Journal of Oral and Maxillofacial Surgery, Medicine, and Pathology xxx (xxxx) xxx–xxx

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Journal of Oral and Maxillofacial Surgery, Medicine, and

Pathology
journal homepage: www.elsevier.com/locate/jomsmp

Anatomic and functional changes after myotomy with or without

mandibular anguloplasty in masseter hypertrophy patients: A prospective
study☆
⁎
Sujata Mohanty , Priyadarshan Kumar, Ujjwal Gulati, Jitender Dabas, Sanchaita Kohli,
Zainab Choudhary
Department of Oral and Maxillofacial Surgery, Maulana Azad Institute of Dental Sciences, MAMC Complex, Bahadur Shah Zafar Marg, New Delhi, 110002, India

A R T I C LE I N FO A B S T R A C T

Keywords: Objective: The current study aims to evaluate the anatomic and functional outcome in patients with masseter
Masseter hypertrophy hypertrophy following surgical debulking of the masseter.
Ultrasonography Methods: 18 patients (28 sites) of masseter hypertrophy underwent surgical muscle debulking with / without
Bite force osseous recontouring. Post-operative assessment was done by measuring change in: a) muscle thickness using
Electromyography
ultrasonography, b) electrical activity of the muscle using electromyography (EMG) and c) maximum bite forces
Masseter thickness
generated 1 year following surgery. Visual Analogue Scale (VAS; 1–10) was used to evaluate the patients’ aes-
thetic satisfaction.
Results: An average reduction in muscle thickness at rest and clench by 6.35 and 5.25 mm, respectively was seen
12 months after surgery. Mean bite force and clench EMG showed a statistically significant decrease 1 year post-
operatively (p = 0.001 and p = 0.0001 respectively). The average mouth opening increased significantly by
8 mm (p < 0.05) and a mean aesthetic satisfaction VAS score of 8.1 was reported by patients after 1 year.
Conclusion: Surgical debulking is a reliable treatment modality for masseter hypertrophy providing good aes-
thetic and functional outcomes.

1. Introduction in the electrical activity of the hypertrophied muscle and bite forces
that take place have been insufficiently reported in literature. The
Benign masseter muscle hypertrophy, first described in 1880 as “an current study aims to evaluate the anatomic and functional changes
ill-defined tumour mass” occurring in the masseter muscle of a twelve- following surgical debulking of the hypertrophied muscle with or
year old girl child [1], is generally characterised by a unilateral or bi- without a concurrent anguloplasty.
lateral enlargement of masseter muscle volume. All but a few patients
report with the complaint of either facial asymmetry in unilateral hy- 2. Materials and methods
pertrophy or a broad/flaring face in bilateral cases [2,3]. Clinical ex-
amination and radiographs viz. orthopantomogram (OPG), postero- A prospective study including unilateral or bilateral cases of mass-
anterior view skull (PA view) and ultrasonography (USG) are the eter hypertrophy (10 bilateral cases) was designed, where the diagnosis
mainstay of diagnosis. An array of management strategies has been was made using patient history and clinical and imaging findings
tried ranging from pharmacological therapy to surgical excision. (Fig. 1: A and B). All patients reporting with a complaint of a painless,
However, botulinum toxin Type A (BT-A) and radiofrequency coagu- soft facial swelling over the mandibular angle region and giving a
lation (RFC) are advised for mild cases and surgical excision for mod- suggestive history (longstanding decayed or missing teeth, abnormal
erate to severe cases [4–7]. Following surgical correction, the changes chewing habits) underwent local examination of the masseter region,

☆
AsianAOMS: Asian Association of Oral and Maxillofacial Surgeons; ASOMP: Asian Society of Oral and Maxillofacial Pathology; JSOP: Japanese Society of Oral
Pathology; JSOMS: Japanese Society of Oral and Maxillofacial Surgeons; JSOM: Japanese Society of Oral Medicine; JAMI: Japanese Academy of Maxillofacial
Implants.
⁎
Corresponding author.
E-mail addresses: [email protected] (S. Mohanty), doctorpd@rediffmail.com (P. Kumar), [email protected] (U. Gulati),
[email protected] (J. Dabas), [email protected] (S. Kohli), [email protected] (Z. Choudhary).

https://doi.org/10.1016/j.ajoms.2018.12.006
Received 5 October 2017; Received in revised form 9 November 2018; Accepted 13 December 2018
2212-5558/ © 2018 Asian AOMS, ASOMP, JSOP, JSOMS, JSOM, and JAMI. Published by Elsevier Ltd All rights reserved.

Please cite this article as: Mohanty, s., Journal of Oral and Maxillofacial Surgery, Medicine, and Pathology,
https://doi.org/10.1016/j.ajoms.2018.12.006
S. Mohanty et al. Journal of Oral and Maxillofacial Surgery, Medicine, and Pathology xxx (xxxx) xxx–xxx

Fig. 1. Pre-operative clinical and radiographic findings of a patient with bilateral masseter hypertrophy.
A. Frontal profile at rest showing square facies with swelling over bilateral mandibular angle region.
B. Pre-operative OPG showing bony hypertrophy in bilateral mandibular angle region.

where palpation of the masseter at rest and during clench was done to 2.3. Surgical technique
assess for an increase in muscle thickness and differentiate it from any
other discrete lesion in the area. Additionally, local examination of the The selected patients underwent surgical debulking of the hyper-
dentition and occlusion was done to look for possible factors causing trophied masseter muscle with / without mandibular angle re-
muscle hypertrophy. The masseter was then further evaluated using contouring under general anaesthesia administered via fiberoptic na-
ultrasonography, where a generalised increased in muscle thickness at soendotracheal intubation. The surgical site was aseptically prepared
rest and during clench confirmed the diagnosis of masseter hyper- and 2% lignocaine with 1:80,000 adrenaline was infiltrated at the site
trophy. All existing factors that could potentially lead to masseter hy- of the incision to aid in haemostasis. The approach for the myotomy
pertrophy were then alleviated, i.e., all carious teeth were appropriately depended on the pre-operative decision to excise only muscle or both
restored, missing teeth were replaced by fixed prosthesis and paraf- muscle and angular spur. Intra-oral approach was used for the former
unctional habits were corrected. After all such factors were eliminated, scenario and extra-oral for the latter (Fig. 2). The amount of muscle
the esthetic correction was planned, where the patients were provided excision to be done was grossly estimated from the muscle thickness
with the option of either undergoing treatment with botulinum toxin recorded on the pre-operative USG, keeping in mind the normal
injections or surgical muscle debulking. All patients who opted for masseter thickness, using which a muscle thickness excess value could
surgical debulking were then included in the current study. Ethical be projected and the same was used to guide the intra-operative volume
clearance for the study was obtained from the institution review board of muscle excision. The osseous recontouring was similarly planned by
and a written informed consent was obtained from all patients. The making a prediction tracing on the patient OPG for an acceptable
following inclusion and exclusion criteria were used for recruitment of looking mandibular angle and then calculating the bony excess by
patients: comparing with the master tracing of the same OPG.

2.1. Inclusion criteria 2.3.1. Extra-oral approach

Through a modified submandibular incision around the angle of
1 Unilateral or bilateral masseter hypertrophy requiring surgical in- mandible, the central two-third portion of the masseter muscle insertion
tervention. was freed from inferior border of the mandible. With the masseter and
2 Age range 18–45 years. its periosteal attachment retracted, the resection of the hypertrophied
3 Healthy dentition. muscle was carried out from its medial surface. When the muscle was
4 No previous surgical treatment received. reduced to its normal thickness, the medial pterygoid was detached
from the medial side of mandible to expose the underlying localized
2.2. Exclusion criteria bony enlargement, which was removed and recontoured using hand
and rotary instruments. The reduced muscle belly was then sutured
1 Temporomandibular disorders/myofunctional pain dysfunction back to the free margin of the pterygomasseteric sling and the incision
syndrome. was closed primarily in layers.
2 Uncontrolled systemic diseases.
3 Pathology/lesion involving the masseter. 2.3.2. Intra-oral approach
An incision was made in the mucosa, 5 mm lateral to the ipsilateral
mandibular buccal vestibule, extending from the first molar to half the
height of the anterior border of the ascending ramus. The buccinator

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S. Mohanty et al. Journal of Oral and Maxillofacial Surgery, Medicine, and Pathology xxx (xxxx) xxx–xxx

examination, measurement of EMG and bite force changes at the in-

tervals of one, three and twelve months and ultrasonographic evalua-
tion twelve months post-operatively. In addition, changes in the active
mouth opening were also assessed, along with the patients’ satisfaction
of aesthetic outcome using Visual Analogue Scale (VAS), number of
cases of marginal mandibular nerve paresis (MMNP) in cases of extra-
oral surgical approach and other complications associated with the
surgery. The patients were followed up for a period ranging from 12 to
70 months.

2.5.1. Clinical assessment

Clinical examination included inspection of the surgical wound,
comparison of pre- and post-operative aesthetics, mouth opening at
one, three and twelve-month intervals.

2.5.2. Anatomic parameters

1 Muscular thickness: The thickness of masseter (at rest and clench)

was assessed using 10 MHz linear transducer with an accuracy of
0.1 mm with patient in a supine position. The site for relevant cross-
section was kept at a level halfway between the zygomatic arch and
the gonial angle, with the transducer directed perpendicular to the
muscle fibres.

2.5.3. Functional parameters

1 EMG: EMG was done using Bio EMG III, Bio research Inc. USA.
Patient was seated comfortably on a dental chair and electrodes
were placed over maximum bulk of the masseter. EMG readings for
the maximum amplitude of the masseter muscle were taken at rest
and at maximum clench and recorded at four stages; pre- and post-
operatively at 1, 3 and 12 months.
2 Bite force: With patient seated in a comfortable position, a pressure-
Fig. 2. Intra-operative picture of surgical debulking of the masseter with sensitive film was placed between occlusal surfaces of the teeth and
mandibular angloplasty showing the resected muscle mass and bone. the patient was instructed to bite with maximal force in maximum
intercuspation. This film was subjected to computer assisted scan-
muscle was transected to expose the anterior border of the ramus fol- ning (NUPAI bite force scanning system, Japan), which calculated
lowed by dissection of the anterior border of the masseter. When the the magnitude of bite force in pounds, which was then converted to
lateral surface of the masseter was visible, the retractor and instruments Newtons (N). Bite force of each patient was also recorded at four
were removed, and the dissection was performed with index finger of stages; pre-operatively and 1, 3 and 12 months post-operatively.
the surgeon. The dissection of the lateral surface was performed in the
masseteric fascia plane, with splitting of the fascia from the superficial All data was collected and analysed by a single observer. The data
musculoaponeurotic system. After the lateral dissection of the masseter, obtained was analysed using the Wilcoxon signed-rank test. Statistical
the medial surface of the muscle was also detached from the ramus with analysis was performed using IBM SPSS Statistics version 20.0 software
a periosteal elevator. With the entire muscle exposed, from the angle up (IBM Corp., Armonk, NY, USA). Data obtained for mouth opening was
to the zygomatic arch, the transverse dimension of the muscle could be analysed using the paired t-test. The 5% probability level was con-
perceived and split in a more desirable manner. The debulking of the sidered as statistically significant, i.e. p < 0.05.
muscle was done from the lateral surface. The volume of muscle to be
resected varied, depending on the severity of the hypertrophy and the 3. Results
associated deformity. After debulking the muscle, haemostasis was
achieved, and primary closure of the incision was done. The present study analysed 28 sites in 18 patients (10 bilateral
cases) of masseter hypertrophy for anatomic and functional changes
following myotomy. The male:female ratio was 1:1 both with respect to
2.4. Post-operative care the number of patients and number of sites affected. Average age of
patients undergoing surgical debulking was 24.8 years (range = 18–32
In the immediate post-operative period, an extra-oral pressure years). All patients reported with the chief complaint of compromised
dressing was maintained for at least 24–48 hours over the surgical site aesthetics and gradual decrease in mouth opening, except one who also
to minimize the post-operative swelling. Intravenous antibiotics and had pain in the hypertrophied muscle. 21 out of the 28 sites, all 10
analgesics were prescribed for an average of 5 days. Passive mouth patients of bilateral hypertrophy and 2 out of the 8 unilateral cases had
opening exercises were advised from the second post-operative day and an associated angular spur and therefore, required angular re-
active physiotherapy one week post-operatively to allow the muscle to contouring (Table 1).
adapt physiologically as early as possible.
3.1. Anatomic parameters
2.5. Post-operative assessment
1 Muscle thickness: Median pre-operative and 1-year post-operative
Post-operative assessment was done with the help of clinical muscle thickness at rest was found to be 13.5 mm and 7.15 mm

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Table 1 2 Bite force analysis: The median pre-operative maximum bite force
Patient demographics, site, complaint, surgical extent and approach. (988.5 N) significantly decreased to a 1-year post-operative median
S. No. Age/Sex Chief Extent and Approach Unilateral/ of 680 N (p = 0.0001) (Table 2).
Complaint Bilateral
3.2.1. Active mouth opening
1. 29/M Cosmetic Muscle + bone, Extraoral Bilateral
A mean increase of 8 ± 1.68 mm in mouth opening was seen from a
plus pain
2. 26/F Cosmetic Muscle + bone, Extraoral Bilateral
pre-operative mean value of 30.32 ± 1.97 mm to the post-operative
3. 31/M Cosmetic Muscle + bone, Extraoral Bilateral mean value of 38.32 ± 1.38 mm (Table 2). This difference obtained
4. 29/F Cosmetic Muscle + bone, Extraoral Bilateral was found to be statistically significant with a p value of 2.59e−13.
5. 23/F Cosmetic Extraoral on one side for both Bilateral
muscle and bone and intraoral
3.2.2. Complications of surgical debulking
on other side for muscle only
6. 29/F Cosmetic Muscle + bone, Extraoral Bilateral A single patient developed MMNP which recovered gradually over a
7. 32/M Cosmetic Muscle + bone, Extraoral Bilateral period of 16 weeks. A sialocoele developed in one patient which was
8. 23/M Cosmetic Muscle, Intraoral Unilateral managed conservatively.
9. 27/F Cosmetic Muscle + bone, Extraoral Unilateral
10. 23/F Cosmetic Muscle, Intraoral Unilateral
11. 23/F Cosmetic Muscle, Intraoral Unilateral
4. Discussion
12. 18/M Cosmetic Muscle + bone, Extraoral Bilateral
13. 24/M Cosmetic Muscle, Intraoral Unilateral Several theories have been proposed to explain the aetiology of
14. 22/F Cosmetic Muscle + bone, Extraoral Unilateral masseter hypertrophy ranging from its description as a ‘work hyper-
15. 19/M Cosmetic Muscle, Intraoral Unilateral
trophy’ due to excessive grinding/chewing [8,9] or an inability to chew
16. 24/M Cosmetic Muscle + bone, Extraoral Bilateral
17. 20/F Cosmetic Muscle + bone, Extraoral Bilateral from other side due to dental diseases like caries, periodontal problems
18. 25/M Cosmetic Muscle, Intraoral Unilateral or missing teeth [10], to masseter fatigue and lack of uniform en-
largement of the muscle hold [2]. In all our patients, we could elicit a
history of abnormal chewing habits viz. bruxism, excessive gum
Table 2 chewing and/or supari/gutka and were able to associate them with the
Pre-operative and Post-operative Comparison of Muscle Thickness, EMG, Bite condition.
Force and Mouth Opening Values. Diagnosis of masseter hypertrophy is mainly based upon clinical
Parameter Patient visit Minimum Maximum Range Median examination, with imaging largely being an adjunct. Inspection at rest
may or may not reveal additional mass in masseteric region, depending
RESTING
upon the degree of hypertrophy. However, clenching commonly leads
MUSCLE Pre-operative 8.3 14.8 6.5 13.5
THICKNESS (mm) After 1 year 5 8 3 7.15
to formation of a tumour like mass on lateral surface of the masseter.
CLENCH Palpation, at rest reveals a soft, non-tender and ill-defined mass along
MUSCLE Pre-operative 12.8 19.1 6.3 17.5 the direction of muscle fibres. Upon clenching, this mass becomes an
THICKNESS (mm) After 1 year 10.1 13.8 3.7 12.25 inherent part of contracted masseter [2,3]. A bony projection may be
Pre-operative 0.57 1.71 1.14 0.96 felt at mandibular angle region flaring laterally like ‘an ear’. This spur
RESTING After 1 month 0.41 1.28 0.87 0.80 can be easily noticed on PA view. OPG also shows this spur as an over-
E.M.G. After 3 months 0.47 1.19 0.72 0.78
inflated anatomical angle region. This “extra bony spur” along with
(microvolts) After 12 months 0.51 1.28 0.77 0.89
muscle mass gives a swollen cheek appearance and additional promi-
Pre-operative 102 580.50 478.5 281.4
nence to mandibular angles; thus, the complaint of broad face/asym-
CLENCH After 1 month 43.20 253.30 210.1 154.4
E.M.G. After 3 months 33.70 269.50 235.8 168.75
metry by the patients. These features act against the natural feminine
(microvolts) After 12 months 26.40 283.70 257.3 210.6 facial contour lines. In our cohort of patients, a bony enlargement was
Pre-operative 582 1303 721 988.5
witnessed in 75% of sites (n = 21), requiring an additional angular
BITE FORCE After 1 month 258 710 452 493 contouring to normalise the aesthetics.
(Newton) After 3 months 433 740 307 616.5 Of late, USG has evolved as an additional investigation. Raadsheer
After 12 months 450 780 330 680 et al in 1996 compared USG and magnetic resonance imaging (MRI) to
MOUTH OPENING Patient Visit Mean S.D.
estimate the thickness of masseter muscle and found no statistical dif-
(mm) Pre-operative 30.32 1.97
After 12 months 38.32 1.38 ference between the two techniques [11]. Rather, USG has an ad-
Difference 8.00 1.68 vantage of being more economical and hence may be used more fre-
quently. It is also psychologically more comfortable for patients. We
diagnosed patients using clinical examination and radiographs (OPG
respectively (Table 2). The decrease in muscle thickness (6.35 mm) and PA skull view). Additionally, USG was used to compare the pre-
was found to be statistically significant (p = 0.0001). Similarly, the operative and post-operative muscle thickness. Kiliaridis in 1991 used
muscle thickness in clench decreased from a median of 17.5 mm pre- USG and reported a resting muscle thickness of 9.7 mm in males and
operatively to 12.25 mm 1 year post-operatively with a difference of 8.7 mm in females [12]. In our study, the median pre-operative and 1-
5.25 mm. This decrease was also found to be statistically significant year post-operative muscle thickness at rest was found to be 13.5 mm
with (p = 0.0001). and 7.15 mm respectively, while the muscle thickness at clench was
2 Patients’ satisfaction of aesthetic outcome: The readings on VAS 17.5 mm and 12.25 mm, respectively (Table 2). A statistically sig-
after 1 year were in range of 6–10 with a mean of 8.07 (Fig. 3: A and nificant reduction in muscle thickness both at rest and clench implies a
B). favourable anatomic outcome with surgical debulking in masseter hy-
pertrophy.
3.2. Functional parameters Among the functional parameters, bite forces have been measured
by different techniques in human subjects [13–15]. Variability in
1 EMG: The median pre-operative resting EMG of 0.96 μV gradually technique and properties and positioning of pressure measurement
and significantly decreased to a median of 0.89 μV over 1 year device has led to variable values in the literature. We used a pressure-
(p = 0.0001), while the median clench EMG decreased significantly sensitive, paper thin sensor and its deformation was analysed using
from 281.4 to 210.6 μV (p = 0.0001) (Table 2). computerised software to estimate the bite force generated. Average

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S. Mohanty et al. Journal of Oral and Maxillofacial Surgery, Medicine, and Pathology xxx (xxxx) xxx–xxx

Fig. 3. One-year post-operative frontal profile of the patient at rest (A) and during clench (B).

bite force in healthy individuals has been found to be in a range of documented the patients’ satisfaction with the final aesthetic outcome
500–700 N. In our study, the observed median pre-operative maximum using a Visual Analogue Scale (VAS), achieving a mean VAS score of
bite force of 988.5 N was well above the normal value. However, this 8.07, suggesting a good aesthetic result. Even though the amount of
significantly decreased over the year to a median of 680 N, a value well muscle and bony excision to be performed was planned pre-operatively
within the range of normal bite force (Table 2). by calculating the excess using pre-operative USG and OPG, the intra-
Changes in the resting as well as clench EMG values were found to operative execution of a precise excision is rarely feasible, and both
be statistically significant in this study (p < 0.05), implying that muscle excision and bone contouring are usually subjective decisions
muscular hypertrophy elevates the EMG significantly and surgical de- which largely depend on surgical expertise. Obtaining a good VAS
bulking restores the value to near normal, as evidenced by the observed score, therefore, reassured the authors of the accuracy of the surgery.
values (Table 2). Myotomy of the masseter can be performed intra-orally or extra-
The assessment of bite force and EMG was done at four intervals for orally. Extra-oral approach provides good access to the surgical site, but
all patients: at the pre-operative visit and at the 1-month, 3-month and there is always a chance of MMNP and an evident scar. In 1959,
6-month post-operative visits. It was observed that following surgery, Ginestet et al addressed this issue by introducing and advocating the
there was a dramatic initial decrease in the bite force and EMG values. use of intra-oral approach for the same [16]. This approach avoids a
For instance, the median bite force value decreased from a pre-opera- scar and nerve damage but is more technique sensitive and the surgeon
tive value of 988.5 N to 493 N, as measured at the 1-month post-op- may struggle to resect larger amounts of muscle mass and the angular
erative visit (50.1% reduction). However, the values recorded at the spur in a symmetric fashion. Therefore, an extra-oral approach is pre-
subsequent visits were seen to gradually increase to 433 N (3 months ferred in cases of anticipated large resections, especially a combination
post-operative) and then to 450 N 1 year following the surgery, showing of muscle mass and angular spurs. We opted for an extra-oral approach
a 37.9% increase from the reading seen at 1 month. The EMG record- in all cases where a myotomy with angular recontouring was required
ings showed a similar trend (Table 2). The authors believe that the and intra-oral approach where sole reduction of muscle mass was
initial stark decrease in values may be ascribed to a loss of the tendi- needed. We encountered only a single case of transient MMNP in one
nous attachment of the muscle from the underlying bone and its partial patient with the extra-oral approach. A medial muscle excision is gen-
denervation during excision, resulting in temporary functional impair- erally preferable to a lateral one as it is believed that it minimises the
ment. With due course of time, however, neuromuscular adaptation risk of marginal mandibular nerve injury. In the current study, a medial
takes place and the muscle regains its structure, physiology, surface myotomy was done in all cases approach extra-orally because in these
area of attachment and the strength of contraction drifts back to cases, the muscle was detached from the lateral ramus surface for
normal, resulting in a gradual increase in bite force and EMG values osseous recontouring and the medial aspect of the muscle was readily
over time. accessible for excision. However, the same was not true when the
Another important observation was a significant increase in the muscle was approached intra-orally, and thus, a lateral myotomy was
mean mouth opening of the patients (p < 0.05). This increase ob- done for such cases.
served may be due to surgical debulking of the muscle or reattachment The authors used surgery as a modality for treatment of masseter
of muscle fibres more superiorly after trimming the angular spur or hypertrophy largely due to the unavailability of funds to procure bo-
reorientation of contraction vector after excision of flared spur. tulinum toxin at their centre and also in pursuit of a relatively longer
Favourable outcomes were thus achieved in terms of normal electrical lasting result. The major drawbacks of this study were a small sample
activity and bite forces, along with an adequate mouth opening fol- size and lack of a definitive criterion to analyse the aesthetic change.
lowing surgical correction (Table 2). However, the main initial com- Further studies are recommended to compare these outcomes with
plaint of our patients was an unaesthetic appearance, so we those achieved following treatment with botulinum toxin.

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5. Conclusion References

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