Oral and maxillofacial surgery
Botulinum toxin in the management of head and neck disorders

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Botulinum toxin is a polypeptide protoxin synthesized by Clostridium botulinum that results in localized reduction of muscle activity by inhibiting acetylcholine release at the neuromuscular junction. In 2004, the US Food and Drug Administration approved its application in the treatment of various medical conditions, such as facial wrinkles, strabismus, cervical dystonia, blepharospasm, and hyperhidrosis. Later, its application extended to improving dental esthetics and gummy smile. It was found to be a safe and effective alternative to medical therapy to treat various head and neck disorders that have a neurologic component. In this review, we will highlight the mechanism of action and therapeutic benefits of botulinum toxin in the management of head and neck disorders.

Section snippets

Biochemistry of BTX

Botulinum toxin is isolated from an anaerobic spore-forming bacterium, Clostridium botulinum. Chemically, it is a 2-chain metalloprotease composed of heavy and light chains with 8 immunologically distinct serotypes (A, B, C1, C2, D, F, G). All but one (C2) are neurotoxins. Serotype A (BTX type A or onabotulinum toxin A, Botox [Allergan, Parsiippany, NJ]) has been the most widely used for a variety of movement and spasticity disorders as well as in cosmetic procedures.6

Neuromuscular blockade

BTX has a neuromuscular blocking effect that results from inhibiting the exocytosis of acetylcholine from presynaptic nerve terminals.7 BTX is internalized into the cytosol from the neuromuscular junction by binding to different gangliosides, namely synaptic vesicle –2, synaptotagmin I, or synaptotagmin II. Heavy chains of BTX facilitate uptake of the whole molecule into the cytosol, where light chains cleave soluble N-ethylmaleimide–sensitive factor attachment protein receptor (SNARE)

Preparation

Botulinum toxin is prepared by laboratory fermentation of C botulinum, which lyses and liberates the toxin into the culture. The toxin is then harvested, purified, crystallized with ammonium sulfate, diluted with human serum albumin, lyophilized, bottled in vials, and sealed. Each vial of BTX contains 100 U of C botulinum type A neurotoxin complex. It retains its potency for 9 months at room temperature (25° C) and for 3 years at refrigerated temperatures (2-8° C).11, 12

Therapeutic Uses in Head and Neck Disorders

Botulinum neurotoxins have been used for years to treat a wide variety of medical and dental diseases. They were used initially in improvement of facial esthetics but have since gained popularity in pain management and treatment of disorders with accelerated muscle contraction. Table I summarizes the therapeutic uses of botulinum toxin.

Conclusion

Various conservative therapies, medicines, and minor and major surgical procedures have been used in the past to treat facial pain, secretory disorders, and head and neck movement disorders. Few patients failed to respond to these treatment modalities, with variable responses. BTX has progressed from being used in cosmetic procedures only to a spectrum of clinical applications, as discussed above. It is a superior treatment option over pharmacotherapy or surgery for head and neck disorders,

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