Methods for treatment of masseter muscle hypertrophy

Abstract

To provide methods for treating masseter muscle hypertrophy (MMH).SOLUTION: Methods and kits for treating or alleviating masseter muscle hypertrophy by local administration of a Clostridial derivative, such as a botulinum toxin, to the masseter muscle are described. Methods and kits for reducing lower face width and for reducing prominence of the masseter muscle of a human are also described.SELECTED DRAWING: None

Description

[Technical field]

[0001] CROSS-REFERENCE TO RELATED APPLICATIONS This application claims the benefit of U.S. Provisional Patent Application No. 62 / 731,064, filed Sep. 13, 2018, which is incorporated herein by reference in its entirety.

[0002] The present disclosure relates to methods for treating masseteric hypertrophy, and in particular to the treatment of masseteric hypertrophy (hereinafter MMH) using a neurotoxin. [Background technology]

[0003] Masseteric hypertrophy (MMH) may be unilateral or bilateral. It may be idiopathic or associated with several conditions such as bruxism, occlusion and muscle disharmony, temporomandibular joint disorder (TMJD) or excessive chewing habits. Aesthetically, MMH may appear as a broad, square or trapezoidal lower face morphology, which is considered undesirable. Reduction of a large or square lower face may be desired by surgical or non-surgical correction of prominent masseter muscles and / or mandible. Successful treatment depends on several factors, including an effective method for determining the efficacy of treatment so that further treatment can be adjusted accordingly, and an effective administration paradigm that produces the desired outcome while minimizing adverse events that may be associated with the treatment. Thus, there is a need for effective methods of treating MMH, as well as effective methods of determining the efficacy and safety of such treatments. Summary of the Invention

[0004] In a first aspect, a method of treating MMH is provided. The method comprises locally administering a Clostridium derivative to a subject with MMH. In some embodiments, the Clostridium derivative is a wild-type or recombinant neurotoxin, a recombinant modified toxin, a fragment thereof, a Targeted vesicular Exocytosis Modulator (TEM), or a combination thereof. In one embodiment, the Clostridium derivative is a botulinum toxin. In one embodiment of the method, the Clostridium derivative is locally administered to the masseter muscle of the patient. In yet another aspect, a kit of parts is provided, comprising: a) a botulinum toxin in an amount of about 5-100 units; and b) instructions for administering the botulinum toxin to a muscle for the treatment of masseteric hypertrophy, wherein the botulinum toxin is administered to a masseter muscle of a subject suffering from masseteric hypertrophy. In one embodiment, the amount of botulinum toxin is about 10-50 units or 20-100 units, preferably about 12-48 units or 24-96 units, more preferably about 24-36 units or 48-72 units. In a specific embodiment, the amount of botulinum toxin is 12 units, 24 units, 36 units, 48 ​​units, 72 units, or 96 units. In one embodiment, the botulinum toxin is packaged in several portions. In another aspect, a method for reducing lower facial width in the masseter region is provided, the method comprising identifying an area of ​​maximum masseter bulge and injecting botulinum toxin into multiple injection sites in the area to administer a dose of botulinum toxin that reduces the lower facial width in the masseter region.

[0005] In one embodiment, the identifying and injecting steps are performed bilaterally, hi another embodiment, the method further comprises repeating the identifying and injecting steps in the opposing masseter muscle. In one embodiment, a dose of about 10-50 units or 20-100 units of botulinum toxin is injected at multiple injection sites. In another embodiment, a dose of about 24-36 units or 48-72 units of botulinum toxin is injected at multiple injection sites. In another embodiment, the dose is about 12-48 units or 24-96 units. In another embodiment, the dose is 12 units, 24 units, 36 units, 48 ​​units, 72 units or 96 units. In yet another embodiment, the dose of botulinum toxin is in a range selected from the group of about 5-100 units, about 15-60 units, about 25-47 units, and about 30-40 units for each muscle treated. In another embodiment, the dose of botulinum toxin is about 36 units for each muscle treated. In another embodiment, the multiple injection sites are 3-5. In some embodiments, a portion of the dose is administered to each of the multiple injection sites, the portion being the same as the dose divided by the number of the multiple injection sites. In other embodiments, the portion of the dose administered to one or more injection sites is not the same as the portion of the dose administered to another injection site. In another embodiment, the method includes assessing or reviewing the subject using the Masseter Muscle Prominence Scale (MMPS) prior to identifying the area of ​​maximum masseter prominence. In one embodiment, the assessment or review involves the subject being ranked as marked or very marked on the MMPS. In one embodiment, the evaluation or review is performed to assess the effectiveness of a previous treatment. In another embodiment, the method is a cosmetic method for reducing lower facial width in the masseter region.

[0006] In yet another aspect, a kit of parts is provided, comprising: a) a botulinum toxin in an amount of about 5-100 units; and b) instructions for administering the botulinum toxin to a muscle to reduce lower facial width in the masseter region, comprising: i) identifying an area of ​​maximum masseter bulge; and ii) injecting the botulinum toxin into multiple injection sites in the area to administer a dose of the botulinum toxin that reduces lower facial width in the masseter region. In one embodiment, the amount of botulinum toxin is about 10-50 units or 20-100 units, preferably about 12-48 units or 24-96 units, more preferably about 24-36 units or 48-72 units. In a specific embodiment, the amount of botulinum toxin is 12 units, 24 units, 36 units, 48 ​​units, 72 units, or 96 units. In one embodiment, the botulinum toxin is packaged in several portions, for example 3-5 portions. In one embodiment, the botulinum toxin is botulinum toxin type A. In one embodiment, the kit of parts further comprises instructions to score or review the score of the subject using the Masseter Muscle Prominence Scale (MMPS) prior to identifying the area of ​​maximum masseter bulge, instructions to identify the area of ​​maximum masseter bulge, and / or instructions to repeat the identification and injection in the opposite masseter muscle. In another aspect, a method for reducing masseteric prominence in a human is provided, the method comprising administering a dose of botulinum toxin to the masseteric region that reduces masseteric prominence, the dose being administered at multiple sites in the masseteric region, the region being identified as the region of maximum masseteric bulge when the jaw is clenched, and the dose being administered with the jaw relaxed.

[0007] In one embodiment, the administering step is performed bilaterally, hi another embodiment, the method further comprises repeating the administration in the opposing masseter muscle. In one embodiment, the administering step is by injection with a needle positioned perpendicular to the masseter muscle during injection. In another embodiment, the dose is administered for distribution to deep and superficial muscles. In yet another embodiment, the dose is administered in a volume of about 0.3 to 3.6 mL. In another embodiment, the dose is administered in a volume of about 0.6 to 2.4 mL. In yet another embodiment, a portion of the dose is administered to each of a plurality of injection sites, and the portion administered to each injection site is variable. In one embodiment, the portion, which may be constant at each injection site or may be variable at each injection site, is administered in a volume of about 0.1 to 0.4 mL. In one embodiment, the multiple injection sites is 3. In another embodiment, the multiple injection sites is 2-5 or 3-5. In one embodiment, at least one of the multiple injection sites is spaced about 1 cm from adjacent sites of the multiple injection sites. In another embodiment, each injection site of the multiple injection sites is spaced about 0.5 cm, 0.75 cm, or 1 cm from adjacent sites. In one embodiment, each injection site is spaced about 1 cm from adjacent sites. In the studies described in Examples 1 and 2, it was observed that a spacing of 1 cm between injection sites provides a uniform, continuous distribution of toxin in the treatment area.

[0008] In another aspect, a kit of parts is provided, comprising: a) a botulinum toxin in an amount of about 5-100 units; and b) instructions for administering the botulinum toxin to a muscle to reduce masseteric prominence in a human, comprising: i) identifying the area of ​​maximum masseteric bulge when the jaw is clenched; and ii) administering a dose of the botulinum toxin to multiple sites in the masseteric area when the jaw is relaxed, the dose reducing masseteric prominence. In one embodiment, the amount of botulinum toxin is about 10-50 units or 20-100 units, preferably about 12-48 units or 24-96 units, more preferably about 24-36 units or 48-72 units. In a specific embodiment, the amount of botulinum toxin is 12 units, 24 units, 36 units, 48 ​​units, 72 units, or 96 units. In one embodiment, the botulinum toxin is a type A botulinum toxin. In one embodiment, the botulinum toxin is packaged in several, preferably 2-5, and more preferably 3, packages. In yet another aspect, a method is provided for temporarily reducing lower facial projection or width associated with a masseteric prominence, the method comprising: identifying a line extending from the lateral commissure of the mouth to the point where the earlobe meets the face; identifying an area of ​​maximum masseteric bulge with the jaw clenched; determining a treatment area that includes the area of ​​maximum bulge and is located at or below the line, posterior to the laughter muscle and anterior to the parotid gland; and injecting botulinum toxin into multiple injection sites in the treatment area to administer a dose of botulinum toxin that reduces the lower facial projection or width.

[0009] In one embodiment, the steps of the method are performed bilaterally, hi another embodiment, the method further comprises repeating the steps on the opposing masseter muscle. In one embodiment, a line extending from the lateral commissure of the mouth to the point where the earlobe meets the face is visually identified as an imaginary line, hi another embodiment, the line is visually identified and physically marked on the patient's skin. In one embodiment, the treatment area is determined visually without marking the skin, while in another embodiment, the determined treatment area is indicated by markings placed on the skin. In another embodiment, a subject assessment using the Masseter Muscle Prominence Scale (MMPS) is performed or a prior assessment of the subject is reviewed. In one embodiment, the subject to be treated is rated as marked or very marked by the MMPS. In one embodiment, the evaluation or review is performed to assess the effectiveness of a previous treatment. In another embodiment, the method is a cosmetic method for temporarily reducing lower facial projection or width associated with the masseteric eminence. In another embodiment, the botulinum toxin is a type A botulinum toxin.

[0010] In another aspect, a kit of parts is provided, comprising: a) a botulinum toxin in an amount of about 5-100 units; and b) instructions for administering the botulinum toxin to a muscle to temporarily reduce lower facial projection or width associated with masseteric prominence, comprising: i) identifying a line extending from the lateral commissure of the mouth to the point where the earlobe meets the face; ii) identifying an area of ​​maximum masseteric bulge with the jaw clenched; iii) determining a treatment area including the area of ​​maximum bulge, located on or below the line, posterior to the laughter muscle and anterior to the parotid gland; and iv) injecting the botulinum toxin into multiple injection sites in the treatment area to administer a dose of the botulinum toxin that reduces lower facial projection or width. In one embodiment, the amount of botulinum toxin is about 10-50 units or 20-100 units, preferably about 12-48 units or 24-96 units, more preferably about 24-36 units or 48-72 units. In specific embodiments, the amount of botulinum toxin is 12 units, 24 units, 36 units, 48 ​​units, 72 units, or 96 units. In one embodiment, the botulinum toxin is packaged in several portions, preferably 2-5 portions, more preferably 3 portions. In one embodiment, the botulinum toxin is a botulinum toxin type A. In one embodiment, the kit of parts further includes instructions to assess or review the subject using the Masseter Muscle Prominence Scale (MMPS), and to have the subject rate the MMPS as marked or very marked. In another aspect, a method for altering the contour of the lower face of a human is provided. The method includes topically administering a Clostridium derivative. In another embodiment, the method includes identifying the area of ​​maximum masseter muscle bulge and administering a dose of Clostridium derivative by injection at multiple injection sites in the area to reduce the lower face width of the masseter muscle area. In one embodiment, the Clostridium derivative is a botulinum toxin. In yet another embodiment, the method includes identifying a line extending from the lateral commissure of the mouth to the point where the earlobe meets the face; identifying the area of ​​maximum masseter muscle bulge with the jaw clenched; determining a treatment area that includes the area of ​​maximum bulge, is located on or below the line, is posterior to the laughter muscle, and is anterior to the parotid gland; and administering a dose of botulinum toxin by injection at multiple injection sites in the treatment area to reduce the lower face projection or width.

[0011] In another aspect, a kit of parts is provided, comprising: a) a botulinum toxin in an amount of about 5-100 units; and b) instructions for administering the botulinum toxin to a muscle to alter the contours of a human lower face, comprising: i) identifying a line extending from the lateral commissure of the mouth to the point where the earlobe meets the face; ii) identifying an area of ​​maximum bulge of the masseter muscle with the jaw clenched; iii) determining a treatment area including the area of ​​maximum bulge, located at or below the line, posterior to the laughter muscle and anterior to the parotid gland; and iv) injecting the botulinum toxin into multiple injection sites in the treatment area to administer a dose of the botulinum toxin that reduces lower face projection or width. In one embodiment, the amount of botulinum toxin is about 10-50 units or 20-100 units, preferably about 12-48 units or 24-96 units, more preferably about 24-36 units or 48-72 units. In specific embodiments, the amount of botulinum toxin is 12 units, 24 units, 36 units, 48 ​​units, 72 units, or 96 units. In one embodiment, the botulinum toxin is packaged in several packages, preferably 2 to 5 packages, more preferably 3 packages. In one embodiment, the botulinum toxin is a botulinum toxin type A. In yet another aspect, a method is provided for shaping or reshaping a human's lower face in the masseter region. Another aspect contemplates a method for reducing lower face protrusion associated with the masseter muscle. In embodiments of these methods, a Clostridium derivative is administered locally according to any of the methods and embodiments described herein. In one embodiment of either the method or kit of parts, the method or composition is directed to a cosmetic treatment method, such as a cosmetic method for reducing a human masseteric prominence, a cosmetic method for temporarily reducing the lower facial projection or width associated with the masseteric prominence, or a cosmetic method for reducing the lower facial width in the masseteric region.

[0012] In another aspect, a kit of parts is provided, comprising: a) a botulinum toxin in an amount of about 5-100 units; and b) instructions for administering the botulinum toxin to a muscle to shape or reshape a human lower face in the masseter region. In one embodiment, the amount of botulinum toxin is about 10-50 units or 20-100 units, preferably about 12-48 units or 24-96 units, more preferably about 24-36 units or 48-72 units. In specific embodiments, the amount of botulinum toxin is 12 units, 24 units, 36 units, 48 ​​units, 72 units, or 96 units. In one embodiment, the botulinum toxin is packaged in several portions, preferably 2-5 portions, more preferably 3 portions. In one embodiment, the botulinum toxin is a type A botulinum toxin. In any of the methods or kits of parts described above, in some embodiments, the botulinum toxin is animal protein free. In other embodiments, the lower facial width in the masseter region, the masseteric prominence in humans, or the lower facial prominence or width associated with the masseteric prominence is reduced for a longer period of time than with an animal protein-containing composition.

[0013] In yet another aspect, a composition is provided that includes a botulinum toxin and a pharma- ceutical acceptable carrier for injection into the area of ​​maximum masseter bulge to reduce lower facial width in a subject in the masseter region. In yet another aspect, there is provided a use of a botulinum toxin injected in the area of ​​maximum masseter bulge to reduce the lower facial width of a subject in the masseter region, to reduce the masseter prominence of a human, and / or to temporarily reduce the lower facial projection or width associated with the masseter prominence of a subject.

[0014] In one embodiment of the composition or use thereof, the subject has a pronounced or very pronounced masseteric ridge, hi one embodiment, the masseteric ridge is determined using MMPS. In another embodiment, the composition or its use reduces lower facial width in the masseter region for 90 days following injection. In another embodiment, the composition or use of the composition is injected into both masseter muscles at multiple injection sites in each masseter muscle, hi one embodiment, the multiple injection sites are 3-5 in each masseter muscle. In another embodiment, the composition or use of the composition is injected with a needle that is positioned perpendicular to the masseter muscle during injection, hi another embodiment, the composition is injected so as to be distributed to the deep and superficial muscles. In yet other embodiments, the composition or its use is directed to cosmetic treatments. In one embodiment, the composition or use thereof is where the botulinum toxin is botulinum toxin type A. In one embodiment, the botulinum toxin is animal protein free. In one embodiment, the lower facial width in the masseter region, the human masseteric prominence, or the lower facial prominence or width associated with the masseteric prominence is reduced for a longer period of time than with an animal protein containing composition. The following figures are provided to illustrate aspects and features of embodiments of the present method. [Brief description of the drawings]

[0015] [Figure 1] FIG. 1 is a schematic side view of a human face illustrating a technique for identifying treatment areas. [Figure 2A]Figure 2A is a bar graph showing the least squares mean (LSMean) change in lower facial volume (cm3) after 90 days of treatment with the indicated doses of botulinum toxin in the masseter muscles, with the volume change at 90 days relative to the lower facial volume before treatment (baseline), where the lower facial volume is calculated using a three-dimensional imaging system. [Figure 2B] 2B is a graph showing the least squares mean (LSMean) change in lower facial volume (cm3) as a function of time following treatment with botulinum toxin in the masseter muscles, with the volume change at each time point relative to the lower facial volume before treatment (baseline), where the lower facial volume was calculated using a three-dimensional imaging system, and bilateral botulinum toxin doses were 24 units (circles), 48 units (squares), 72 units (triangles), and 96 units (diamonds). [Figure 3A] FIG. 3A is a graph showing the percentage of subjects in each treatment dose cohort who were ranked Grade 3 or less by the Masseter Muscle Prominence Scale (MMPS) as a function of time after treatment with untreated placebo subjects (dashed line) and bilateral total botulinum toxin doses of 24 units (circles), 48 units (squares), 72 units (triangles), and 96 units (diamonds). [Figure 3B] FIG. 3B is a graph showing the percentage of subjects in each treatment dose cohort who had a change of 2 or more ranks on the MMPS as a function of time after treatment with untreated placebo subjects (dashed line) and bilateral total botulinum toxin doses of 24 units (circles), 48 units (squares), 72 units (triangles), and 96 units (diamonds). [Figure 4A] FIG. 4A is a bar graph showing the percentage of subjects in each treatment dose cohort who were ranked Grade 3 or less on the MMPS 90 days after treatment with bilateral botulinum toxin doses of 24 units, 48 ​​units, 72 units, and 96 units, as well as untreated placebo subjects. [Figure 4B]FIG. 4B is a bar graph showing the percentage of subjects in each treatment dose cohort who had a change of 2 or more ranks on the MMPS 90 days after treatment with bilateral botulinum toxin doses of 24 units, 48 ​​units, 72 units, and 96 units, as well as untreated placebo subjects. [Diagram 5] FIG. 5 is a bar graph showing duration of effect in subjects in each treatment dose cohort who experienced a change in MMPS ranking of 2 or more after treatment with bilateral botulinum toxin doses of 24 units, 48 ​​units, 72 units, and 96 units, as well as in untreated placebo subjects. [Figure 6] 6 is a graph showing the least squares mean (LSMean) change in lower facial volume (cm3) as a function of time following treatment with botulinum toxin in the masseter muscle, with the volume change at each time point relative to the lower facial volume before treatment (baseline), where the lower facial volume was calculated using a three-dimensional imaging system and the bilateral botulinum toxin doses were 24 units (circles), 48 units (squares), 72 units (triangles), and 96 units (diamonds) on days 1 and 180. [Figure 7A] FIG. 7A shows questions from the Lower Facial Shape Questionnaire, a questionnaire that assesses lower facial shape. [Figure 7B] FIG. 7B shows questions from the Lower Facial Morphology Questionnaire, a questionnaire for assessing lower facial morphology. DETAILED DESCRIPTION OF THE PREFERRED EMBODIMENTS

[0016] definition As used herein, "about" or "approximately" means within an acceptable error range for a particular value as determined by one of ordinary skill in the art, and depends in part on how the value is measured or determined (i.e., the limitations of the measurement system). For example, "about" can mean within 1 or more than 1 standard deviation per the practice in the art. When a particular value is described in the present application and claims, unless otherwise specified, the term "about" means within an acceptable error range for the particular value. "Administration" or "administering" refers to the step of giving (i.e., administering) a botulinum toxin to a subject, or to a subject receiving a pharmaceutical composition. The method can be performed by routes of administration including intramuscular, non-intramuscular, intradermal, subcutaneous, transdermal, implantation (e.g., of a sustained release device such as a polymeric implant or mini-osmotic pump), or a combination thereof. "Alleviate" refers to a reduction in the manifestation of a symptom. Thus, alleviate includes some reduction, significant reduction, near complete reduction, and complete reduction. The alleviation effect may not be clinically evident for 1-7 days or longer after administration of the Clostridium derivative to the patient. "Animal protein free" means the absence of blood-derived, blood-stasis and other animal-derived products or compounds. "Animal" means mammals (such as humans), birds, reptiles, fish, insects, spiders, or other animal species. "Animal" does not include microorganisms such as bacteria. Thus, an animal protein free pharmaceutical composition may contain botulinum neurotoxins. For example, an "animal protein free" pharmaceutical composition means a pharmaceutical composition that is substantially free, essentially free, or completely free of other animal derived proteins such as serum derived albumins, gelatins, and immunoglobulins. An example of an animal protein free pharmaceutical composition is a pharmaceutical composition that comprises or consists of botulinum toxin (as an active ingredient) and a suitable polysaccharide as a stabilizer or excipient. "Botulinum toxin" refers to neurotoxins produced by Clostridium botulinum, as well as non-clostridial recombinantly engineered botulinum toxins (or their light or heavy chains). As used herein, the term "botulinum toxin" includes botulinum toxin serotype A (BoNT / A), botulinum toxin serotype B (BoNT / B), botulinum toxin serotype C (BoNT / C), botulinum toxin serotype D (BoNT / D), botulinum toxin serotype E (BoNT / E), botulinum toxin serotype F (BoNT / F), botulinum toxin serotype G (BoNT / G), botulinum toxin serotype H (BoNT / H), botulinum toxin serotype X (BoNT / X), and mosaic botulinum toxins and / or subtypes and variants thereof. As used herein, “botulinum toxin” also includes “denatured botulinum toxin.” Additionally, as used herein, “botulinum toxin” also includes botulinum toxin complexes (e.g., the 300, 600 and 900 kDa complexes) as well as the neurotoxic component of botulinum toxin (150 kDa) that is not associated with a complex protein.

[0017] "Clostridial derivative" refers to a molecule that contains any portion of a Clostridial toxin. As used herein, the term "Clostridial derivative" includes wild-type or recombinant neurotoxins, recombinant modified toxins, fragments thereof, targeted vesicular exocytosis modulators (TEMs), or combinations thereof. "Clostridial toxin" refers to any toxin produced by a Clostridial toxin strain capable of executing all of the cellular mechanisms by which the Clostridial toxin enters a cell and achieves binding of the Clostridial toxin to a low or high affinity Clostridial toxin receptor, internalization of the toxin / receptor complex, translocation of the Clostridial toxin light chain to the cytoplasm, and enzymatic denaturation of the Clostridial toxin substrate. Non-limiting examples of Clostridial toxins include botulinum toxins such as BoNT / A, BoNT / B, BoNT / C1, BoNT / D, BoNT / E, BoNT / F, BoNT / G, Tetanus toxin (TeNT), Baratii toxin (BaNT), and Butyricum toxin (BuNT). BoNT / C2 cytotoxin and BoNT / C3 cytotoxin are not neurotoxins and are excluded from the term "Clostridial toxin". Clostridial toxins disclosed herein include, but are not limited to, naturally occurring clostridial toxin variants, such as clostridial toxin isoforms and clostridial toxin subtypes; non-naturally occurring clostridial toxin variants, such as conserved clostridial toxin variants, non-conserved clostridial toxin variants, clostridial toxin chimeric variants and active clostridial toxin fragments thereof, or any combination thereof. Clostridial toxins disclosed herein also include clostridial toxin complexes. As used herein, the term "clostridial toxin complex" refers to a complex comprising a clostridial toxin and a non-toxic associated protein (NAP), such as a botulinum toxin complex, a tetanus toxin complex, a Balati toxin complex, and a butyricum toxin complex. Non-limiting examples of clostridial toxin complexes include those produced by Clostridium botulinum, such as the 900 kDa BoNT / A complex, the 500 kDa BoNT / A complex, the 300 kDa BoNT / A complex, the 500 kDa BoNT / B complex, the 500 kDa BoNT / C1 complex, the 500 kDa BoNT / D complex, the 300 kDa BoNT / D complex, the 300 kDa BoNT / E complex, and the 300 kDa BoNT / F complex.

[0018] An "effective amount" as applied to a bioactive ingredient generally means the amount of the ingredient that is sufficient to induce a desired change in a subject. "Implant" refers to a controlled release (e.g., pulsatile or continuous) composition or drug delivery system that can be injected, inserted, or implanted into the human body, for example. "Local administration" refers to administration of a pharmaceutical agent to a patient by a non-systemic route, such as by intramuscular or subcutaneous administration. Thus, local administration does not include systemic routes of administration, such as intravenous or oral administration. Masseter muscle hypertrophy (MMH), used synonymously herein as masseter muscle prominence (MMP), refers to a condition in which one or both masseter muscles become enlarged.

[0019] "Modified botulinum toxin" refers to a botulinum toxin in which at least one amino acid has been deleted, modified, or substituted compared to wild-type botulinum toxin. Furthermore, the modified botulinum toxin can be a recombinantly produced neurotoxin or a derivative or fragment of a recombinantly produced neurotoxin. The modified botulinum toxin retains at least one biological activity of the wild-type botulinum toxin, such as the ability to bind to a botulinum toxin receptor or inhibit neurotransmitter release from a neuron. One example of a modified botulinum toxin is a botulinum toxin having a light chain of one botulinum toxin serotype (such as serotype A) and a heavy chain of a different botulinum toxin serotype (such as serotype B). Another example of a modified botulinum toxin is a botulinum toxin bound to a neurotransmitter, such as substance P. "Mutation" refers to the structural modification of a natural protein or nucleic acid sequence. For example, in the case of a nucleic acid mutation, the mutation can be the deletion, addition, or substitution of one or more nucleotides in the DNA sequence. In the case of a protein sequence mutation, the mutation can be the deletion, addition, or substitution of one or more amino acids in the protein sequence. For example, a particular amino acid comprising a protein sequence can be replaced with another amino acid, such as an amino acid selected from the group including alanine, asparagine, cysteine, aspartic acid, glutamic acid, phenylalanine, glycine, histidine, isoleucine, lysine, leucine, methionine, proline, glutamine, arginine, serine, threonine, valine, tryptophan, tyrosine amino acid, or any other natural or unnatural amino acid or chemically modified amino acid. Mutations to a protein sequence are the result of mutations in the DNA sequence, which, when the DNA is transcribed and the resulting mRNA is translated, produces a mutated protein sequence. Mutations to a protein sequence can also be made by attaching a peptide sequence containing the desired mutation to the desired protein sequence.

[0020] "Peripheral administration" means administration away from the location of the condition, as opposed to local administration. "Pharmaceutical composition" means a composition that includes an active pharmaceutical ingredient, such as a Clostridial toxin active ingredient, such as a botulinum toxin, as well as at least one additional ingredient, such as a stabilizer or excipient. Thus, a pharmaceutical composition is a formulation that is suitable for diagnostic or therapeutic administration to a subject, such as a human patient. A pharmaceutical composition can be, for example, a lyophilized or vacuum-dried form, a solution formed after reconstitution of a lyophilized or vacuum-dried pharmaceutical composition, or a solution or solid that does not require reconstitution. A "pharmacologically acceptable excipient" is synonymous with "pharmacological excipient" or "excipient" and refers to any excipient that has substantially no long-term or permanent adverse effects when administered to a mammal and includes compounds such as stabilizers, bulking agents, cryoprotectants, antidispersants, additives, solvents, carriers, diluents, or adjuvants. Excipients are generally mixed with the active ingredient or are capable of diluting or containing the active ingredient and may be solid, semi-solid, or liquid agents. It is also envisioned that pharmaceutical compositions that include a clostridial toxin active ingredient can include one or more pharma- ceutically acceptable excipients to facilitate processing of the active ingredient into a pharma-ceutically acceptable composition. To the extent that any pharma-ceutically acceptable excipient is not incompatible with the clostridial toxin active ingredient, its use in a pharma-ceutically acceptable composition is contemplated. Non-limiting examples of pharmacologically acceptable excipients include those described in, for example, Pharmaceutical Dosage Forms and Drug Delivery Systems (Howard C. Ansel et al., eds., Lippincott Williams & Wilkins Publishers, 7 th ed.1999); Remington: The Science and Practice of Pharmacy (Alfonso R. Gennaro ed., Lippincott, Williams & Wilkins, 20 th ed.2000);Goodman&Gilman's The Pharmacological Basis of Therapeutics(Joel G.Hardman et al.,eds.,McGraw-Hill Professional,10 th ed. 2001); and Handbook of Pharmaceutical Excipients (Raymond C. Rowe et al., AphA Publications, 4 th edition 2003, each of which is incorporated herein by reference in its entirety.

[0021] As used herein, "TEM" is synonymous with "targeted exocytosis modulator" or "retargeted endopeptidase." In general, TEMs include an enzymatic domain of a clostridial toxin light chain, a translocation domain of a clostridial toxin heavy chain, and a targeting domain. The targeting domain of a TEM alters the cellular targeting ability and targets the molecule to a receptor other than the wild-type clostridial toxin receptor utilized by the native clostridial toxin. This retargeted ability is achieved by replacing the native binding domain of a clostridial toxin with a targeting domain that has binding activity to a non-clostridial toxin receptor. TEMs bind to non-clostridial toxin receptors but undergo all other steps of the intoxication process, including internalization of the TEM / receptor complex into the cytoplasm, formation of pores in the vesicle membrane and the two-stranded molecule, translocation of the enzymatic domain into the cytoplasm, and carrying out proteolytic effects on components of the SNARE complex of the target cell. "Treating" or "treatment" means alleviating (or eliminating) at least one symptom, either temporarily or permanently. A "therapeutically effective amount" refers to an amount sufficient to achieve a desired therapeutic or cosmetic effect. "Mutant" means a Clostridial neurotoxin, such as wild-type botulinum toxin serotypes A, B, C, D, E, F, or G, that is modified by at least one amino acid substitution, modification, addition, or deletion compared to the wild-type botulinum toxin. The wild-type botulinum toxin is recognized by and internalized by a target cell and catalytically cleaves SNARE (SNAP (soluble NSF attachment protein) receptor) proteins in the target cell. An example of a mutant neurotoxic component can include a mutant light chain of a botulinum toxin in which one or more amino acids have been substituted, modified, deleted and / or added. The mutant light chain may have the same or better ability to prevent exocytosis, e.g., release of neurotransmitter vesicles. Furthermore, the biological effect of the mutant may be reduced compared to the parent chemical component. For example, a mutant light chain of a botulinum toxin type A in which an amino acid sequence has been deleted may have a shorter biological persistence than the parent (or wild-type) botulinum toxin type A light chain.

[0022] Treatment method In a first aspect, a method of treating MMH is provided, comprising administering a therapeutically effective amount of a Clostridium derivative to a muscle, such as the masseter, to reduce muscle activity, which reduces muscle size and is perceived as facial shaping or slimming. Other aspects to be mentioned include a method for reducing the lower face width in the masseter region, a method for temporarily reducing the lower face prominence or width associated with the masseter protuberance, a method for altering the contour of the lower face of a human, a method for shaping or reshaping the lower face of a human in the masseter region, and a method for reducing the lower face prominence associated with the masseter muscle. In another aspect, a method for reducing facial asymmetry is provided. In one embodiment, the method comprises locally administering a Clostridium derivative, such as a botulinum toxin. In another embodiment, the method comprises identifying the area of ​​maximum masseter prominence and administering a dose of the Clostridium derivative by injecting the Clostridium derivative into multiple injection sites in the area. In yet another embodiment, the method includes identifying a line extending from the lateral commissure of the mouth to the point where the earlobe meets the face; identifying an area of ​​maximum bulging of the masseter muscle with the jaw clenched; determining a treatment area that (i) includes the area of ​​maximum bulging, (ii) is located at or below the line, (iii) is posterior to the lollar muscle, and (iv) is anterior to the parotid gland; and administering a Clostridium derivative to multiple administration sites in the treatment area to administer a dose of the Clostridium derivative. The method can be performed unilaterally or bilaterally.

[0023] The method comprises administering a therapeutically effective amount of a Clostridium derivative to a treatment area in the masseter muscle of a subject. One way of identifying the treatment area is to identify the area of ​​maximum masseter muscle bulge. In this embodiment, the area of ​​maximum masseter muscle bulge corresponds to the treatment area. The area of ​​maximum masseter muscle bulge is identified, for example, by the subject clenching the jaw. Typically, the subject clenches the jaw to the maximum (mouth closed, teeth together) to make the masseter muscle more visible. In addition to or rather than visually inspecting the maximum masseter muscle bulge, the maximum masseter muscle bulge can be identified or confirmed by manually palpating the masseter muscle to check for the maximum masseter muscle bulge. Another approach to identifying the treatment area is shown in FIG. 1, which is a schematic side view of a human face 10. In this embodiment, the treatment area is determined by identifying a line extending from the corner of the mouth, also called the lateral commissure 12, to the point 14 where the earlobe meets the face. This line is identified in FIG. 1 as line A. Identifying the area of ​​maximum masseter muscle bulge is done in one approach by asking the subject to clench their jaw. Typically, the subject will clench their jaw to the maximum (mouth closed, teeth together) to make the masseter muscle more visible. In addition to, or rather than visually inspecting the maximum masseter muscle bulge, the maximum masseter muscle bulge can be identified or confirmed by manually palpating the masseter muscle to check for maximum masseter. A treatment area is defined that includes the area of ​​maximum masseter muscle bulge and is located at or below the line (line A in FIG. 1), posterior to the laughter muscle 16 and anterior to the parotid gland 18. In FIG. 1, this treatment area is indicated by a dashed circle 20. The identified treatment area can be visually marked with a virtual line or physically marked on the skin. In one embodiment, line A is identified and not physically marked, but its location is visualized. In another embodiment, line A is identified and physically marked on the skin. The same technique can be applied to the laughter muscles, bulging area, parotid gland, and treatment area, each of which can be visually marked with a virtual line or physically marked on the skin.

[0024] Once the treatment area is identified, a Clostridium derivative, such as a botulinum toxin, is administered. In one embodiment, the Clostridium derivative is administered to a single administration site in the treatment area, and in another embodiment, to multiple administration sites in the treatment area. The multiple administration sites can range from 2-10, 2-9, 2-8, 2-7, 2-6, 2-5, 2-4, 2-3, 3-10, 3-9, 3-8, 3-7, 3-6, 3-5, or 3-4. In one embodiment, the number of multiple administration sites is 2, 3, 4, 5, 6, 7, 8, 9, or 10. The administration sites are spaced apart from one another evenly or unevenly. In one embodiment, at least one of the multiple administration sites is spaced apart from an adjacent site of the multiple administration sites by about 0.5 cm, 0.75 cm, or 1 cm. In another embodiment, each administration site of the plurality of administration sites is spaced about 0.5 cm, 0.75 cm, or 1 cm from any adjacent administration site. In another embodiment, each administration site of the plurality of administration sites is spaced about 0.5 cm, 0.75 cm, or 1 cm from any adjacent administration site. When the Clostridium derivative is administered by injection, the administration site is referred to as an injection site. The pattern or arrangement of the administration sites may vary, especially when there are more than one administration site. For example, in one embodiment, the largest point of the masseter muscle or the largest bulge of the masseter muscle is identified and designated as the first administration site; the next or further administration sites are located relative to the first administration site. The multiple administration sites may form a triangle or an inverted triangle in the treatment area. The multiple administration sites may form a line, in one embodiment, the administration sites are along a line that runs in one direction from the jawline. In another embodiment, the administration sites are along a line that runs in one direction from the shoulder to the eyelid. In one embodiment, the administration sites are evenly spaced and spread across the treatment area. It is understood that administration can be unilateral (to one masseter muscle) or bilateral (to the masseter muscles on each side of the face).

[0025] The Clostridium derivative can be administered by injection, transdermal, topical or implantation. Exemplary implants include implanting a sustained release device, such as a polymeric implant or a mini-osmotic pump, that releases the Clostridium derivative. When administered by injection, the injection can be intramuscular, non-intramuscular, intradermal or subcutaneous. In one embodiment, the needle position of the injection is perpendicular to the deepest part of the masseter muscle. That is, the direction of the needle in the muscle is perpendicular, not oblique, and the injection volume is distributed to the deeper and more superficial muscle layers. Without being limited to theory, administration by injection with a needle oriented perpendicular to the muscle ensures delivery of the toxin to the masseter muscle. In another embodiment, the needle position is selected to distribute the dose administered at a given injection site to the superficial muscles and / or tissues as well as the deeper muscle layers. Without being limited to theory, distribution of the dose to the superficial muscles and / or tissues as well as the deeper muscle layers is beneficial to distribute the toxin evenly to the various muscle layers. In another embodiment, the Clostridium derivative is administered with the jaw relaxed. In one embodiment, each masseter muscle is treated by administering a dose of botulinum toxin to multiple injection sites in each muscle, each of the multiple injection sites being spaced at least about 0.25 cm, 0.30 cm, 0.35 cm, 0.40 cm, 0.45 cm, 0.50 cm, 0.55 cm, 0.60 cm, 0.65 cm, 0.70 cm, 0.75 cm, 0.80 cm, 0.85 cm, 0.90 cm, 0.95 cm, 1.0 cm, 1.25 cm, 1.50 cm, or 2.0 cm apart from adjacent injection sites. In another embodiment, each of the multiple injection sites is spaced about 0.25-1.5 cm, 0.25-1.10 cm, 0.35-1.5 cm, 0.35-1.10 cm, 0.45-1.5 cm, 0.45-1.10 cm, 0.50-1.50 cm, 0.50-1.10 cm, 0.75-1.5 cm, 0.75-1.10 cm, 0.80-1.5 cm, or 0.90-1.10 cm from an adjacent injection site. In one embodiment, each injection site is spaced about 1 cm from an adjacent site. Without being limited by theory, optimal spacing is beneficial for uniform, continuous distribution of the total dose throughout the treatment area to produce the intended results. If injection sites are located too far from adjacent injection sites, the dose administered to each injection site will affect different parts of the muscle, resulting in uneven toxin distribution in the treatment area, creating a lumpy or swollen appearance. Injection sites spaced too closely together will also result in uneven toxin distribution in the treatment area.

[0026] In some embodiments, the method comprises determining masseteric ridge or reviewing the determination of masseteric ridge.There are various techniques for determining masseteric ridge, such as computed tomography (CT), cone-beam computed tomography (CBCT), magnetic resonance imaging (MRI), ultrasound, questionnaire, three-dimensional quantitative analysis of facial morphology, such as based on image subtraction technique, moire topography, liquid crystal scanning, luminance scanning, laser scanning, stereolithography, or passive stereophotogrammetry.As an example, for the study described in Example 1, the volume of the lower face is measured using a three-dimensional imaging system and CT. Another technique for determining the masseteric prominence, including the lower facial width, is to measure where the lower facial width, lines A, B, and C, are drawn on a frontal facial image. Line A corresponds to the facial width at the height of the stomion, which is the point on the midline at the junction of the upper and lower vermilion borders. Line B corresponds to the alar base width, defined as the distance between the left and right nostrils, not the junction of the left and right alar grooves. Line C corresponds to the distance between the right and left medial canthus. The medial canthus distance (C) and alar base width (B) are expected to remain constant over the course of the study and not be affected by the study treatment. The facial width (A) is calculated for the subject, as well as the ratio of the alar base width to the facial width (B / A) and the medial canthus width to the facial width (C / A). Another technique is the mandibular angle, which can be calculated by averaging the left and right angles and rounding to the nearest whole number. The mandibular facial angle is (1) the angle between an oblique line 1 drawn on the horizontal part of the jawline and another oblique line 2 drawn from the lateral most aspect of the cheek to the angle of the mandible, showing the plane contour of the face containing the vertical ramus. Lines 1 and 2 meet at the apex of the angle of the mandible, and the mandibular angle is considered to be the internal angle between lines 1 and 2.

[0027] In a preferred embodiment, the masseteric prominence is assessed before, during or after treatment using a questionnaire. The questionnaire may be completed by the subject seeking or undergoing treatment, or by a third party, such as an individual administering the treatment or assessment. Examples of questionnaires include the Lower Facial Shape Classification (LFSC); the Lower Facial Morphology Questionnaire (LFSQ); or the Masseteric Prominence Scale (MMPS). The LFSC is a 4-point scale designed for assessors or subjects to judge the lower face morphology of the subject. The scale and lower face morphology descriptors associated with each grade are shown in Table 1. [Table 1] The LFSQ obtains (1) a symptom rating; (2) an impact rating; (3) a satisfaction rating; or (4) a combination of these. The questionnaire seeks to determine the subject's view of efficacy, as well as any side effects from the treatment. The questionnaire presents seven questions for the subject to consider and respond to regarding the lower face. When answering the questions, responders are asked to consider only the lower face, i.e., the lower half of the face from the top of the cheeks to the chin. The questions in the LFSQ are shown in Figures 7A-7B.

[0028] The MMPS provides a method for assessing masseteric prominence at rest and during maximum contraction (full clenching) by evaluating the right and left sides of the subject's face separately using a ranking scale of 1 to 5. In this assessment, masseteric prominence is identified by visually inspecting the masseter muscles, palpating the masseter muscles, or both. The visual inspection involves examining the subject's facial contours in clenched and non-clenched states, defining the posterior and anterior borders and the upper and lower borders of each masseter muscle, and ranking the prominence of the masseter muscles using a scale such as that shown in Table 2. Palpative examination included examining the size and surface texture of each masseter muscle while the subject clenched and relaxed, identifying the posterior and anterior as well as the upper and lower edges of each masseter muscle, distinguishing the master muscles from bone and other non-muscle soft tissues (e.g., fat) while the subject clenched and relaxed, and ranking the prominence of the masseter muscles using a scale such as that shown in Table 2. [Table 2]

[0029] In some embodiments, the MMPS is used to select subjects with square faces for treatment with Clostridium derivatives. Square faces can be due to osteogenic hypertrophy, or soft tissue-derived hypertrophy including muscle hypertrophy, parotid gland enlargement, and fat deposits, or a combination thereof. Osteogenic hypertrophy results in a square face and prominent mandibular angle. Osteogenic hypertrophy cannot be treated by administering Clostridium derivatives. In some embodiments, the MMPS is used to select subjects with MMH from subjects with osteogenic hypertrophy. A study was conducted as described in Example 1 using MMPS to identify subjects with significant (grade 4) or very significant (grade 5) MMH for treatment with Clostridium derivative. For this study and to validate the MMPS, subjects' lower facial volumes were also measured using imaging methods (see Materials and Methods below). Botulinum toxin was used as an example of a Clostridium derivative, and it should be understood that other Clostridium derivatives described below are suitable for this method. In the study of Example 1, subjects with significant or very significant MMH were identified by MMPS for treatment with a total dose of 24 units, 48 ​​units, 72 units, or 96 units of botulinum toxin on both sides (see Table 1-1 in Example 1). Subjects were 18 years of age or older. The dose was split evenly into two for intramuscular injection into each masseter muscle on both sides. Three injections were given to each masseter muscle for a total of six injections for both sides of the treatment. For example, each subject in cohort 1 was treated with a total dose of 24 units, and the total dose was split evenly for both sides of the treatment, with 12 units given to each masseter muscle. The 12 unit dose for each masseter muscle was divided equally into 3 injection sites per masseter muscle. Each subject in cohort 4 was treated with a total dose of 96 units, and the total dose was divided equally for treatment of both sides, with 48 units for each masseter muscle. The 48 unit dose for each masseter muscle was divided equally into 3 injection sites per masseter muscle. The 3 injection sites for each masseter muscle were located on or below the line that runs from the lateral commissure of the mouth to the point where the earlobe meets the face, including the area of ​​the maximum masseter muscle bulge, posterior to the laughter muscle, and anterior to the parotid gland, within the treatment area.

[0030] After one year of treatment with the indicated dose, each subject was evaluated monthly. At each monthly visit, lower face volumes (cm) were measured using a three-dimensional imaging system. 3 ) were calculated and entered into the MMPS. With reference to Figures 2A-2B, the volumetric changes in the lower face are shown 90 days after treatment (Figure 2A) and monthly over the 180-day evaluation period (Figure 2B). Figure 2A shows the volumetric changes in the lower face (cm) 90 days after treatment of the masseter muscles with the indicated doses of botulinum toxin. 3 2A and 2B are bar graphs showing the least squares mean (LSMean) change in facial volume (cm) at day 90 relative to pre-treatment lower facial volume (baseline), where lower facial volume is calculated using a three-dimensional imaging system. There was a significant reduction in facial volume at day 90 compared to the placebo group, and the reduction in facial volume in the 48 unit dose group was statistically significantly greater compared to the group treated with 24 units. Figure 2B shows the facial volume change at each monthly assessment over the one-year post-treatment period. Lower facial volume (cm) 3 Least squares mean (LSMean) changes in facial volume, facial contour, and facial features (FVC) decreased for at least 6 months after treatment in all treatment groups (24 units (circles), 48 units (squares), 72 units (triangles), and 96 units (diamonds) (p ≤ 0.05). Volumetric changes in the lower face as determined by 3-dimensional imaging VECTRA were confirmed by CT evaluation. Study subjects in Example 1 completed the MMPS at monthly evaluations. Prior to treatment, study subjects were assessed using the MMPS to have masseter muscle prominences of grade 4 (significant) or grade 5 (very significant). Figure 3A shows the percentage of subjects in each treatment dose cohort who were ranked grade 3 or less by clinician assessment of the subjects using the MMPS. Figure 3B shows the percentage of subjects in each treatment dose cohort who had a change in ranking of grade 2 or more by clinician assessment using the MMPS. Statistically significant responses were observed for subjects treated with bilateral total botulinum toxin doses of 48 units (squares), 72 units (triangles), and 96 units (diamonds) for 180 days after treatment. Notably, a bilateral total botulinum toxin dose of 72 units (unilateral dose of 36 units) resulted in a greater number of subjects with an MMPS grade of 3 or less at day 120 ( Fig. 3A ) and a greater number of subjects with an MMPS grade change of 2 or more than the number of subjects treated with the higher bilateral dose of 96 units (unilateral dose of 48 units) ( Fig. 3B ).

[0031] With reference to Figures 4A-4B, the MMPS assessments are shown 90 days after treatment. Figure 4A shows the percentage of subjects in each treatment dose cohort who were ranked Grade 3 or less by the MMPS after 90 days of treatment with bilateral botulinum toxin doses at the doses indicated. Figure 4B shows the percentage of subjects in each treatment dose cohort who had a change in ranking of 2 or more by the MMPS after 90 days of treatment with bilateral botulinum toxin doses at the doses indicated. The difference in response with the 48 unit bilateral dose and the 72 unit bilateral dose was statistically significant for responders who had a change in MMPS ranking of 2 or more. The high efficacy of bilateral treatment doses of greater than 48 units (24 units per side) and less than about 96 units (48 units per side) can be seen in Figure 5, which is a bar graph showing the duration of efficacy in subjects in each treatment dose cohort who had a change in rank of 2 or greater by MMPS after treatment with bilateral botulinum toxin doses of 24 units, 48 ​​units, 72 units, and 96 units. Subjects treated with a bilateral dose of 72 units (unilateral dose of 36 units) had a longer duration of efficacy than the bilateral dose of 48 units and the bilateral dose of 96 units.

[0032] As described in Example 2, subjects enrolled in the study of Example 1 were eligible for a second treatment (retreatment) if they had significant (Grade 4) or very significant (Grade 5) bilateral masseteric hypertrophy based on clinician assessment using the MMPS on Day 180 (180 days after the first dose at the indicated dose in Example 1). Subjects eligible for retreatment received a second treatment at the Day 180 visit at the same dose level and in the same treatment location as at the start of the study (Day 1). Retreatment subjects were evaluated every month for 180 days and lower facial volumes (cm2) were measured using a 3D imaging system. 3 The results are shown in Figure 6. Lower face volume (cm ) as a function of time after treatment with botulinum toxin in the masseter muscles 3 The least squares mean (LSMean) change in ) is shown in Figure 6. The arrow TX1 points to the first treatment with botulinum toxin (Example 1) and the arrow TX2 points to the second treatment with botulinum toxin (Example 2). The second treatment significantly reduced the lower face volume in this patient group. The studies in Examples 1 and 2 demonstrate that administration of a Clostridium derivative unilaterally or bilaterally to subjects with MMH reduces the volume of the lower face for at least about 90 days or at least about 180 days compared to untreated MMH subjects. Treatment of MMH with a Clostridium derivative botulinum toxin reduces the lower face width in the masseter region, reduces the masseteric prominence, and reduces the lower face prominence or width temporarily by causing a non-permanent, temporary reduction in the volume of the lower face. In this context, "temporary" is intended to be non-permanent, and in one embodiment, is at least about 60 days, at least about 90 days, at least about 120 days, or at least about 180 days, or at least about 270 days, or at least about 360 days. The study in Example 2 demonstrates that in subjects with a pronounced or very pronounced masseteric prominence by MMPS, a second treatment causes a reduction in volume, and a bilateral dose of more than 48 units and up to 96 units improves MMH severity by at least 2 grades when assessed using the MMPS. From this study, subjects treated with a first bilateral dose of 72 units showed a longer duration and more pronounced effect than subjects treated with a bilateral dose of 96 units.

[0033] The studies in Examples 1 and 2 also demonstrate that treatment in accordance with the methods described herein does not appear to have any effect on the subjects' dental status and / or bone density, as determined by CT scans and dental examinations. As mentioned above, the studies in Examples 1 and 2 were carried out using botulinum toxin as a model Clostridium derivative. It is understood that other Clostridium derivatives are contemplated and suitable. In some embodiments, the Clostridium derivatives that can be used in the methods include wild-type recombinant Clostridium toxins, recombinant modified toxins, fragments thereof, TEMs, or combinations thereof. One example of a Clostridium derivative is a botulinum toxin. Botulinum neurotoxins (BoNTs), such as BoNT / A and BoNT / B, act on the nervous system by blocking the release of neurosecretory substances, such as neurotransmitters. The action of BoNT begins by binding to receptor molecules at the cell surface, after which the toxin-receptor complex undergoes endocytosis. Once inside the cell, BoNT cleaves exocytosis-specific proteins, known as SNARE proteins (soluble N-ethylmaleimide-sensitive factor attachment protein receptors), which are responsible for the docking and release of neurotransmitters from the cell. The resulting transient chemical denervation has medical applications, blocking motor neuron transmission at the neuromuscular junction, leading to a variety of therapeutic applications.

[0034] The botulinum toxin may be a type A, B, C1, D, E, F, or G, H, X botulinum toxin, as well as mosaic botulinum toxins and / or subtypes and variants thereof. The botulinum neurotoxin may be a recombinantly produced botulinum neurotoxin, such as a botulinum toxin produced by E. coli. In an alternative embodiment, the Clostridium derivative is a TEM. The botulinum neurotoxin may be a modified neurotoxin, i.e., a botulinum neurotoxin in which at least one of its amino acids has been deleted, modified or substituted compared to the wild-type toxin, or the modified botulinum neurotoxin may be a recombinantly produced botulinum neurotoxin or a derivative or fragment thereof. In one embodiment, the modified toxin has altered cell targeting ability to a neuronal or non-neuronal cell of interest. This alteration of ability is achieved by replacing the native targeting domain of the botulinum toxin with a targeting domain that exhibits selective binding activity to a non-botulinum toxin receptor present in non-botulinum toxin target cells. Such modifications to the targeting domain result in a modified toxin that can selectively bind to a non-botulinum toxin receptor (target receptor) present in non-botulinum toxin target cells (retargeting). A modified botulinum toxin with targeting activity for non-botulinum toxin target cells can bind to a receptor present in non-botulinum toxin target cells, translocate to the cytoplasm, and exert a proteolytic effect on the SNARE complex of the target cell. In effect, by selecting the appropriate targeting domain, the botulinum toxin light chain, including the enzyme domain, can be delivered intracellularly to any desired cell. Additionally, as used herein, "botulinum toxin" also includes botulinum toxin complexes (eg, the 300, 600 and 900 kDa complexes), as well as the neurotoxic component of a botulinum toxin (150 kDa) that is not associated with a complex protein. Clostridium derivatives such as botulinum toxin can be stored in a container under vacuum pressure, lyophilized, vacuum dried, or as a stable liquid. Prior to lyophilization, the botulinum toxin can be combined with a pharma- ceutically acceptable excipient, stabilizer, and / or carrier, such as, for example, albumin. Acceptable excipients or stabilizers include protein excipients such as albumin or gelatin, or non-protein excipients including poloxamers, sugars, polyethylene glycol, and the like. In embodiments containing albumin, the albumin can be, for example, human serum albumin or recombinant human albumin. The lyophilized material can be reconstituted with a suitable liquid, such as, for example, saline, water, or the like, to create a solution or composition containing the botulinum toxin that is administered to a patient. In some embodiments, the Clostridium derivative is provided in a controlled release system comprising a polymer matrix that encapsulates the Clostridium derivative, and discrete amounts of the Clostridium derivative are controlled-released from the polymer matrix over an extended period of time. Controlled release neurotoxin systems are disclosed, for example, in U.S. Patent Nos. 6,585,993; 6,585,993; 6,306,423 and 6,312,708, each of which is incorporated herein by reference in its entirety.

[0035] The therapeutically effective amount of a Clostridium derivative, such as a botulinum toxin, administered by the present method may vary depending on the potency of the toxin and the extent of masseteric hypertrophy, such as its prominence, and various other patient variables, such as size, weight, age, and response to treatment. The potency of the botulinum toxin was measured using the LD 50 One unit (U) of toxin is defined as the amount of toxin that causes 50% mortality in a group of 18-20 female Swiss Webster mice weighing approximately 20 grams each. In the present method, the therapeutically effective amount of botulinum toxin may vary depending on the potency of the particular botulinum toxin, such that commercially available botulinum toxin preparations do not have equal potency units. For example, one unit of Botox® (onabotulinumA), a botulinum toxin type A available from Allergan, is reported to have approximately equal potency units to 3-5 units of Dysport® (abobotulinumA), a botulinum toxin type A available from Ipsen. Myoblock®, a botulinum toxin type B available from Elan, has a much lower potency unit compared to Botox®. In some embodiments, the botulinum neurotoxin may be a pure toxin without complexing proteins, such as Zeomaine® (incobotulinumtoxinA). One unit of incobotulinumtoxinA is reported to have approximately equal potency to one unit of onabotulinumtoxinA. Thus, the amount of toxin administered and the frequency of administration will be up to the treating physician and will be commensurate with the safety issues and effects produced by the particular toxin formulation.

[0036] Dosages used in the methods disclosed herein range from about 0.01 to about 1,000 units; for example, up to about 500 units, preferably from about 10 to about 460 units per patient per treatment. More specifically, in light of the results of Examples 1 and 2, a therapeutically effective amount of botulinum toxin type A, such as Botox®, is administered to the masseter muscle. In some embodiments, the therapeutically effective amount ranges from about 1 unit / masseter muscle to about 200 units / masseter muscle. In other embodiments, the therapeutically effective amount administered to each masseter muscle is about 5-100 units, 5-50 units, or 10-50 units. In one embodiment, the dose administered to each masseter muscle is greater than or equal to 24 units and less than or equal to 48 units, and in a particular embodiment, the dose administered to each masseter muscle is 36 units. In other embodiments, the dose for treatment administered to each masseter muscle is 1 unit, 2 units, 3 units, 4 units, 5 units, 6 units, 7 units, 8 units, 9 units, 10 units, 11 units, 12 units, 13 units, 14 units, 15 units, 16 units, 17 units, 18 units, 19 units, 20 units, 21 units, 22 units, 23 units, 24 units, 25 units, 26 units, 27 units, 28 units, 29 units, 30 units, 31 units, 32 units, 33 units, 34 units, 35 units, 36 units, 37 units, 38 units, 39 units, 40 units, 41 units, 42 units, 43 units, 44 units, 45 units, 46 units, 47 units, 48 ​​units, 49 units, 50 units, 51 units, 52 units, 53 units, 54 units, 55 units, 56 units, 57 units, 58 units, 59 units, 60 units, 61 units, 62 units, 63 units, 64 units, 65 units, 66 units, 67 units, 68 units, 69 units, 70 units, 71 units, 72 units, 73 units, 74 units, 75 units, 76 units, 77 units, 78 units, 79 units, 80 units, 81 units, 82 units, 83 units, 84 units, 85 units, 86 units, 87 units, 88 units, 89 units, 89 units, 90 units, 91 units, 92 units, 93 units, 94 units, 95 units, 96 units, 97 units, 98 units, 99 units, 100 5, 6, 7, 8, 9, 10, 11, 12, 13, 14, 15, 16, 17, 18, 19, 20, 21, 22, 23, 24, 25, 26, 27, 28, 29, 30, 31, 32, 33, 34, 35, 36, 37, 38, 39, 40, 41, 42, 43, 44, 45, 46, 47, 48, 49, 50, 51, 52, 53, 54, 55, 56, 57, 58, 59, 60, 61, 62, 63, 64, 65, 66, 67, 68, 69, 70, 71, 72, 73, 74, 375, 76, 77, 78, 79, 80, 81, 82, 83, 84, 85, 86, 87, 88, 89, 90, 91, 92, 93, 94, 95, 96, 97, 98, 99, 100, 101, 102, 103, 104, 105, 106, 107, 108, 109, or 110 units. The volume of the administered dose varies depending on the formulation. Typical volume ranges are 0.1-5 mL, more specifically 0.1-4 mL, 0.2-4 mL, 0.2-2 mL, 0.3-4 mL, 0.3-2 mL, 0.3-1.5 mL, and 0.3-1.2 mL per treatment area. In one embodiment, the volume per injection is about 0.05-1 mL, 0.05-0.8 mL, 0.05-0.6 mL, 0.1-2 mL, 0.1-1.5 mL, 0.1-1.0 mL, 0.1-0.8 mL, 0.1-0.7 mL, 0.1-0.6 mL, 0.1-0.5 mL, and 0.1-0.4 mL.

[0037] It is understood that subjects treated in accordance with the methods described herein can be evaluated after treatment to ascertain the efficacy and safety of the treatment. The therapeutically effective amount or dose of the Clostridium derivative can be modified depending on the efficacy and safety evaluation. In one embodiment, the efficacy evaluation corresponds to a change in the ranking of masseteric protuberance using MMPS. In some embodiments, the safety evaluation includes evaluation of side effects such as chewing problems, injection site pain, facial paralysis, headache, etc. In some embodiments, the safety evaluation further includes determining whether the treatment methods described herein have any effect on the condition of the mandible and / or teeth of the subject. In some embodiments, the effect on the mandible is evaluated by CT. In some other embodiments, the effect on the condition of the teeth is evaluated by dental examination. In some embodiments, the determining step is performed about 1 month to about 6 months after the MMH treatment.The MMH treatment may be repeated, taking into account the change in muscle volume determined during the determining step.The therapeutically effective amount of the Clostridium derivative for the next treatment may be determined, taking into account the change in muscle volume determined during the determining step. In some embodiments, the method further comprises administering a second treatment to patients or subjects with bilateral masseteric hypertrophy that is marked (Grade 4) or very marked (Grade 5) by MMPS. In alternative embodiments, the method comprises assessing the subject's lower facial morphology using the LFSC as described herein and identifying patients or subjects with a wide, angular jawline (Grade 3) or a trapezoidal, wide, protruding jawline (Grade 4) for subsequent treatment. The MMPS can be used to determine the effectiveness of MMH treatment according to the method. In some embodiments, the method includes ranking the masseteric prominence of the subject before and after treatment, identifying subjects whose MMPS grade is reduced by 1 or more from their baseline grade, and classifying subjects whose MMPS grade is reduced by 1 or more from their baseline grade as positive responders to treatment. In an alternative embodiment, the method includes classifying the lower facial morphology of the subject using a 4-point scale LFSC before and after MMH treatment, identifying subjects whose LFSC grade is reduced by 1 or more from their baseline grade, and classifying subjects whose LFSC grade is reduced by 1 or more from their baseline grade as positive responders to treatment.

[0038] In other embodiments, the present disclosure provides a method for treating MMH. In some embodiments, the method includes using one or more criteria described herein to select a subject for MMH treatment, administering a therapeutically effective amount of a Clostridium derivative to the subject, determining the effectiveness of the MMH treatment using one or more efficacy criteria described herein, and re-administering a second therapeutically effective amount of a Clostridium derivative to the subject. In one embodiment, the selection step includes ranking the subject's masseteric protuberance using the MMPS. In some other embodiments, the selection step further includes classifying the subject's lower facial morphology using the Lower Facial Morphology Classification Scale, obtaining the subject's own assessment of lower facial morphology using the LFSQ, or a combination thereof.

[0039] Parts Kits In another aspect, a kit of parts is provided. In one embodiment, the kit includes a botulinum toxin and instructions for administering the botulinum toxin to a muscle for the treatment of masseteric hypertrophy, and optionally an MMPS scale and / or instructions for identifying a subject for treatment using the MMPS. In another aspect, a kit of parts is provided that includes: a) a botulinum toxin in an amount of about 5-100 units; and b) instructions for administering the botulinum toxin to a muscle for the treatment of masseteric hypertrophy, where the botulinum toxin is administered to the masseter muscle of a subject suffering from masseteric hypertrophy. In one embodiment, the amount of botulinum toxin is about 10-50 units or 20-100 units, preferably about 12-48 units or 24-96 units, more preferably about 24-36 units or 48-72 units. In a specific embodiment, the amount of botulinum toxin is 12 units, 24 units, 36 units, 48 ​​units, 72 units, or 96 units. In one embodiment, the botulinum toxin is packaged in several portions. In another aspect, a kit of parts is provided that includes a) a botulinum toxin in an amount of about 5-100 units, and b) instructions for administering the botulinum toxin to a muscle to reduce the lower facial width in the masseter region, by: i) identifying the area of ​​maximum masseter bulge; and ii) injecting the botulinum toxin into multiple injection sites in the area to administer a dose of the botulinum toxin that reduces the lower facial width in the masseter region. In one embodiment, the amount of botulinum toxin is about 10-50 units or 20-100 units, preferably about 12-48 units or 24-96 units, more preferably about 24-36 units or 48-72 units. In a specific embodiment, the amount of botulinum toxin is 12 units, 24 units, 36 units, 48 ​​units, 72 units, or 96 units. In one embodiment, the botulinum toxin is packaged in several portions, for example 3-5 portions. In one embodiment, the botulinum toxin is botulinum toxin type A. In one embodiment, the kit of parts further comprises instructions to score or review the score of the subject using the Masseter Muscle Prominence Scale (MMPS) prior to identifying the area of ​​maximum masseter bulge, instructions to identify the area of ​​maximum masseter bulge, and / or instructions to repeat the identification and injection in the opposite masseter muscle.

[0040] In another aspect, a kit of parts is provided that includes: a) a botulinum toxin in an amount of about 5-100 units; and b) instructions for administering the botulinum toxin to a muscle to reduce masseteric prominence in a human, comprising: i) identifying the area of ​​maximum masseteric bulge when the jaw is clenched; and ii) administering a dose of the botulinum toxin to multiple sites in the masseteric region that reduces masseteric prominence when the jaw is relaxed. In one embodiment, the amount of botulinum toxin is about 10-50 units or 20-100 units, preferably about 12-48 units or 24-96 units, more preferably about 24-36 units or 48-72 units. In a specific embodiment, the amount of botulinum toxin is 12 units, 24 units, 36 units, 48 ​​units, 72 units, or 96 units. In one embodiment, the botulinum toxin is a type A botulinum toxin. In one embodiment, the botulinum toxin is packaged in several, preferably 2-5, and more preferably 3, packages. In another aspect, a kit of parts is provided that includes: a) a botulinum toxin in an amount of about 5-100 units; and b) instructions for administering the botulinum toxin to a muscle to temporarily reduce lower facial projection or width associated with masseteric prominence, comprising: i) identifying a line extending from the lateral commissure of the mouth to the point where the earlobe meets the face; ii) identifying an area of ​​maximum masseteric bulge with the jaw clenched; iii) determining a treatment area that includes the area of ​​maximum bulge and is located on or below the line, posterior to the laughter muscle and anterior to the parotid gland; and iv) injecting the botulinum toxin into multiple injection sites in the treatment area to administer a dose of the botulinum toxin that reduces lower facial projection or width. In one embodiment, the amount of the botulinum toxin is about 10-50 units or 20-100 units, preferably about 12-48 units or 24-96 units, more preferably about 24-36 units or 48-72 units. In specific embodiments, the amount of botulinum toxin is 12 units, 24 units, 36 units, 48 ​​units, 72 units, or 96 units. In one embodiment, the botulinum toxin is packaged in several portions, preferably 2-5 portions, more preferably 3 portions. In one embodiment, the botulinum toxin is a botulinum toxin type A. In one embodiment, the kit of parts further includes instructions for assessing or reviewing the subject using the Masseter Muscle Prominence Scale (MMPS), and the subject is ranked as marked or very marked on the MMPS.

[0041] In another aspect, a kit of parts is provided that includes: a) a botulinum toxin in an amount of about 5-100 units; and b) instructions for administering the botulinum toxin to muscles to alter the contours of a human's lower face, comprising: i) identifying a line extending from the lateral commissure of the mouth to the point where the earlobe meets the face; ii) identifying an area of ​​maximum bulge of the masseter muscle with the jaw clenched; iii) determining a treatment area that includes the area of ​​maximum bulge and is located at or below the line, posterior to the laughter muscle and anterior to the parotid gland; and iv) injecting the botulinum toxin into multiple injection sites in the treatment area to administer a dose of the botulinum toxin that reduces lower face projection or width. In one embodiment, the amount of botulinum toxin is about 10-50 units or 20-100 units, preferably about 12-48 units or 24-96 units, more preferably about 24-36 units or 48-72 units. In specific embodiments, the amount of botulinum toxin is 12 units, 24 units, 36 units, 48 ​​units, 72 units, or 96 units. In one embodiment, the botulinum toxin is packaged in several portions, preferably 2-5 portions, more preferably 3 portions. In one embodiment, the botulinum toxin is a botulinum toxin type A. In another aspect, a kit of parts is provided, comprising: a) a botulinum toxin in an amount of about 5-100 units; and b) instructions for administering the botulinum toxin to a muscle to shape or reshape the human lower face in the masseter region. In one embodiment, the amount of botulinum toxin is about 10-50 units or 20-100 units, preferably about 12-48 units or 24-96 units, more preferably about 24-36 units or 48-72 units. In specific embodiments, the amount of botulinum toxin is 12 units, 24 units, 36 units, 48 ​​units, 72 units, or 96 units. In one embodiment, the botulinum toxin is packaged in several packages, preferably 2 to 5 packages, more preferably 3 packages. In one embodiment, the botulinum toxin is a botulinum toxin type A. EXAMPLES

[0042] The following non-limiting examples provide those of skill in the art with specific and preferred methods of treating conditions within the scope of the present invention and are not intended to limit the scope of the invention. Materials and Methods: Computed tomography was used to quantify the lower face volume. The selected area of ​​measurement was created by the perimeter (CFDE) formed by the anatomical landmarks: lateral canthus (A), alar recess (B), earlobe attachment (C), prejowl sulcus (D), and mandibular point (E). One intercalary landmark (F) was also used at the intersection of the surface lines between points (A)-(D) and (B)-(C). The volumetric difference of the lower face in two 3D surface models of the same subject, for example at baseline (pretreatment) and different time points after treatment, was used to determine the volumetric changes of the face. The lower face volume was the sum of the left and right sides of the face and was compared for each baseline / posttreatment pair of the study. The lower face volume was performed using a VECTRA M3 3D Stereo Photogrammetry System digital photography system (Canfield Scientific, Fairfield, NJ, USA). Volumetric changes in the lower face quantified by VECTRA were also confirmed by CT evaluation.

[0043] Example 1 Treatment of MMH A placebo-controlled, double-blind, randomized study was conducted to evaluate the efficacy and safety of a range of doses of botulinum toxin type A for treating subjects with masseteric hypertrophy (MMH). The Masseter Muscle Prominence Scale (MMPS) and digital photography were used to qualify potential subjects for treatment and to determine lower facial volume. Subjects ranked as having grade 4 "significant" or grade 5 "very significant" MMH were enrolled in the study. One hundred and eighty-seven subjects were enrolled and randomized into four treatment cohorts for treatment with botulinum toxin type A (Botox®) at the doses listed in Table 1-1. [Table 3]

[0044] The total dose prescribed was administered intramuscularly to each masseter muscle of each subject in each cohort. Three injections were administered to each masseter muscle, for a total of six injections for both sides of the treatment. For example, each subject in cohort 1 was treated with a total dose of 24 units, with the total dose divided equally between both sides of the treatment, and 12 units were administered to each masseter muscle. The 12 unit dose for each masseter muscle was equally divided into three injection sites per masseter muscle. Each subject in cohort 4 was treated with a total dose of 96 units, with the total dose divided equally between both sides of the treatment, and 48 units were used for each masseter muscle. The 48 unit dose for each masseter muscle was equally divided into three injection sites per masseter muscle. The three injection sites for each masseter muscle were located on or below a line extending from the lateral commissure of the mouth to the point where the earlobe meets the face, and were within the treatment area that included the area of ​​the maximum masseter bulge, posterior to the laughter muscle, and anterior to the parotid gland. Each subject was evaluated monthly for one year after treatment. Of the 187 subjects enrolled, 167 completed the one-year study. Of the 20 patients who did not complete the study, the majority (13 / 20) discontinued for personal reasons. Only one discontinuation was due to an adverse event in one subject in the placebo group. At each monthly visit, lower facial volumes (cm 3) was calculated with a three-dimensional imaging system (VECTRA M3, Canfield Scientific). The results are shown in Figures 2-5. Briefly, lower face volumes were significantly reduced in all dose groups versus placebo at 90 days (p<0.001), and significant volume reductions (p<0.05) were maintained for at least 6 months after two treatments with 48U, 72U, or 96U, respectively. Lower face volume changes quantified by VECTRA were confirmed by CT evaluation. The proportion of MMPS grades 3 and ≥2 grades change or responders at 90 days was significant for all dose groups versus placebo (p<0.001). Significant differences (p<0.05) were maintained at all time points with 48U, 72U, or 96U doses over 180 days compared to placebo. Reductions in MMH severity were sustained over 9 months after a single dose of 72U or 96U. The most frequent treatment-related side effect was chewing disturbance (Botox 5.3%, placebo 2.7%), reported mainly as mild reduced chewing. Treatment was well tolerated, with no clinically relevant correlation between side effect rate and dose. No abnormal clinically relevant changes were observed by CT scan or dental examination.

[0045] Example 2 Treatment of MMH Subjects enrolled in the study of Example 1 were evaluated on Day 180 of the study and were eligible for a second treatment (retreatment) if the subject had significant (Grade 4) or very significant (Grade 5) bilateral masseteric hypertrophy based on clinician assessment using the MMPS. For subjects eligible for retreatment, the second treatment was administered at the Day 180 visit at the same dose level as at the start of the study (Day 1). Subjects undergoing retreatment were evaluated every other month for 180 days to measure lower facial volumes (cm) using a three-dimensional imaging system (VECTRA M3, Canfield Scientific). 3 The volumetric changes in the lower face quantified by VECTRA were confirmed by CT evaluation. The results are shown in Figure 6.

[0046] Those skilled in the art can make many changes and modifications without departing from the spirit and scope of the present disclosure. Therefore, it should be understood that the described embodiments are set forth for illustrative purposes only, and that these embodiments are not to be considered as limiting the scope of the following claims. Therefore, the following claims should be construed to include not only the combinations of elements literally recited, but also all equivalent elements for performing substantially the same function in substantially the same way to obtain substantially the same results. Thus, the claims should be understood to include those described above, those that are conceptually equivalent, and those that incorporate the ideas of the present disclosure.

Claims

1. 1. A method for reducing lower face width in the masseter region, comprising: Identifying an area of ​​maximum bulge of the masseter muscle; injecting botulinum toxin into multiple injection sites in said area to administer a dose of botulinum toxin that reduces lower facial width in said masseter region; The method includes:

2. The method of claim 1 , wherein said identifying and said injecting are performed bilaterally.

3. 10. The method of claim 1, further comprising repeating said identifying and said injecting in the opposing masseter muscle.

4. 4. The method of any one of claims 1 to 3, wherein the injection comprises injecting a dose of botulinum toxin in a range selected from the group of about 5 to 100 units, about 15 to 60 units, about 25 to 47 units, and about 30 to 40 units for each of the muscles to be treated, or wherein the dose is about 36 units for each of the muscles to be treated.

5. The method of any one of claims 1 to 3, wherein the injection comprises injecting a dose of botulinum toxin that is about 24 to 72 units.

6. The method of any one of claims 1 to 5, wherein the multiple injection sites are 3 to 5.

7. 7. The method of any one of claims 1 to 6, wherein a portion of the dose is administered to each injection site of the multiple injection sites, the portion being equal to the dose divided by the number of injection sites of the multiple injection sites.

8. The method according to any one of claims 1 to 7, further comprising assessing or reviewing the assessment of the subject using the Masseter Muscle Prominence Scale (MMPS) prior to said identification.

9. 9. The method of claim 8, wherein the assessment or review ranks the subject as marked or very marked on the MMPS.

10. The method of claim 8, wherein the assessment or review is performed to evaluate the effectiveness of a previous treatment.

11. The method according to any one of claims 1 to 9, which is a cosmetic method for reducing the lower face width in the masseter region.

12. 1. A method of reducing masseteric prominence in a human, comprising administering to the masseteric region a dose of botulinum toxin that reduces the masseteric prominence, the dose is administered at multiple sites in the masseter muscle region; said area being identified as the area of ​​maximum bulge of said masseter muscle when the jaw is clenched; wherein the dose is administered with the jaw relaxed.

13. The method of claim 12, wherein the administration is performed bilaterally.

14. 13. The method of claim 12, wherein said administering comprises administering a dose of about 5-100 units, about 15-60 units, about 25-47 units, about 30-40 units, or about 36 units of botulinum toxin to each of the muscles to be treated.

15. 13. The method of claim 12, further comprising repeating said administration to the opposite masseter muscle of said person.

16. The method of any one of claims 12 to 15, wherein administration is by injection with a needle that is positioned perpendicular to the masseter muscle during injection.

17. The method of any one of claims 12 to 16, wherein the dose is administered to distribute to deep and superficial muscles.

18. 18. The method of any one of claims 12-17, wherein the dose is administered in a volume of about 0.6-2.4 mL.

19. 18. The method of any one of claims 12 to 17, wherein a portion of the dose is administered to each injection site of the plurality of injection sites, and the portion administered to each injection site is not constant.

20. 20. The method of claim 19, wherein the portion is administered in a volume of about 0.1 to 0.4 mL.

21. 21. The method of any one of claims 12 to 20, wherein the multiple injection sites are three.

22. The method of any one of claims 12 to 21, further comprising selecting a human subject using an MMPS prior to said administering.

23. 23. The method according to any one of claims 12 to 22, which is a cosmetic method for reducing the masseter prominence in a human.

24. 1. A method for temporarily reducing lower facial projection or width associated with a masseteric prominence, comprising: (i) identifying a line extending from the lateral commissure of the mouth to the point where the earlobe meets the face; (ii) identifying an area of ​​maximum bulge of the masseter muscle with the jaw clenched; (iii) determining a treatment area that includes the area of ​​maximum bulge, is located at or below the line, is posterior to the laughter muscle, and is anterior to the parotid gland; (iv) injecting botulinum toxin into multiple injection sites in said treatment area to administer a dose of botulinum toxin that reduces lower facial protrusion or width.

25. 25. The method of claim 24, wherein steps (i) to (iv) are performed on both sides.

26. 26. The method of claim 24 or claim 25, wherein injecting comprises injecting a dose of about 5-100 units, about 15-60 units, about 25-47 units, about 30-40 units, or about 36 units of botulinum toxin into each of the muscles to be treated.

27. 25. The method of claim 24, further comprising: (v) repeating steps (i)-(iv) on the opposing masseter muscle of the face.

28. A method according to any one of claims 24 to 27, wherein step (i) comprises visually identifying the imaginary line.

29. A method according to any one of claims 24 to 27, wherein step (i) comprises marking said lines on the facial skin.

30. 30. The method of any one of claims 24 to 29, wherein step (iii) comprises visually determining the treatment area without marking the skin.

31. The method according to any one of claims 24 to 29, wherein step (iii) comprises determining the treatment area and marking the treatment area on the skin.

32. 32. The method of any one of claims 24 to 31, further comprising prior to step (i) assessing or reviewing the assessment of the subject using the Masseter Muscle Prominence Scale (MMPS).

33. 33. The method of claim 32, wherein the assessment or review ranks the subject as marked or very marked on the MMPS.

34. 34. The method of claim 32 or claim 33, wherein the assessment or review of the subject using the MMPS is performed to assess the effectiveness of a previous treatment.

35. 35. The method of any one of claims 24 to 34, which is a cosmetic method for temporarily reducing lower facial projection or width associated with the masseteric prominence.

36. The method of any one of claims 1 to 35, wherein the botulinum toxin is a botulinum toxin type A.

37. 37. The method of any one of claims 1 to 36, wherein the botulinum toxin is animal protein free.

38. 38. The method of claim 37, wherein the lower facial width in the masseter region, the prominence of the masseter muscle in a human, or the lower facial prominence or width associated with the masseter prominence is reduced for a longer period of time using an animal protein-containing composition.

39. 1. A cosmetic method for reducing lower facial width in the masseter region, comprising: Identifying an area of ​​maximum bulge of the masseter muscle; injecting botulinum toxin into multiple injection sites in said area to administer a dose of botulinum toxin that reduces lower facial width in said masseter region; The method, wherein injecting comprises injecting a dose of about 15-60 units, about 25-47 units, about 30-40 units, or about 36 units of botulinum toxin into each of said muscles to be treated.

40. 1. A cosmetic method for reducing the masseteric prominence in a human, comprising administering to the masseteric region a dose of botulinum toxin that reduces the masseteric prominence, the dose is administered at multiple sites in the masseter muscle region; the area being identified as the area of ​​maximum bulge of the masseter muscle when the jaw is clenched; the dose is administered with the jaw relaxed; The method, wherein administering comprises administering a dose of about 15-60 units, about 25-47 units, about 30-40 units, or about 36 units of botulinum toxin to each of said muscles to be treated.

41. 1. A cosmetic method for temporarily reducing lower facial projection or width associated with a masseteric prominence, comprising: Identifying a line extending from the lateral commissure of the mouth to the point where the earlobe meets the face; identifying an area of ​​maximum bulge of the masseter muscle while the jaw is clenched; determining a treatment area including the area of ​​maximum bulge, located at or below the line, posterior to the sarcomere and anterior to the parotid gland; and injecting botulinum toxin into multiple injection sites in said treatment area to administer a dose of botulinum toxin that reduces lower facial projection or width, wherein the injections comprise injecting a dose of about 15-60 units, about 25-47 units, about 30-40 units, or about 36 units of botulinum toxin into each of said muscles to be treated.

42. 42. The method of any one of claims 39 to 41, wherein the lower facial width in the masseter region, the prominence of the masseter muscle in a human, or the lower facial prominence or width associated with the masseter prominence is reduced for a longer period of time at lower or higher dosages than specified.

43. a) a botulinum toxin in an amount of about 5 to about 100 units; b) instructions for administering a botulinum toxin to a muscle for said treatment of masseteric hypertrophy; wherein administering a botulinum toxin to the masseter muscle of a subject having masseteric hypertrophy is useful for treating said masseteric hypertrophy.

44. 44. The kit of parts of claim 43, wherein the instructions include instructions for bilateral administration.

45. 45. The kit of parts of claim 43 or claim 44, wherein the instructions comprise instructions to administer a dose of botulinum toxin in a range selected from the group of about 15-60 units, about 24-72 units, about 25-47 units, about 30-40 units, or about 36 units to each of the muscles to be treated.

46. The kit of parts according to any one of claims 43 to 45, wherein the instructions comprise instructions for administering doses of botulinum toxin at 3 to 5 multiple injection sites.

47. 47. The kit of parts according to claim 46, wherein a portion of the dose is administered to each injection site of the plurality of injection sites, the portion being equal to the dose divided by the number of injection sites of the plurality of injection sites.

48. 48. The kit of parts according to any one of claims 43 to 47, wherein the instructions include instructions to score and / or review the score of the subject using the Masseter Muscle Prominence Scale (MMPS).

49. 49. The kit of parts of claim 48, wherein the MMPS rates the subject as significant or very significant.

50. a) a botulinum toxin in an amount of about 5 to about 100 units; b) instructions to administer botulinum toxin to the muscle to reduce lower facial width in the masseter region; A kit of parts comprising: i) identifying the area of ​​maximum bulge of the masseter muscle; ii) injecting botulinum toxin into multiple injection sites in said area to administer a dose of botulinum toxin that reduces lower facial width in said masseter region.

51. 45. The kit of parts of claim 44, wherein said identifying and said injecting are performed bilaterally.

52. 52. The kit of parts according to claim 44 or claim 51, further comprising repeating said identifying and said injecting in the opposing masseter muscle.

53. 53. The kit of parts according to any one of claims 44 to 52, wherein the injection comprises injecting a dose of botulinum toxin in a range selected from the group of about 15 to 60 units, about 25 to 47 units, about 30 to 40 units, or about 36 units for each of the muscles to be treated.

54. The kit of parts according to any one of claims 44 to 52, wherein the injection comprises injecting a dose of botulinum toxin that is between about 24 and 72 units.

55. The kit of parts according to any one of claims 44 to 54, wherein the multiple injection sites are 3 to 5.

56. 56. The kit of parts according to any one of claims 44 to 55, wherein a portion of the dose is administered to each injection site of the plurality of injection sites, said portion being equal to the dose divided by the number of injection sites of the plurality of injection sites.

57. 57. The kit of parts according to any one of claims 44 to 56, further comprising assessing or reviewing the assessment of the subject using a Masseter Muscle Prominence Scale (MMPS) prior to said identification.

58. 58. The kit of parts of claim 57, wherein said assessment or review ranks said subject as marked or very marked in said MMPS.

59. a) a botulinum toxin in an amount of about 5 to about 100 units; b) administering a botulinum toxin to a muscle to reduce the masseter muscle prominence in a human; and A kit of parts comprising: i) determining the area of ​​maximum bulge of the masseter muscle when the jaw is clenched; ii) administering doses of botulinum toxin to multiple sites in the masseter region when the jaw is relaxed, which reduces the masseter prominence.

60. 60. The kit of parts of claim 59, wherein the administration is performed bilaterally.

61. 61. The kit of parts according to claim 59 or 60, wherein said administering comprises administering a dose of about 5-100 units, about 15-60 units, about 25-47 units, about 30-40 units, or about 36 units of botulinum toxin to each of the muscles to be treated.

62. 62. The kit of parts according to any one of claims 59 to 61, wherein the instructions further provide instructions for repeating the administration to the opposing masseter muscle of the person.

63. The kit of parts according to any one of claims 59 to 62, wherein the administration is by injection with a needle that is positioned perpendicular to the masseter muscle during injection.

64. The kit of parts according to any one of claims 59 to 63, wherein the botulinum toxin is administered so as to be distributed in deep and superficial muscles.

65. The kit of parts according to any one of claims 59 to 64, wherein the botulinum toxin is administered in a volume of about 0.6 to 2.4 mL.

66. 66. The kit of parts according to any one of claims 59 to 65, wherein a portion of the dose of botulinum toxin is administered to each injection site of the plurality of injection sites, the portion administered to each injection site being variable.

67. The kit of parts according to any one of claims 59 to 66, wherein said portion is administered in a volume of about 0.1 to 0.4 mL.

68. The kit of parts according to any one of claims 59 to 67, wherein the multiple injection sites are three.

69. The kit of parts according to any one of claims 59 to 68, further comprising selecting a human subject using an MMPS prior to said administration.

70. 70. The kit of parts according to any one of claims 59 to 69, which is a cosmetic method for reducing the masseter muscle prominence in a human.

71. a) a botulinum toxin in an amount of about 5 to about 100 units; b) instructions to administer botulinum toxin to the muscle to temporarily reduce the masseteric prominence and associated lower facial projection or width; A kit of parts comprising: i) Identify a line extending from the lateral commissure of the mouth to the point where the earlobe meets the face; ii) identifying the area of ​​maximum masseter muscle bulge with the jaw clenched; iii) determining a treatment area that includes the area of ​​maximum bulge, is located at or below the line, is posterior to the laughter muscle, and is anterior to the parotid gland; iv) injecting botulinum toxin into multiple injection sites in said treatment area to administer a dose of botulinum toxin that reduces lower facial protrusion or width.

72. 72. The kit of parts of claim 71, wherein steps (i) to (iv) are performed on both sides.

73. 73. The kit of parts according to claim 71 or claim 72, wherein the injection comprises injecting a dose of about 5-100 units, about 15-60 units, about 25-47 units, about 30-40 units, or about 36 units of botulinum toxin into each of the muscles to be treated.

74. 74. The kit of parts according to any one of claims 71 to 73, further comprising: (v) repeating steps (i) to (iv) on the opposing masseter muscle of the face.

75. 75. The kit of parts according to any one of claims 71 to 74, wherein step (i) comprises visually identifying the imaginary line.

76. 75. The kit of parts according to any one of claims 71 to 74, wherein step (i) comprises marking said lines on said facial skin.

77. 77. The kit of parts according to any one of claims 71 to 76, wherein step (iii) comprises visually determining the treatment area without marking the skin.

78. 77. The kit of parts according to any one of claims 71 to 76, wherein step (iii) comprises determining the treatment area and marking the treatment area on the skin.

79. 79. The kit of parts according to any one of claims 71 to 78, further comprising prior to step (i) assessing or reviewing the assessment of the subject using the Masseter Muscle Prominence Scale (MMPS).

80. 80. The kit of parts of claim 79, wherein said assessment or review ranks said subject as marked or very marked in said MMPS.

81. 80. The kit of parts of claim 79, wherein the assessment or review of a subject using the MMPS is performed to evaluate the effectiveness of a previous treatment.

82. The kit of parts according to any one of claims 43 to 81, wherein the kit is for a cosmetic treatment.

83. The kit of parts according to any one of claims 43 to 82, wherein the botulinum toxin is a botulinum toxin type A.

84. The kit of parts according to any one of claims 43 to 83, wherein the botulinum toxin is animal protein free.

85. 85. The kit of parts of claim 84, wherein the lower facial width in the masseter region, the prominence of the masseter muscle in a human, or the lower facial prominence or width associated with the masseter prominence is reduced for a longer period of time using an animal protein containing composition.

86. A composition comprising a botulinum toxin and a pharma- ceutically acceptable carrier for injection into the area of ​​the greatest masseter bulge to reduce lower facial width in a subject in the area of ​​the masseter muscle.

87. 87. The composition of claim 86, wherein the subject has a prominent or very prominent masseteric ridge.

88. 88. The composition of claim 87, wherein the masseteric ridge is determined using the MMPS.

89. 89. The composition of any one of claims 86 to 88, wherein the composition reduces lower face width in the masseter region for 90 days after injection.

90. 90. The composition of any one of claims 86 to 89, wherein the composition is injected into multiple injection sites in each masseter muscle on both sides of the masseter muscle.

91. 91. The composition of claim 90, wherein the multiple injection sites are 3 to 5 per masseter muscle.

92. 92. The composition of claim 90 or claim 91, wherein the dose of the composition injected is about 5-100 units, about 15-60 units, about 25-47 units, about 30-40 units, or about 36 units for each of the muscles to be treated.

93. The composition of any one of claims 86 to 92, wherein the composition is injected with a needle that is positioned perpendicular to the masseter muscle during injection.

94. The composition of any one of claims 86 to 93, wherein the composition is injected so as to be distributed in deep and superficial muscles.

95. The composition according to any one of claims 86 to 94, wherein the composition is for cosmetic treatment.

96. The composition of any one of claims 86 to 95, wherein the botulinum toxin is a botulinum toxin type A.

97. 97. The composition of any one of claims 86 to 96, wherein the botulinum toxin is animal protein free.

98. 98. The composition of claim 97, wherein the lower facial width in the masseter region, the prominence of the masseter muscle in a human, or the lower facial prominence or width associated with the masseter prominence is reduced for a longer period of time using an animal protein-containing composition.

99. Use of botulinum toxin injected in the area of ​​maximum masseter prominence to reduce the lower facial width of a subject in the masseter region, to reduce the masseter prominence in a human, and / or to temporarily reduce the lower facial prominence or width associated with the masseter prominence in a subject.

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