differences divided by sums of temporalis versus masseter muscles) were considered as a linear combination, the AUC increased to 0.742 (95% CI; 0.783–0.934).In conclusion, the raw sEMG evaluation of rest provided moderate sensitivity and specificity to discriminate between healthy individuals and those with TMD. The use of the indexes (mainly assessing the dominance of temporalis over masseter muscles during rest) is strongly recommended to increase the discriminatory capacity of raw sEMG evaluation.     

Response of type B and E Botulinum toxins to purified sulfhydryl-dependent protease produced by Clostridium botulinum type F.

A sulfhydryl-dependent protease (SHP) was purified from a culture of Clostridium botulinum type F. The enzyme can activate type E progenitor toxin completely but type B progenitor toxin only partially. This may suggest that SHP by itself could completely activate the toxin of proteolytic C. botulinum types A and F in culture. The toxicity of type E progenitor toxin potentiated by the treatment with SHP persisted, whereas that of derivative toxin decreased rapidly by further incubation with SHP. This may indicate that only the progenitor toxin, the complex of the toxic and nontoxic components, activated by SHP withstands the subsequent exposure to the enzyme in cultures of proteolytic C. botulinum.     

New indications for botulinum toxin type a in cosmetics: mouth and neck

Botulinum toxin type A is frequently used to smooth hyperkinetic lines in the periocular and forehead areas of the upper face, but it has been used less frequently for indications in the lower face and neck. This study was designed to determine whether botulinum toxin treatment of the mouth and neck areas is as clinically successful as the treatment of the upper face. This was a retrospective study of patients who were treated with botulinum toxin type A (Botox) to soften hyperkinetic facial wrinkles. Of 100 patients randomly selected from a single clinical practice, 91 met the inclusion criteria and were divided into two groups for analysis. The 56 patients in group 1 did not receive treatment in the mouth and neck areas, whereas the 35 patients in group 2 were treated at least once in the mouth and neck areas. Patients were surveyed for periods ranging from 7 to 49 months. Most patients in each group had a single botulinum procedure during this period. Both groups of patients had comparable improvement of wrinkles both at the evaluation immediately after the neuromuscular blockade and during follow-up. In comparison with patients whose treatment was confined to the upper face, patients who received global treatment with botulinum toxin type A, including injections in the mouth and neck areas, were injected in more sites per procedure and had more procedures in combination with other therapies. Patient satisfaction with botulinum toxin treatment and outcomes was high in both groups. Botulinum toxin type A is an important tool within the therapeutic spectrum for the treatment of hyperkinetic facial wrinkles, including those in the areas of the mouth and neck.     

Double-blind,placebo-controlled study of the safety and efficacy of botulinum toxin type A for patients with glabellar lines

The objective of this study was to evaluate the efficacy and safety of botulinum toxin type A for the treatment of glabellar lines. Patients with moderate or severe glabellar lines at maximal frown received intramuscular injections of placebo or 20 U of botulinum toxin type A (Botox; Allergan, Inc., Irvine, Calif.) distributed among five injection sites (one in the procerus muscle and two in each corrugator supercilii). Follow-up assessments were performed at 7, 30, 60, 90, and 120 days after injections. Efficacy measures were the physician's rating of glabellar line severity at maximal frown and at rest (none, mild, moderate, or severe) and the patient's global assessment of changes in glabellar lines, from +4 (100 percent better) to -4 (100 percent worse). A total of 273 patients were enrolled (botulinum toxin, 202 patients; placebo, 71 patients). All except five patients (botulinum toxin, two patients; placebo, three patients) completed the study. For the physician's rating at maximal frown, the responder rate (percentage of patients with severity ratings of none or mild in follow-up evaluations) for the botulinum toxin group peaked at 77 percent at day 30 and was significantly greater than that for the placebo group at every follow-up visit (p < 0.001). For the patient's assessment, the responder rate (percentage of patients with scores of +2 or more) for the botulinum toxin group peaked at 89 percent at day 30 and was significantly greater than that for the placebo group at every follow-up visit (p < 0.001). Rates of adverse events were similar for the two groups. The only adverse event with an incidence of >/=5 percent was headache (botulinum toxin, 11 percent; placebo, 20 percent). The incidence of blepharoptosis was 1 percent for the botulinum toxin group. Botulinum toxin type A was remarkably safe and effective in reducing glabellar lines.     

Medial pterygoid muscle activity during the closing and compressive phases of human mastication

The lack of specific data correlating activity in the human medial pterygoid muscle with displacement of the jaw during mastication, and the hint of possible differences in function between certain mammalian species, prompted a study of unilateral mastication in six adult subjects. Muscle activity in the medial pterygoid, masseter, and anterior temporal muscles was recorded simultaneously with three-dimensional movement of an incisor point on the mandible. Signals from muscles and displacement transducer were sampled by a disc-based computer system programmed to analyze data averaged over 30 chewing cycles on each side and in some instances over 30 open-close and clench cycles. Patterns of medial pterygoid activity were consistent for the group as a whole, demonstrating activation of both muscles early in the closing cycle with strong ipsilateral muscle activity before and throughout the intercuspal phase of mastication. By contrast contralateral activity ceased during the crushing phase of the cycle, reappearing in some subjects just before the end of intercuspation. Medial pterygoid activity mirrored masseter and anterior temporal activity only during certain phases of the closing cycle, suggesting that these muscles should be considered as being selectively coactivated with, rather than synergists of, the major elevators of the jaw. The muscles were active during horizontal components of movement of the incisor teeth in chewing, but were inactive during the open-close and clench task despite vigorous contraction of the masseter muscles. Overall, the observations complement previous reports of medial pterygoid muscle activity in humans. They also confirm, for these muscles at least, a general similarity between man and the little brown bat, a relationship hitherto suspected but unsubstantiated.     

Autophagic-lysosomal pathway functions in the masseter and tongue muscles in the klotho mouse, a mouse model for aging

Klotho mutant (kl/kl) mice, a type of short-lived mouse models, display several aging-related phenotypes. To investigate whether the atrophy of skeletal muscles is induced in these mice via activation of the ubiquitin-proteasomal pathway and/or the autophagic-lysosomal pathway through an alteration of insulin/IGF-I signaling, we analyzed the activity of the two pathways for protein degradation and components of the insulin/IGF signaling pathway in their skeletal muscles. The masseter, tongue, and gastrocnemius muscles in kl/kl showed marked reductions in muscle weight and in myofiber diameter compared with +/+. The autophagic-lysosomal pathway in kl/kl was activated in the masseter and tongue, but not in the gastrocnemius, compared with that in +/+, whereas the ubiquitin-proteasomal pathway in these three muscles of kl/kl was not altered. No marked difference in the phosphorylation levels of insulin/IGF-I signaling components, such as insulin/IGF-I receptor, Akt, and FoxO in three muscles studied were found between kl/kl and +/+, but the phosphorylation levels of signaling component at the downstream of mTOR such as 4E-BP1 and p70 S6K were suppressed in the masseter and tongue of kl/kl compared with +/+. Deficiency of essential amino acids is reported to activate the autophagy-lysosomal pathway through the down-regulation of mTOR, not through IGF-Akt-FoxO. The masseter and tongue seem to be more actively moved than limb muscles in kl/kl, because they are essential for survival activities such as mastication, swallowing, and respiration. Thus, the deficiency of amino acid by the active movement of the masseter and tongue seems to stimulate the autophagic-lysosomal pathway via the down-regulation of mTOR signalling pathway.     

Effect of treatment with botulinum toxin on neurogenic blepharospasm.

Botulinum toxin type A creates temporary localised flaccid paralysis after injection into skeletal muscle. Thirty four patients with blepharospasm, of whom 28 also had the oromandibular dystonia syndrome, were treated with injections of botulinum toxin type A into the orbicularis oculi, and 28 showed functional improvement after the treatment. A high incidence of local side effects occurred, especially partial ptosis, which was well tolerated. There were no systemic side effects. The average period of relief was 2.5 months, increasing to 2.8 months after a second injection. Functional improvement was limited in patients with severe associated dystonia.     

Temporary management of upper lid ptosis, lid malposition, and eyelid fissure asymmetry with botulinum toxin type A

During the past 10 years the primary focus for the aesthetic use of botulinum toxin has been directed to the treatment of dynamic facial lines. This agent has been shown to be very effective for the improvement of facial shape. The use of botulinum toxin type A for the correction of a variety of presentations of facial asymmetry has also been well established. The general principles regarding the counter-effects of facial muscle protagonists and antagonists and their potential effects on the position of facial soft-tissue regions apply here as well. Twenty-two patients received botulinum toxin type A for the temporary treatment of mild to moderate unilateral upper eyelid ptosis and aesthetic improvement of lower eyelid position, with favorable results. Although commonly related to a rare yet feared adverse consequence from the inappropriate application of botulinum toxin, its application for the treatment of upper eyelid ptosis, eyelid position, and other lid fissure asymmetries for aesthetic improvement is presented.     

A型肉毒毒素轻链胞内持留模型的建立

[目的] 建立A型肉毒毒素轻链胞内持留模型来模拟A型肉毒毒素引起的长期中毒。[方法] 设计构建pcDNA3.1-ALC-GFP重组质粒,提取质粒进行PCR验证,并将其转染进Nureo-2a细胞中表达,利用Western Blot与细胞免疫荧光分析验证ALC-GFP的表达情况及其在细胞内的长时间持留,建立A型肉毒毒素轻链的胞内持留模型,并将该模型用于抗肉毒药物的筛选。[结果] 成功构建pcDNA3.1-ALC-GFP重组质粒并将其转染进Nureo-2a细胞中,验证了ALC-GFP在细胞内具有长时间持留性,成功建立了A型肉毒毒素轻链胞内持留模型,并利用该模型筛选出潜在抗肉毒药物CB3。[结论] 成功建立了A型肉毒毒素轻链胞内持留模型,并初步应用于CS1,CE2和CB3药物筛选,为A型肉毒毒素长期中毒的解毒研究奠定了基础。     

Identification of type A, B, E, and F botulinum neurotoxin genes and of botulinum neurotoxigenic clostridia by denaturing high-performance liquid chromatography

Denaturing high-performance liquid chromatography (DHPLC) is a recently developed technique for rapid screening of nucleotide polymorphisms in PCR products. We used this technique for the identification of type A, B, E, and F botulinum neurotoxin genes. PCR products amplified from a conserved region of the type A, B, E, and F botulinum toxin genes from Clostridium botulinum, neurotoxigenic C. butyricum type E, and C. baratii type F strains were subjected to both DHPLC analysis and sequencing. Unique DHPLC peak profiles were obtained with each different type of botulinum toxin gene fragment, consistent with nucleotide differences observed in the related sequences. We then evaluated the ability of this technique to identify botulinal neurotoxigenic organisms at the genus and species level. A specific short region of the 16S rRNA gene which contains genus-specific and in some cases species-specific heterogeneity was amplified from botulinum neurotoxigenic clostridia and from different food-borne pathogens and subjected to DHPLC analysis. Different peak profiles were obtained for each genus and species, demonstrating that the technique could be a reliable alternative to sequencing for the rapid identification of food-borne pathogens, specifically of botulinal neurotoxigenic clostridia most frequently implicated in human botulism.