����JFIFXX�����    $.' ",#(7),01444'9=82<.342  2!!22222222222222222222222222222222222222222222222222����"��4�� ���,�PG"Z_�4�˷����kjز�Z�,F+��_z�,�© �����zh6�٨�ic�fu���#ډb���_�N�?��wQ���5-�~�I���8����TK<5o�Iv-�����k�_U_�����~b�M��d����Ӝ�U�Hh��?]��E�w��Q���k�{��_}qFW7HTՑ��Y��F�?_�'ϔ��_�Ջt��=||I ��6�έ"�����D���/[�k�9���Y�8ds|\���Ҿp6�Ҵ���]��.����6�z<�v��@]�i%��$j��~�g��J>��no����pM[me�i$[����s�o�ᘨ�˸ nɜG-�ĨU�ycP�3.DB�li�;��hj���x7Z^�N�h������N3u{�:j�x�힞��#M&��jL P@_���� P��&��o8������9�����@Sz6�t7#O�ߋ �s}Yf�T���lmr����Z)'N��k�۞p����w\�Tȯ?�8`�O��i{wﭹW�[�r�� ��Q4F�׊���3m&L�=��h3����z~��#�\�l :�F,j@�� ʱ�wQT����8�"kJO���6�֚l����}���R�>ډK���]��y����&����p�}b��;N�1�m�r$�|��7�>e�@B�TM*-iH��g�D�)� E�m�|�ؘbҗ�a��Ҿ����t4���o���G��*oCN�rP���Q��@z,|?W[0�����:�n,jWiE��W��$~/�hp\��?��{(�0���+�Y8rΟ�+����>S-S����VN;�}�s?.����� w�9��˟<���Mq4�Wv'��{)0�1mB��V����W[�����8�/<� �%���wT^�5���b��)iM� pg�N�&ݝ��VO~�q���u���9� ����!��J27����$O-���! �:�%H��� ـ����y�ΠM=t{!S�� oK8������t<����è:a������[�����ա�H���~��w��Qz`�po�^ ����Q��n� �,uu�C�$ ^���,������8�#��:�6��e�|~���!�3�3.�\0��q��o�4`.|� ����y�Q�`~;�d�ׯ,��O�Zw�������`73�v�܋�<���Ȏ�� ـ4k��5�K�a�u�=9Yd��$>x�A�&�� j0� ���vF��� Y�|�y��� ~�6�@c��1vOp�Ig����4��l�OD���L����� R���c���j�_�uX6��3?nk��Wy�f;^*B� ��@�~a�`��Eu������+���6�L��.ü>��}y���}_�O�6�͐�:�YrG�X��kG�����l^w���~㒶sy��Iu�!� W ��X��N�7BV��O��!X�2����wvG�R�f�T#�����t�/?���%8�^�W�aT��G�cL�M���I��(J����1~�8�?aT ���]����AS�E��(��*E}� 2��#I/�׍qz��^t�̔���b�Yz4x���t�){ OH��+(E��A&�N�������XT��o��"�XC��'���)}�J�z�p� ��~5�}�^����+�6����w��c��Q�|Lp�d�H��}�(�.|����k��c4^�"�����Z?ȕ ��a<�L�!039C� �Eu�C�F�Ew�ç ;�n?�*o���B�8�bʝ���'#Rqf���M}7����]����s2tcS{�\icTx;�\��7K���P���ʇ Z O-��~��c>"��?�������P��E��O�8��@�8��G��Q�g�a�Վ���󁶠�䧘��_%#r�>�1�z�a��eb��qcPѵ��n���#L��� =��׀t� L�7�`��V���A{�C:�g���e@�w1 Xp3�c3�ġ����p��M"'-�@n4���fG��B3�DJ�8[Jo�ߐ���gK)ƛ��$���� ���8�3�����+���� �����6�ʻ���� ���S�kI�*KZlT _`���?��K����QK�d����B`�s}�>���`��*�>��,*@J�d�oF*����弝��O}�k��s��]��y�ߘ��c1G�V���<=�7��7����6�q�PT��tXԀ�!9*4�4Tހ3XΛex�46���Y��D ����� �BdemDa����\�_l,��G�/���֌7���Y�](�xTt^%�GE�����4�}bT���ڹ�����;Y)���B�Q��u��>J/J �⮶.�XԄ��j�ݳ�+E��d ��r�5�_D�1 ��o�� �B�x�΢�#���<��W�����8���R6�@g�M�.��� dr�D��>(otU��@x=��~v���2� ӣ�d�oBd��3�eO�6�㣷�����ݜ6��6Y��Qz`��S��{���\P�~z m5{J/L��1������<�e�ͅPu�b�]�ϔ���'������f�b� Zpw��c`"��i���BD@:)ִ�:�]��hv�E�w���T�l��P���"Ju�}��وV J��G6��. J/�Qgl߭�e�����@�z�Zev2u�)]կ�����7x���s�M�-<ɯ�c��r�v�����@��$�ޮ}lk���a���'����>x��O\�ZFu>�����ck#��&:��`�$�ai�>2Δ����l���oF[h��lE�ܺ�Πk:)���`�� $[6�����9�����kOw�\|���8}������ބ:��񶐕��I�A1/�=�2[�,�!��.}gN#�u����b��� ~��݊��}34q����d�E��Lc��$��"�[q�U�硬g^��%B �z���r�pJ�ru%v\h1Y�ne`ǥ:g���pQM~�^�Xi� ��`S�:V29.�P���V�?B�k�� AEvw%�_�9C�Q����wKekPؠ�\�;Io d�{ ߞo�c1eP����\� `����E=���@K<�Y���eڼ�J���w����{av�F�'�M�@/J��+9p���|]�����Iw &`��8���&M�hg��[�{��Xj��%��Ӓ�$��(����ʹN���<>�I���RY���K2�NPlL�ɀ)��&e����B+ь����( � �JTx���_?EZ� }@ 6�U���뙢ط�z��dWI�n` D����噥�[��uV��"�G&Ú����2g�}&m��?ċ�"����Om#��������� ��{�ON��"S�X��Ne��ysQ���@Fn��Vg���dX�~nj�]J�<�K]:��FW��b�������62�=��5f����JKw��bf�X�55��~J �%^����:�-�QIE��P��v�nZum� z � ~ə ���� ���ة����;�f��\v���g�8�1��f24;�V���ǔ�)����9���1\��c��v�/'Ƞ�w�������$�4�R-��t���� e�6�/�ġ �̕Ecy�J���u�B���<�W�ַ~�w[B1L۲�-JS΂�{���΃������A��20�c#��@ 0!1@AP"#2Q`$3V�%45a6�FRUq��� ����^7ׅ,$n�������+��F�`��2X'��0vM��p�L=������5��8������u�p~���.�`r�����\���O��,ư�0oS ��_�M�����l���4�kv\JSd���x���SW�<��Ae�IX����������$I���w�:S���y���›R��9�Q[���,�5�;�@]�%���u�@ *ro�lbI �� ��+���%m:�͇ZV�����u�̉����θau<�fc�.����{�4Ա� �Q����*�Sm��8\ujqs]{kN���)qO�y�_*dJ�b�7���yQqI&9�ԌK!�M}�R�;������S�T���1���i[U�ɵz�]��U)V�S6���3$K{�ߊ<�(� E]Զ[ǼENg�����'�\?#)Dkf��J���o��v���'�%ƞ�&K�u�!��b�35LX�Ϸ��63$K�a�;�9>,R��W��3�3� d�JeTYE.Mϧ��-�o�j3+y��y^�c�������VO�9NV\nd�1 ��!͕_)a�v;����թ�M�lWR1��)El��P;��yوÏ�u 3�k�5Pr6<�⒲l�!˞*��u־�n�!�l:����UNW ��%��Chx8vL'��X�@��*��)���̮��ˍ��� ���D-M�+J�U�kvK����+�x8��cY������?�Ԡ��~3mo��|�u@[XeY�C�\Kp�x8�oC�C�&����N�~3-H���� ��MX�s�u<`���~"WL��$8ξ��3���a�)|:@�m�\���^�`�@ҷ)�5p+��6���p�%i)P M���ngc�����#0Aruz���RL+xSS?���ʮ}()#�t��mˇ!��0}}y����<�e� �-ή�Ԩ��X������ MF���ԙ~l L.3���}�V뽺�v�����멬��Nl�)�2����^�Iq��a��M��qG��T�����c3#������3U�Ǎ���}��לS�|qa��ڃ�+���-��2�f����/��bz��ڐ�� �ݼ[2�ç����k�X�2�* �Z�d���J�G����M*9W���s{��w���T��x��y,�in�O�v��]���n����P�$�JB@=4�OTI�n��e�22a\����q�d���%�$��(���:���: /*�K[PR�fr\nڙdN���F�n�$�4�[�� U�zƶ����� �mʋ���,�ao�u 3�z� �x��Kn����\[��VFmbE;�_U��&V�Gg�]L�۪&#n%�$ɯ�dG���D�TI=�%+AB�Ru#��b4�1�»x�cs�YzڙJG��f��Il��d�eF'T� iA��T���uC�$����Y��H?����[!G`}���ͪ� �纤Hv\������j�Ex�K���!���OiƸ�Yj�+u-<���'q����uN�*�r\��+�]���<�wOZ.fp�ێ��,-*)V?j-kÊ#�`�r��dV����(�ݽBk�����G�ƛk�QmUڗe��Z���f}|����8�8��a���i��3'J�����~G_�^���d�8w������ R�`(�~�.��u���l�s+g�bv���W���lGc}��u���afE~1�Ue������Z�0�8�=e�� f@/�jqEKQQ�J��oN��J���W5~M>$6�Lt�;$ʳ{���^��6�{����v6���ķܰg�V�cnn �~z�x�«�,2�u�?cE+Ș�H؎�%�Za�)���X>uW�Tz�Nyo����s���FQƤ��$��*�&�LLXL)�1�" L��eO��ɟ�9=���:t��Z���c��Ž���Y?�ӭV�wv�~,Y��r�ۗ�|�y��GaF�����C�����.�+� ���v1���fήJ�����]�S��T��B��n5sW}y�$��~z�'�c ��8 ��� ,! �p��VN�S��N�N�q��y8z˱�A��4��*��'������2n<�s���^ǧ˭P�Jޮɏ�U�G�L�J�*#��<�V��t7�8����TĜ>��i}K%,���)[��z�21z ?�N�i�n1?T�I�R#��m-�����������������1����lA�`��fT5+��ܐ�c�q՝��ʐ��,���3�f2U�եmab��#ŠdQ�y>\��)�SLY����w#��.���ʑ�f��� ,"+�w�~�N�'�c�O�3F�������N<���)j��&��,-� �љ���֊�_�zS���TǦ����w�>��?�������n��U仆�V���e�����0���$�C�d���rP �m�׈e�Xm�Vu� �L��.�bֹ��� �[Դaզ���*��\y�8�Է:�Ez\�0�Kq�C b��̘��cө���Q��=0Y��s�N��S.���3.���O�o:���#���v7�[#߫ ��5�܎�L���Er4���9n��COWlG�^��0k�%<���ZB���aB_���������'=��{i�v�l�$�uC���mƎҝ{�c㱼�y]���W�i ��ߧc��m�H� m�"�"�����;Y�ߝ�Z�Ǔ�����:S#��|}�y�,/k�Ld� TA�(�AI$+I3��;Y*���Z��}|��ӧO��d�v��..#:n��f>�>���ȶI�TX��� 8��y����"d�R�|�)0���=���n4��6ⲑ�+��r<�O�܂~zh�z����7ܓ�HH�Ga롏���nCo�>������a ���~]���R���̲c?�6(�q�;5%� |�uj�~z8R=X��I�V=�|{v�Gj\gc��q����z�؋%M�ߍ����1y��#��@f^���^�>N�����#x#۹��6�Y~�?�dfPO��{��P�4��V��u1E1J �*|���%���JN��`eWu�zk M6���q t[�� ��g�G���v��WIG��u_ft����5�j�"�Y�:T��ɐ���*�;� e5���4����q$C��2d�}���� _S�L#m�Yp��O�.�C�;��c����Hi#֩%+) �Ӎ��ƲV���SYź��g |���tj��3�8���r|���V��1#;.SQ�A[���S������#���`n�+���$��$I �P\[�@�s��(�ED�z���P��])8�G#��0B��[ى��X�II�q<��9�~[Z멜�Z�⊔IWU&A>�P~�#��dp<�?����7���c��'~���5 ��+$���lx@�M�dm��n<=e�dyX��?{�|Aef ,|n3�<~z�ƃ�uۧ�����P��Y,�ӥQ�*g�#먙R�\���;T��i,��[9Qi歉����c>]9�� ��"�c��P�� �Md?٥��If�ت�u��k��/����F��9�c*9��Ǎ:�ØF���z�n*�@|I�ށ9����N3{'��[�'ͬ�Ҳ4��#}��!�V� Fu��,�,mTIk���v C�7v���B�6k�T9��1�*l� '~��ƞF��lU��'�M ����][ΩũJ_�{�i�I�n��$���L�� j��O�dx�����kza۪��#�E��Cl����x˘�o�����V���ɞ�ljr��)�/,�߬h�L��#��^��L�ф�,íMƁe�̩�NB�L�����iL����q�}��(��q��6IçJ$�W�E$��:������=#����(�K�B����zђ <��K(�N�۫K�w��^O{!����)�H���>x�������lx�?>Պ�+�>�W���,Ly!_�D���Ō�l���Q�!�[ �S����J��1��Ɛ�Y}��b,+�Lo�x�ɓ)����=�y�oh�@�꥟/��I��ѭ=��P�y9��� �ۍYӘ�e+�p�Jnϱ?V\SO%�(�t� ���=?MR�[Ș�����d�/ ��n�l��B�7j� ��!�;ӥ�/�[-���A�>�dN�sLj ��,ɪv��=1c�.SQ�O3�U���ƀ�ܽ�E����������̻��9G�ϷD�7(�}��Ävӌ\�y�_0[w ���<΍>����a_��[0+�L��F.�޺��f�>oN�T����q;���y\��bՃ��y�jH�<|q-eɏ�_?_9+P���Hp$�����[ux�K w�Mw��N�ی'$Y2�=��q���KB��P��~������Yul:�[<����F1�2�O���5=d����]Y�sw:���Ϯ���E��j,_Q��X��z`H1,#II ��d�wr��P˂@�ZJV����y$�\y�{}��^~���[:N����ߌ�U�������O��d�����ؾe��${p>G��3c���Ė�lʌ�� ת��[��`ϱ�-W����dg�I��ig2��� ��}s ��ؤ(%#sS@���~���3�X�nRG�~\jc3�v��ӍL��M[JB�T��s3}��j�Nʖ��W����;7��ç?=X�F=-�=����q�ߚ���#���='�c��7���ڑW�I(O+=:uxq�������������e2�zi+�kuG�R��������0�&e�n���iT^J����~\jy���p'dtG��s����O��3����9* �b#Ɋ�� p������[Bws�T�>d4�ۧs���nv�n���U���_�~,�v����ƜJ1��s�� �QIz��)�(lv8M���U=�;����56��G���s#�K���MP�=��LvyGd��}�VwWBF�'�à �?MH�U�g2�� ����!�p�7Q��j��ڴ����=��j�u��� Jn�A s���uM������e��Ɔ�Ҕ�!)'��8Ϣ�ٔ��ޝ(��Vp���צ֖d=�IC�J�Ǡ{q������kԭ�߸���i��@K����u�|�p=..�*+����x�����z[Aqġ#s2a�Ɗ���RR�)*HRsi�~�a &f��M��P����-K�L@��Z��Xy�'x�{}��Zm+���:�)�) IJ�-i�u���� ���ܒH��'�L(7�y�GӜq���� j��� 6ߌg1�g�o���,kر���tY�?W,���p���e���f�OQS��!K�۟cҒA�|ս�j�>��=⬒��˧L[�� �߿2JaB~R��u�:��Q�] �0H~���]�7��Ƽ�I���(}��cq '�ήET���q�?f�ab���ӥvr� �)o��-Q��_'����ᴎo��K������;��V���o��%���~OK ����*��b�f:���-ťIR��`B�5!RB@���ï�� �u �̯e\�_U�_������� g�ES��3�������QT��a����x����U<~�c?�*�#]�MW,[8O�a�x��]�1bC|踤�P��lw5V%�)�{t�<��d��5���0i�XSU��m:��Z�┵�i�"��1�^B�-��P�hJ��&)O��*�D��c�W��vM��)����}���P��ܗ-q����\mmζZ-l@�}��a��E�6��F�@��&Sg@���ݚ�M����� ȹ 4����#p�\H����dYDo�H���"��\��..R�B�H�z_�/5˘����6��KhJR��P�mƶi�m���3�,#c�co��q�a)*Pt����R�m�k�7x�D�E�\Y�閣_X�<���~�)���c[[�BP����6�Yq���S��0����%_����;��Àv�~�| VS؇ ��'O0��F0��\���U�-�d@�����7�SJ*z��3n��y��P����O���������m�~�P�3|Y��ʉr#�C�<�G~�.,! ���bqx���h~0=��!ǫ�jy����l�O,�[B��~��|9��ٱ����Xly�#�i�B��g%�S��������tˋ���e���ې��\[d�t)��.+u�|1 ������#�~Oj����hS�%��i.�~X���I�H�m��0n���c�1uE�q��cF�RF�o���7� �O�ꮧ� ���ۛ{��ʛi5�rw?׌#Qn�TW��~?y$��m\�\o����%W� ?=>S�N@�� �Ʈ���R����N�)�r"C�:��:����� �����#��qb��Y�. �6[��2K����2u�Ǧ�HYR��Q�MV��� �G�$��Q+.>�����nNH��q�^��� ����q��mM��V��D�+�-�#*�U�̒ ���p욳��u:�������IB���m���PV@O���r[b= �� ��1U�E��_Nm�yKbN�O���U�}�the�`�|6֮P>�\2�P�V���I�D�i�P�O;�9�r�mAHG�W�S]��J*�_�G��+kP�2����Ka�Z���H�'K�x�W�MZ%�O�YD�Rc+o��?�q��Ghm��d�S�oh�\�D�|:W������UA�Qc yT�q������~^�H��/��#p�CZ���T�I�1�ӏT����4��"�ČZ�����}��`w�#�*,ʹ�� ��0�i��課�Om�*�da��^gJ݅{���l�e9uF#T�ֲ��̲�ٞC"�q���ߍ ոޑ�o#�XZTp����@ o�8��(jd��xw�]�,f���`~�|,s��^����f�1���t��|��m�򸄭/ctr��5s��7�9Q�4�H1꠲BB@l9@���C�����+�wp�xu�£Yc�9��?`@#�o�mH�s2��)�=��2�.�l����jg�9$�Y�S�%*L������R�Y������7Z���,*=�䷘$�������arm�o�ϰ���UW.|�r�uf����IGw�t����Zwo��~5 ��YյhO+=8fF�)�W�7�L9lM�̘·Y���֘YLf�큹�pRF���99.A �"wz��=E\Z���'a� 2��Ǚ�#;�'}�G���*��l��^"q��+2FQ� hj��kŦ��${���ޮ-�T�٭cf�|�3#~�RJ����t��$b�(R��(����r���dx� >U b�&9,>���%E\� Ά�e�$��'�q't��*�א���ެ�b��-|d���SB�O�O��$�R+�H�)�܎�K��1m`;�J�2�Y~9��O�g8=vqD`K[�F)k�[���1m޼c��n���]s�k�z$@��)!I �x՝"v��9=�ZA=`Ɠi �:�E��)`7��vI��}d�YI�_ �o�:ob���o ���3Q��&D&�2=�� �Ά��;>�h����y.*ⅥS������Ӭ�+q&����j|UƧ����}���J0��WW< ۋS�)jQR�j���Ư��rN)�Gű�4Ѷ(�S)Ǣ�8��i��W52���No˓� ۍ%�5brOn�L�;�n��\G����=�^U�dI���8$�&���h��'���+�(������cȁ߫k�l��S^���cƗjԌE�ꭔ��gF���Ȓ��@���}O���*;e�v�WV���YJ\�]X'5��ղ�k�F��b 6R�o՜m��i N�i����>J����?��lPm�U��}>_Z&�KK��q�r��I�D�Չ~�q�3fL�:S�e>���E���-G���{L�6p�e,8��������QI��h��a�Xa��U�A'���ʂ���s�+טIjP�-��y�8ۈZ?J$��W�P� ��R�s�]��|�l(�ԓ��sƊi��o(��S0��Y� 8�T97.�����WiL��c�~�dxc�E|�2!�X�K�Ƙਫ਼�$((�6�~|d9u+�qd�^3�89��Y�6L�.I�����?���iI�q���9�)O/뚅����O���X��X�V��ZF[�یgQ�L��K1���RҖr@v�#��X�l��F���Нy�S�8�7�kF!A��sM���^rkp�jP�DyS$N���q��nxҍ!U�f�!eh�i�2�m���`�Y�I�9r�6� �TF���C}/�y�^���Η���5d�'��9A-��J��>{�_l+�`��A���[�'��յ�ϛ#w:݅�%��X�}�&�PSt�Q�"�-��\縵�/����$Ɨh�Xb�*�y��BS����;W�ջ_mc�����vt?2}1�;qS�d�d~u:2k5�2�R�~�z+|HE!)�Ǟl��7`��0�<�,�2*���Hl-��x�^����'_TV�gZA�'j� ^�2Ϊ��N7t�����?w�� �x1��f��Iz�C-Ȗ��K�^q�;���-W�DvT�7��8�Z�������� hK�(P:��Q- �8�n�Z���܃e貾�<�1�YT<�,�����"�6{/ �?�͟��|1�:�#g��W�>$����d��J��d�B��=��jf[��%rE^��il:��B���x���Sּ�1հ��,�=��*�7 fcG��#q� �eh?��2�7�����,�!7x��6�n�LC�4x��},Geǝ�tC.��vS �F�43��zz\��;QYC,6����~;RYS/6���|2���5���v��T��i����������mlv��������&� �nRh^ejR�LG�f���? �ۉҬܦƩ��|��Ȱ����>3����!v��i�ʯ�>�v��オ�X3e���_1z�Kȗ\<������!�8���V��]��?b�k41�Re��T�q��mz��TiOʦ�Z��Xq���L������q"+���2ۨ��8}�&N7XU7Ap�d�X��~�׿��&4e�o�F��� �H����O���č�c�� 懴�6���͉��+)��v;j��ݷ�� �UV�� i��� j���Y9GdÒJ1��詞�����V?h��l����l�cGs�ځ�������y�Ac�����\V3�? �� ܙg�>qH�S,�E�W�[�㺨�uch�⍸�O�}���a��>�q�6�n6����N6�q������N ! 1AQaq�0@����"2BRb�#Pr���3C`��Scst���$4D���%Td�� ?���N����a��3��m���C���w��������xA�m�q�m���m������$����4n淿t'��C"w��zU=D�\R+w�p+Y�T�&�պ@��ƃ��3ޯ?�Aﶂ��aŘ���@-�����Q�=���9D��ռ�ѻ@��M�V��P��܅�G5�f�Y<�u=,EC)�<�Fy'�"�&�չ�X~f��l�KԆV��?�� �W�N����=(� �;���{�r����ٌ�Y���h{�١������jW����P���Tc�����X�K�r��}���w�R��%��?���E��m�� �Y�q|����\lEE4���r���}�lsI�Y������f�$�=�d�yO����p�����yBj8jU�o�/�S��?�U��*������ˍ�0������u�q�m [�?f����a�� )Q�>����6#������� ?����0UQ����,IX���(6ڵ[�DI�MNލ�c&���υ�j\��X�R|,4��� j������T�hA�e��^���d���b<����n�� �즇�=!���3�^�`j�h�ȓr��jẕ�c�,ٞX����-����a�ﶔ���#�$��]w�O��Ӫ�1y%��L�Y<�wg#�ǝ�̗`�x�xa�t�w��»1���o7o5��>�m뭛C���Uƃߜ}�C���y1Xνm�F8�jI���]����H���ۺиE@I�i;r�8ӭ����V�F�Շ| ��&?�3|x�B�MuS�Ge�=Ӕ�#BE5G�����Y!z��_e��q�р/W>|-�Ci߇�t�1ޯќd�R3�u��g�=0 5��[?�#͏��q�cf���H��{ ?u�=?�?ǯ���}Z��z���hmΔ�BFTW�����<�q�(v� ��!��z���iW]*�J�V�z��gX֧A�q�&��/w���u�gYӘa���; �i=����g:��?2�dž6�ى�k�4�>�Pxs����}������G�9��3 ���)gG�R<>r h�$��'nc�h�P��Bj��J�ҧH� -��N1���N��?��~��}-q!=��_2hc�M��l�vY%UE�@|�v����M2�.Y[|y�"Eï��K�ZF,�ɯ?,q�?v�M 80jx�"�;�9vk�����+ ֧�� �ȺU��?�%�vcV��mA�6��Qg^M����A}�3�nl� QRN�l8�kkn�'�����(��M�7m9و�q���%ޟ���*h$Zk"��$�9��: �?U8�Sl��,,|ɒ��xH(ѷ����Gn�/Q�4�P��G�%��Ա8�N��!� �&�7�;���eKM7�4��9R/%����l�c>�x;������>��C�:�����t��h?aKX�bhe�ᜋ^�$�Iհ �hr7%F$�E��Fd���t��5���+�(M6�t����Ü�UU|zW�=a�Ts�Tg������dqP�Q����b'�m���1{|Y����X�N��b �P~��F^F:����k6�"�j!�� �I�r�`��1&�-$�Bevk:y���#yw��I0��x��=D�4��tU���P�ZH��ڠ底taP��6����b>�xa����Q�#� WeF��ŮNj�p�J* mQ�N����*I�-*�ȩ�F�g�3 �5��V�ʊ�ɮ�a��5F���O@{���NX��?����H�]3��1�Ri_u��������ѕ�� ����0��� F��~��:60�p�͈�S��qX#a�5>���`�o&+�<2�D����: �������ڝ�$�nP���*)�N�|y�Ej�F�5ټ�e���ihy�Z �>���k�bH�a�v��h�-#���!�Po=@k̆IEN��@��}Ll?j�O������߭�ʞ���Q|A07x���wt!xf���I2?Z��<ץ�T���cU�j��]��陎Ltl �}5�ϓ��$�,��O�mˊ�;�@O��jE��j(�ا,��LX���LO���Ц�90�O �.����a��nA���7������j4 ��W��_ٓ���zW�jcB������y՗+EM�)d���N�g6�y1_x��p�$Lv:��9�"z��p���ʙ$��^��JԼ*�ϭ����o���=x�Lj�6�J��u82�A�H�3$�ٕ@�=Vv�]�'�qEz�;I˼��)��=��ɯ���x �/�W(V���p�����$ �m�������u�����񶤑Oqˎ�T����r��㠚x�sr�GC��byp�G��1ߠ�w e�8�$⿄����/�M{*}��W�]˷.�CK\�ުx���/$�WPw���r� |i���&�}�{�X� �>��$-��l���?-z���g����lΆ���(F���h�vS*���b���߲ڡn,|)mrH[���a�3�ר�[1��3o_�U�3�TC�$��(�=�)0�kgP���� ��u�^=��4 �WYCҸ:��vQ�ר�X�à��tk�m,�t*��^�,�}D*� �"(�I��9R����>`�`��[~Q]�#af��i6l��8���6�:,s�s�N6�j"�A4���IuQ��6E,�GnH��zS�HO�uk�5$�I�4��ؤ�Q9�@��C����wp�BGv[]�u�Ov���0I4���\��y�����Q�Ѹ��~>Z��8�T��a��q�ޣ;z��a���/��S��I:�ܫ_�|������>=Z����8:�S��U�I�J��"IY���8%b8���H��:�QO�6�;7�I�S��J��ҌAά3��>c���E+&jf$eC+�z�;��V����� �r���ʺ������my�e���aQ�f&��6�ND��.:��NT�vm�<- u���ǝ\MvZY�N�NT��-A�>jr!S��n�O 1�3�Ns�%�3D@���`������ܟ 1�^c<���� �a�ɽ�̲�Xë#�w�|y�cW�=�9I*H8�p�^(4���՗�k��arOcW�tO�\�ƍR��8����'�K���I�Q�����?5�>[�}��yU�ײ -h��=��% q�ThG�2�)���"ו3]�!kB��*p�FDl�A���,�eEi�H�f�Ps�����5�H:�Փ~�H�0Dت�D�I����h�F3�������c��2���E��9�H��5�zԑ�ʚ�i�X�=:m�xg�hd(�v����׊�9iS��O��d@0ڽ���:�p�5�h-��t�&���X�q�ӕ,��ie�|���7A�2���O%P��E��htj��Y1��w�Ѓ!����  ���� ࢽ��My�7�\�a�@�ţ�J �4�Ȼ�F�@o�̒?4�wx��)��]�P��~�����u�����5�����7X ��9��^ܩ�U;Iꭆ 5 �������eK2�7(�{|��Y׎ �V��\"���Z�1� Z�����}��(�Ǝ"�1S���_�vE30>���p;� ΝD��%x�W�?W?v����o�^V�i�d��r[��/&>�~`�9Wh��y�;���R��� ;;ɮT��?����r$�g1�K����A��C��c��K��l:�'��3 c�ﳯ*"t8�~l��)���m��+U,z��`(�>yJ�?����h>��]��v��ЍG*�{`��;y]��I�T� ;c��NU�fo¾h���/$���|NS���1�S�"�H��V���T���4��uhǜ�]�v;���5�͠x��'C\�SBpl���h}�N����� A�Bx���%��ޭ�l��/����T��w�ʽ]D�=����K���ž�r㻠l4�S�O?=�k �M:� ��c�C�a�#ha���)�ѐxc�s���gP�iG��{+���x���Q���I= �� z��ԫ+ �8"�k�ñ�j=|����c ��y��CF��/��*9ж�h{ �?4�o� ��k�m�Q�N�x��;�Y��4膚�a�w?�6�>e]�����Q�r�:����g�,i"�����ԩA�*M�<�G��b�if��l^M��5� �Ҩ�{����6J��ZJ�����P�*�����Y���ݛu�_4�9�I8�7���������,^ToR���m4�H��?�N�S�ѕw��/S��甍�@�9H�S�T��t�ƻ���ʒU��*{Xs�@����f�����֒Li�K{H�w^���������Ϥm�tq���s� ���ք��f:��o~s��g�r��ט� �S�ѱC�e]�x���a��) ���(b-$(�j>�7q�B?ӕ�F��hV25r[7 Y� }L�R��}����*sg+��x�r�2�U=�*'WS��ZDW]�WǞ�<��叓���{�$�9Ou4��y�90-�1�'*D`�c�^o?(�9��u���ݐ��'PI&� f�Jݮ�������:wS����jfP1F:X �H�9dԯ���˝[�_54 �}*;@�ܨ�� ð�yn�T���?�ןd�#���4rG�ͨ��H�1�|-#���Mr�S3��G�3�����)�.᧏3v�z֑��r����$G"�`j �1t��x0<Ɔ�Wh6�y�6��,œ�Ga��gA����y��b��)��h�D��ß�_�m��ü �gG;��e�v��ݝ�nQ� ��C����-�*��o���y�a��M��I�>�<���]obD��"�:���G�A��-\%LT�8���c�)��+y76���o�Q�#*{�(F�⽕�y����=���rW�\p���۩�c���A���^e6��K������ʐ�cVf5$�'->���ՉN"���F�"�UQ@�f��Gb~��#�&�M=��8�ט�JNu9��D��[̤�s�o�~������ G��9T�tW^g5y$b��Y'��س�Ǵ�=��U-2 #�MC�t(�i� �lj�@Q 5�̣i�*�O����s�x�K�f��}\��M{E�V�{�υ��Ƈ�����);�H����I��fe�Lȣr�2��>��W�I�Ȃ6������i��k�� �5�YOxȺ����>��Y�f5'��|��H+��98pj�n�.O�y�������jY��~��i�w'������l�;�s�2��Y��:'lg�ꥴ)o#'Sa�a�K��Z� �m��}�`169�n���"���x��I ��*+� }F<��cГ���F�P�������ֹ*�PqX�x۩��,� ��N�� �4<-����%����:��7����W���u�`����� $�?�I��&����o��o��`v�>��P��"��l���4��5'�Z�gE���8���?��[�X�7(��.Q�-��*���ތL@̲����v��.5���[��=�t\+�CNܛ��,g�SQnH����}*F�G16���&:�t��4ُ"A��̣��$�b �|����#rs��a�����T�� ]�<�j��BS�('$�ɻ� �wP;�/�n��?�ݜ��x�F��yUn�~mL*-�������Xf�wd^�a�}��f�,=t�׵i�.2/wpN�Ep8�OР���•��R�FJ� 55TZ��T �ɭ�<��]��/�0�r�@�f��V��V����Nz�G��^���7hZi����k��3�,kN�e|�vg�1{9]_i��X5y7� 8e]�U����'�-2,���e"����]ot�I��Y_��n�(JҼ��1�O ]bXc���Nu�No��pS���Q_���_�?i�~�x h5d'�(qw52] ��'ޤ�q��o1�R!���`ywy�A4u���h<קy���\[~�4�\ X�Wt/� 6�����n�F�a8��f���z �3$�t(���q��q�x��^�XWeN'p<-v�!�{�(>ӽDP7��ո0�y)�e$ٕv�Ih'Q�EA�m*�H��RI��=:��� ���4牢) �%_iN�ݧ�l]� �Nt���G��H�L��� ɱ�g<���1V�,�J~�ٹ�"K��Q�� 9�HS�9�?@��k����r�;we݁�]I�!{ �@�G�[�"��`���J:�n]�{�cA�E����V��ʆ���#��U9�6����j�#Y�m\��q�e4h�B�7��C�������d<�?J����1g:ٳ���=Y���D�p�ц� ׈ǔ��1�]26؜oS�'��9�V�FVu�P�h�9�xc�oq�X��p�o�5��Ա5$�9W�V(�[Ak�aY錎qf;�'�[�|���b�6�Ck��)��#a#a˙��8���=äh�4��2��C��4tm^ �n'c���]GQ$[Wҿ��i���vN�{Fu ��1�gx��1┷���N�m��{j-,��x�� Ūm�ЧS�[�s���Gna���䑴�� x�p 8<������97�Q���ϴ�v�aϚG��Rt�Һ׈�f^\r��WH�JU�7Z���y)�vg=����n��4�_)y��D'y�6�]�c�5̪�\� �PF�k����&�c;��cq�$~T�7j ���nç]�<�g ":�to�t}�159�<�/�8������m�b�K#g'I'.W�����6��I/��>v��\�MN��g���m�A�yQL�4u�Lj�j9��#44�t��l^�}L����n��R��!��t��±]��r��h6ٍ>�yҏ�N��fU�� ���� Fm@�8}�/u��jb9������he:A�y�ծw��GpΧh�5����l}�3p468��)U��d��c����;Us/�֔�YX�1�O2��uq�s��`hwg�r~�{ R��mhN��؎*q 42�*th��>�#���E����#��Hv�O����q�}�����6�e��\�,Wk�#���X��b>��p}�դ��3���T5��†��6��[��@�P�y*n��|'f�֧>�lư΂�̺����SU�'*�q�p�_S�����M�� '��c�6�����m�� ySʨ;M��r���Ƌ�m�Kxo,���Gm�P��A�G�:��i��w�9�}M(�^�V��$ǒ�ѽ�9���|���� �a����J�SQ�a���r�B;����}���ٻ֢�2�%U���c�#�g���N�a�ݕ�'�v�[�OY'��3L�3�;,p�]@�S��{ls��X�'���c�jw�k'a�.��}�}&�� �dP�*�bK=ɍ!����;3n�gΊU�ߴmt�'*{,=SzfD� A��ko~�G�aoq�_mi}#�m�������P�Xhύ����mxǍ�΂���巿zf��Q���c���|kc�����?���W��Y�$���_Lv����l߶��c���`?����l�j�ݲˏ!V��6����U�Ђ(A���4y)H���p�Z_�x��>���e��R��$�/�`^'3qˏ�-&Q�=?��CFVR �D�fV�9��{�8g�������n�h�(P"��6�[�D���< E�����~0<@�`�G�6����Hг�cc�� �c�K.5��D��d�B���`?�XQ��2��ٿyqo&+�1^� DW�0�ꊩ���G�#��Q�nL3��c���������/��x ��1�1[y�x�პCW��C�c�UĨ80�m�e�4.{�m��u���I=��f�����0QRls9���f���������9���~f�����Ǩ��a�"@�8���ȁ�Q����#c�ic������G��$���G���r/$W�(��W���V�"��m�7�[m�A�m����bo��D� j����۳� l���^�k�h׽����� ��#� iXn�v��eT�k�a�^Y�4�BN��ĕ��0 !01@Q"2AaPq3BR������?���@4�Q�����T3,���㺠�W�[=JK�Ϟ���2�r^7��vc�:�9 �E�ߴ�w�S#d���Ix��u��:��Hp��9E!�� V 2;73|F��9Y���*ʬ�F��D����u&���y؟��^EA��A��(ɩ���^��GV:ݜDy�`��Jr29ܾ�㝉��[���E;Fzx��YG��U�e�Y�C���� ����v-tx����I�sם�Ę�q��Eb�+P\ :>�i�C'�;�����k|z�رn�y]�#ǿb��Q��������w�����(�r|ӹs��[�D��2v-%��@;�8<a���[\o[ϧw��I!��*0�krs)�[�J9^��ʜ��p1)� "��/_>��o��<1����A�E�y^�C��`�x1'ܣn�p��s`l���fQ��):�l����b>�Me�jH^?�kl3(�z:���1ŠK&?Q�~�{�ٺ�h�y���/�[��V�|6��}�KbX����mn[-��7�5q�94�������dm���c^���h� X��5��<�eޘ>G���-�}�دB�ޟ� ��|�rt�M��V+�]�c?�-#ڛ��^ǂ}���Lkr���O��u�>�-D�ry� D?:ޞ�U��ǜ�7�V��?瓮�"�#���r��չģVR;�n���/_� ؉v�ݶe5d�b9��/O��009�G���5n�W����JpA�*�r9�>�1��.[t���s�F���nQ� V 77R�]�ɫ8����_0<՜�IF�u(v��4��F�k�3��E)��N:��yڮe��P�`�1}�$WS��J�SQ�N�j�ٺ��޵�#l���ј(�5=��5�lǏmoW�v-�1����v,W�mn��߀$x�<����v�j(����c]��@#��1������Ǔ���o'��u+����;G�#�޸��v-lη��/(`i⣍Pm^���ԯ̾9Z��F��������n��1��� ��]�[��)�'������:�֪�W��FC����� �B9،!?���]��V��A�Վ�M��b�w��G F>_DȬ0¤�#�QR�[V��kz���m�w�"��9ZG�7'[��=�Q����j8R?�zf�\a�=��O�U����*oB�A�|G���2�54 �p��.w7� �� ��&������ξxGHp� B%��$g�����t�Џ򤵍z���HN�u�Я�-�'4��0��;_��3 !01"@AQa2Pq#3BR������?��ʩca��en��^��8���<�u#��m*08r��y�N"�<�Ѳ0��@\�p��� �����Kv�D��J8�Fҽ� �f�Y��-m�ybX�NP����}�!*8t(�OqѢ��Q�wW�K��ZD��Δ^e��!� ��B�K��p~�����e*l}z#9ң�k���q#�Ft�o��S�R����-�w�!�S���Ӥß|M�l޶V��!eˈ�8Y���c�ЮM2��tk���� ������J�fS����Ö*i/2�����n]�k�\���|4yX�8��U�P.���Ы[���l��@"�t�<������5�lF���vU�����W��W��;�b�cД^6[#7@vU�xgZv��F�6��Q,K�v��� �+Ъ��n��Ǣ��Ft���8��0��c�@�!�Zq s�v�t�;#](B��-�nῃ~���3g������5�J�%���O������n�kB�ĺ�.r��+���#�N$?�q�/�s�6��p��a����a��J/��M�8��6�ܰ"�*������ɗud"\w���aT(����[��F��U՛����RT�b���n�*��6���O��SJ�.�ij<�v�MT��R\c��5l�sZB>F��<7�;EA��{��E���Ö��1U/�#��d1�a�n.1ě����0�ʾR�h��|�R��Ao�3�m3 ��%�� ���28Q� ��y��φ���H�To�7�lW>����#i`�q���c����a��� �m,B�-j����݋�'mR1Ήt�>��V��p���s�0IbI�C.���1R�ea�����]H�6����������4B>��o��](��$B���m�����a�!=��?�B� K�Ǿ+�Ծ"�n���K��*��+��[T#�{E�J�S����Q�����s�5�:�U�\wĐ�f�3����܆&�)����I���Ԇw��E T�lrTf6Q|R�h:��[K�� �z��c֧�G�C��%\��_�a�84��HcO�bi��ؖV��7H �)*ģK~Xhչ0��4?�0��� �E<���}3���#���u�?�� ��|g�S�6ꊤ�|�I#Hڛ� �ա��w�X��9��7���Ŀ%�SL��y6č��|�F�a 8���b��$�sק�h���b9RAu7�˨p�Č�_\*w��묦��F ����4D~�f����|(�"m���NK��i�S�>�$d7SlA��/�²����SL��|6N�}���S�˯���g��]6��; �#�.��<���q'Q�1|KQ$�����񛩶"�$r�b:���N8�w@��8$�� �AjfG|~�9F ���Y��ʺ��Bwؒ������M:I岎�G��`s�YV5����6��A �b:�W���G�q%l�����F��H���7�������Fsv7��k�� 403WebShell
403Webshell
Server IP : 104.21.45.146  /  Your IP : 172.69.130.107
Web Server : Apache/2.4.52 (Ubuntu)
System : Linux ip-172-31-19-221 6.8.0-1029-aws #31~22.04.1-Ubuntu SMP Thu Apr 24 21:16:18 UTC 2025 x86_64
User : www-data ( 33)
PHP Version : 8.1.28
Disable Function : NONE
MySQL : OFF  |  cURL : ON  |  WGET : ON  |  Perl : ON  |  Python : OFF  |  Sudo : ON  |  Pkexec : ON
Directory :  /efsdata/scitechnol.com/httpdocs/submission/uploads/

Upload File :
current_dir [ Writeable ] document_root [ Writeable ]

 

Command :


[ Back ]     

Current File : /efsdata/scitechnol.com/httpdocs/submission/uploads/0-0-Manuscript-2013-05-30.doc
��ࡱ�>��	`b����_�������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������[�	��JNbjbj����4jΐΐF+���������������������8$4X<��*���������#*%*%*%*%*%*%*$<-��/VI*������I*����^*O$O$O$��	����#*O$�#*O$O$:g),�)������CA]��e!��)*t*0�*�)
40=#40�)40��)\��O$�����I*I*O$����*������������������������������������������������������������������������40�����������:The use of botulinum toxin in the treatment of the consequences of bruxism on cervical spine musculature

 PJ Finiels MD, MSc*, D Batifol MD**

*Department of Neurosurgery and Spine Pathology, Kennedy Medical Center, N�mes
**Department of Maxillofacial Surgery, Montpellier University Hospital, Montpellier (France)




Botulinum toxin injections have shown their effectiveness in the treatment of temporomandibular joint disorders (9, 20), doses used varying according to body weight, muscle tonicity and bruxism intensity. Hypertonia and hyperactivity of masticatory muscles are involved in pain and contractions of the cervical spine musculature (15), often extremely present at the first contact. It has been shown elsewhere that the association of botulinum toxin injections and physiotherapy of the masticatory muscles could lead to release of hypertonia in cervical muscles and diminution of pain, although no specific medication was used at the same time. Knowing the effects of spinal surgery on sagittal balance (8, 18), the effectiveness of botulinum toxin injections in the treatment of certain dystonias and spasmodic torticollis (3, 16, 17),  as more recently proved in post operative pain after cervical spine surgery (6), the search for the real interest of the use of botulinum toxin in such conditions came to light.

Material and methods�:
This prospective study was performed after the written consent and approval of the ethics committee of our institution. 8 patients, all of female gender, showing disabling posterior neck muscle contractures linked with bruxism were prospectively treated and followed for a 15,1 (13-19)  month period.
Injections of botulinum toxin A (Botox* / Allergan Pharmaceuticals, Westport, Ireland) were made under electromyographic control, varying from 10 to 100U Botox*, according to the muscles chosen, without administration of more than 280U Botox* at the same time. The first follow-up session for each patient was set at 6 weeks and 3 months after injection by a non involved physician. Each time it was necessary, new injections were made at least 3 months after the previous one, in order to avoid the release of toxin antibodies. Pain was measured according to the visual analogue scale (VAS) which had scores of 0 to 10, with 0 meaning analgesia and 10 major pain. At the same time, the  modification of the angle of cervical lordosis according to Matsumoto�s criteria (14) were calculated on lateral sitting radiographs in neutral position, the value obtained being considered negative in the case of kyphotic curvature or curve inversion 
Good results were considered to be achieved in the case of a 2 point diminution of VAS score as well as at least a 5� positive gain in the curve.

Results�:
The characteristics of the patients in the series are summarized in Table 1:


2-1. Population:

All the patients who were injected were of female gender.  The average age was 55.8 (27-76) years.  All the patients except 3 were active and in employment at the beginning of treatment.  

2-2. Clinical signs:
All the patients showed posterior cervical pain, along with muscular contractures which could be identified to the masseter and/or temporal muscles, sometimes associated with contractures of other muscular groups, improved more or less by physiotherapy, but all showing failure of usual therapies including the use of morphinic drugs and injectable myorelaxants. Measurement of pain on the VAS at the beginning of treatment showed an average value of 5.75 (4-7) ; at the end of the treatment period (3 sessions [2�6] on average) this was reduced to 1.25 (0-4), that is to say an improvement of � 4.5 points on the VAS (Table I).

3-3. Radiological measurements:
The measurement of the average angle of lordosis was 9�37� (-10�-20�) at the beginning of the treatment period and 25�15� (5-61�) at the end of the treatment period, that is to say an average improvement of + 15�38�. 

3-4. Clinical illustrations:
Case n� 3: Patient aged 49, referred by her general practitioner for dental articulation problems associated with strong cervicalgia (VAS = 6), following a craniocervical trauma due to a road accident in 2003.  The clinical examination showed bilateral contractures of the masseters, predominant on the right side, as well as bilateral posterior paravertebral contractures.  The initial x-rays (Fig. 2A) showed normal arthritic joint degeneration for age and partial suppression of physiological lordosis, the Matsumoto angle being measured at 19�.  The patient was injected with botulinum toxin in the masseter muscles (40 then 50 U Botox* from the 3rd session) and the temporal muscles (25 then 15U Botox* from the 3rd session), on the 12.04, 13.07, 13.10.2010, 21.02 and 20.05.2011. X-ray examinations (Fig. 2B), carried out 6 weeks after the 4th injection, showed a significant improvement in sagittal equilibrium of the spinal column, with the return of a normal lordosis, the Matsumoto angle increasing to 26�. Clinical observations confirmed an improvement in cervical pain, the patient assessing pain at 1 on the VAS, a 5 point improvement on the initial state. 

Case n� 6: Patient aged 27, referred for suspected TMJD.  Clinical examination showed off-center nocturnal and centered diurnal bruxism, with facet wear.  The mastication muscles appeared to be very tonic, the trapezium was very painful on palpation, especially on the right side.  The initial x-rays examinations (Fig. 3A) showed a rigidified appearance of the cervical spine, the physiological lordosis was totally erased (Matsumoto angle measured at 9�). The patient received injections of botulinum toxin in the masseter muscles (60 then 50 U Botox* from the 3rd session), the temporal muscles (20U Botox* each session) and the trapezium muscles (60U Botox* on the right and 40 U on the left), on the 26.05, 29.08, 17.11.2010, 05.01 and 13.04.2011. X-ray examinations (Fig. 3B), carried out 6 weeks after the last injection, showed an improvement in sagittal equilibrium of the spinal column, the Matsumoto angle having increased to 61�! Clinical observations confirmed an improvement in cervical pain, the patient assessing pain at 0 on the VAS, as compared to 5 at the start of treatment.

Case n� 8: 69 years old depressive patient, showing bruxism on mandibular instability, confirmed by clinical examination.  In addition to this, there was perfectly palpable masseter hypertrophy.  The initial x-rays showed tiered arthrosis changes with double discopathy C5-C6, C6-C7 and associated foraminal stenosis.  Lordosis was inversed with a kyphotic tendency (10� lordosis angle (Fig. 4A).  Palpation of the cervical mass is claimed to be very painful.  The masseter and temporal muscles were successively injected using toxin A (50 then 40U Botox* from the 3rd session in the masseter muscles, the temporal muscles only receiving 10 U Botox* for 2 sessions) on the 29.09., 05.12.2010., 02.04 and 20.08.2011. Note that there was simultaneous injection of non reticulated hyaluronic acid (Arthrum*, 1ml) under local anesthetic in the left temporomandibular joint.  Excellent clinical results, the buccal opening increasing from 25 to 43mm after the first injection, and the cervical pain being completely relieved after 4 injections, with a net lordosis gain of around 22� in  x-ray examinations (Fig 4B).

Discussion�:

If the existence of paravertebral muscular contractures, especially posterior ones, or even of true dystonias is well documented in numerous conditions of impairment of the orofacial musculature (12, 20), their pathophysiology remains nonetheless unknown.
It was recently put forward that a sensorial dysfunction could play a key role in the formation of certain focal dystonias such as blepharospasm and Meige's syndrome (4).  Patients with this type of condition all show an activation deficit in sensitive representation zones with somatotopic disorder, not only in the pathological areas (especially cephalic extremities), but also in healthy areas, such as the hand.  In such conditions, the use of botulinum toxin, whilst clinically effective, would not modify the cortical dysfunction, but would significantly diminish the activation of the thalamus and the controlateral putamen during stimulation of the cephalic extremity, including the face.   

The role of botulinum toxin on the craniocervical muscular balance has moreover been shown in two experimental studies in rats (2, 19). 
Babuccu et al (2) thus developed, in 2009, an experimental model on the newborn rat, injecting alternately 0,4U Botox* either in the masseter muscle, or in the temporal muscle, always on the same side in 2 groups of rats, which were successively paired with a control group which received no injection and another which was injected only with saline solution.  The histological analysis, 4 months later, confirmed firstly the muscular atrophy which was to be expected in subjects which had received a toxin injection, but also a reduction in length of certain bones in the facial skeleton (nasal bone, maxillar, zygomatic arch) whichever muscle was injected, and a significant reduction in the dimensions of the base of the skull with cervical repercussions in the case of injection into the temporal muscle only.

Some months later, Tsai et al (19), used the same method and confirmed these results, with larger injections of neurotoxin (1 U Botox*) in the same muscles.  Interestingly, the muscles being injected symmetrically, global repercussions on the cranial morphology were shown, forming a true dolichocephalism but only on the upper part of the skull, corresponding with the insertion zones of the muscles which had thus been treated, associated with an increase of mandible�s ramus length.

The two studies thus show the repercussions of atrophy of the masticatory muscles on cranio-facial growth and highlight the assessment difficulties when the toxin is used in very young children.  On the other hand, they completely concur with the hypothesis of differential evolution of the species, which makes atrophy of the masticatory muscles one of the main elements of evolution/differentiation from primates to the Homo species, since it allowed greater expansion of the cranial vault under cerebral growth and, eventually, the increase in parenchymatous mass, characteristic of the species.  
Finally, an interesting relationship between a cervical arthro-muscular dysfunction and the formation of nocturnal bruxism was also shown in children (10), thus confirming the association between the two pathologies, as can be seen in adults. 

Botulinum toxin is the most powerful known neurotoxin, produced by an anaerobic gram-positive bacteria, Clostridium botulinium. This was described for the first time in 1817 by JC Kerner, but it was not until 1895 that the cause of botulism was highlighted by Van Ermengem, and the type A toxin was finally isolated by Sommer in 1920.  Only after the Second World War did work on the different forms of toxin really begin, and their practical application into human pathology only began at the end of the 1970's with the work of Scott in the treatment of strabismus (11). Seven toxin serotypes (A to G) are currently known, only three of them (A, B and E) seem to be toxic to mankind.  The toxin acts by causing a sort of chemical denervation by blocking neurotransmitter release at the synaptic cleft of the acetylcholine fibers of the motor nerves and of the autonomic nervous system (7). It can thus be used as a local-acting anti-acetylcholine agent.  But, contrary to other anti-acetylcholine drugs such as atropine or probanthine, it has few side effects, and these are always restricted to the area of injection (allergic reaction or muscular weakness) (13).
Botulinum toxin has already been successfully used in the treatment of spasmodic torticollis (3, 16, 17), in laryngeal dystonia, hemifacial spasm, blepharospasm, and, more recently, in the treatment of certain autonomic dysfunctions such as hyperhidrosis, achalasia, Frey's syndrome or in the treatment of sialoceles after traumatic section of the parotid duct (1).
In this series we used toxin A, at the average dose necessary, adjusted according to the muscular mass in question, around  40 (10�100) U Botox* per muscle treated.
The simultaneous use of electro-myographic control seems essential to ensure that the end of the needle is correctly positioned in the center of the muscle. The first signs of effectiveness (reduction in the sensation of muscular contraction in the muscle groups involved) are generally felt after around ten days and wear off after three months, thus possibly requiring a repeat of the injections, as it has already been noted by other teams in other indications (1, 5). Repeat injections thus need to be done every three months, but to avoid the appearance of antitoxin antibodies which would reduce their effectiveness, they should not be done more frequently than this. 
7 patients out of 8 showed a real improvement in their symptoms, which justified continuing investigations to evaluate the part played by this relatively non-invasive technique.  The average cost of a 100U Botox* injection is 200$ in a hospital setting, which should be compared with long-term cost of standard methods (non steroidal anti-inflammatories, type II or III analgesics, cervical physiotherapy)  and the loss of productivity due to extended periods of sick leave.  To our knowledge, this is the first time that the interest of the use of botulinum toxin has been established in this type of indication.  The follow-up period of patients was relatively short in our series but seems to point to, in a fairly small sample, the definite effectiveness of toxin injections, although no statistical study is possible, since there is no control group because of the size of the group concerned.  Nevertheless, the general impression, confirmed by the patients' experience, seems to suggest a potential place for its use amongst the array of treatments which can be offered in certain selected cases which associate bruxism and posterior cervical contractions.  It appears to us that the toxin could offer an interesting alternative in terms of cost, effectiveness and relative innocuousness.  Taking into account these limitations, the results observed seem to us to be sufficiently interesting to justify a case study with control group in the long term. 

Bibliography�:

1 - Arnaud S, Batifol D, Goudot P, Yachouh J.
Non surgical management of traumatic injuries of the parotid gland and duct using type A botulinum toxin.
Plast. Reconstr. Surg. 117 (7): 2426�2430, 2006.
2 - Babuccu B, Babuccu O, Yurdakan G , Ankarali H.
The effect of the Botulinum toxin-A on craniofacial development: an experimental study.
Ann Plast Surg. 63 (4): 449-456, 2009.
3 - Boghen D, Flanders M.
Effectiveness of botulinum toxin in the treatment of spasmodic torticollis. 
Eur. Neurol. 33 (3): 199�203, 1993.
4 - Dresel C, Bayer F, Castrop F, Rimpau C, Zimmer C, Haslinger B.
Botulinum toxin modulates basal ganglia but not deficient somatosensory activation in orofacial dystonia.
Mov Disord. 20 Mai 2011, doi: 10.1002/mds. 23497 (Electronic publication, awaiting printing)
5 - Ellis M, Laskawi R, Rohrbach-Volland S, Arglebe C.
Up-to-date report of botulinum toxin therapy in patients with drooling caused by different etiologies.
J. Oral Maxillofac Surg. 61 : 454�457, 2003.



6 - Finiels PJ, Batifol D.
Utilisation de la toxine botulinique dans les cervicalgies postop�ratoires en chirurgie rachidienne : r�sultats pr�liminaires. 
Neurochir. 56: 374-381, 2010.
7 - Hallet M.
One man�s poison: clinical applications of botulinum toxin. 
N. Engl. J. Med. 341 (2): 118�120, 1999.
8 - Hosono N, Yonenobu K, Ono K. 
Neck and shoulder pain after laminoplasty: A noticeable complication. 
Spine 21 (17): 1969�1973, 1996.
9 - Ihde SK, Konstantinovic VS.
The therapeutic use of botulinum toxin in cervical and maxillofacial conditions: an evidence-based review.
Oral Surg Oral Med Oral Pathol Oral Radiol Endod. 104 (2): 1-11, 2007.
10 - Knutson GA.
Vectored upper cervical manipulation for chronic sleep bruxism, headache, and cervical pain in children.
J Manipulative Physiol Ther. 26 (6): E 16, 2003.
11 - Kreyden OP, Geiges ML, B�ni R, Burg G. 
Botulinum toxin: from poison to drug. A historical review. 
Hautarzt 51 (10): 733�737, 2000.
12 - Lobbezoo F, Naeije M.
Dental implications of some common movement disorders: a concise review.
Arch Oral Biol. 52 (4): 395-398, 2007.

13 - Mann AC.
Localized autonomic failure due to botulinum toxin injection. 
J Neurol Neurosurg Psychiatr. 57 (11): 1320, 1994.
14 - Matsumoto, M, Watanabe K, Tsuji T, Ishii K, Takaishi H, Nakamura M, Toyama Y, Chiba K.
Risk factors for closure of lamina after open-door laminoplasty.
J Neurosurg. Spine 9: 530�537, 2008.
15 - O�Shaughnessy T.
Craniomandibular / temporomandibular / cervical implications of a forced hyper-extension / hyper-flexion episode (i.e., whiplash).
Funct Orthod. 11 (2): 5-10, 1994.
16 - Poewe W, Schelosky L, Kleedorfer B, Heinen F, Wagner M, Deuschl G.
Treatment of spasmodic torticollis with local injections of botulinum toxin: One year follow-up in 37 patients. J. Neurol. 239 (1): 21�25, 1992.
17 - Swope D, Barbano R. 
Treatment recommendations and practical applications of botulinum toxin treatment of cervical dystonia. 
Neurol. Clin. 26 (Suppl.1): 54�65, 2008.
18 - Takemoto M, Ikenaga M, Tanaka C, Sonobe M, Shikata J.
Cervical dystonia induced by cervical spine surgery: a case report. 
Spine 31 (1): E31�E34, 2006.
19 - Tsai CY, Yang LY, Chen KT, Chiu WC.
The influence of masticatory hypofunction on developing rat craniofacial structure.
Int J Oral Maxillofac Surg. 39 (6)�: 593-598, 2010.

20 � Watts MW, Tan EK, Jankovic J.
Bruxism and cranial-cervical dystonia: is there a relationship?
Cranio. 17 (3): 196-201, 1999.













































 PAGE   \* MERGEFORMAT 1




iju}~�����<	>	

�
8�����|��	����$��-L��elx���VXj���������������������ʻ�ʳ�����ᳫ����������ᳫ����������h�B*H*phh�CB*phh��B*phhG	RB*phh�B*phh�B*ph�hG	RhG	RhG	Rh�hlwhFhG	Rh�!�h�h�5�>*CJ0"hFh�5�CJOJQJ\�aJ8ij���<	=	>	?	@	7
8
O
|)������������������������gdG	R$a$gd�$
&Fd�a$gd�
$d�a$gd�$a$gdG	R$a$gd�gd�$a$gdG	R&'���op�jk�c d �$�$�$�$�%��������������������$
&Fd�a$gd�$�hd�^�ha$gd�$�hd�^�ha$gd�$
&Fd�a$gd�
$d�a$gd�$a$gd�&��1PR����c d m v w �!�!]"|"�"�"!#@#�$y%�%_(`(�()l))@,S,�,-1-P-�-�-
.
..%.&.�/�/�1�1�1�1�2�2�3�������������������������������������警Ҧ������hlwB*phh�6�B*]�phh�2[h�h�2[B*phhmQ�B*phhFB*phh�X�B*ph	h�H*h�X�h&iB*phh�B*H*phh�B*phh�h&ih�CJaJ7�%�(�()?,@,&.'.�0t1u16q78�:n@o@~@@�@AHA{A�A�ABaB�B�B����������������������������
$d�a$gd��3�3�4�4&565�56a6j6�6m7n75868�9�9�;�;n@o@~@@�@�@A5AHAlAmA{A�A�A�ABBBaBtB�B�B�C�C�C-DYDZD\D]D������������������Ƚ���Ƚ���Ƚ����Ƚ�|h�hlwB*mHphsHhlwB*mHphsHh�B*mHphsHh�h�B*mHphsHh�X�5�B*\�phh�5�B*\�phhlw5�B*\�phh�5�>*\�hlwB*phh�h�X�B*phh�B*phh�B*	phf0�B2C�C�C-DZD[D\D]DxD�DE$EaE�E�E�EF3F�F�F�F_G�G�G�GH5H~H����������������������������
$d�a$gd�]DxD�D�DEE E$EaEyE�E�E�E�E�E�E�E�EFF
FF3F�F�F�F�FcG�G�G�G�G�G�G	HH5H�H�H�H�H�H�H�HI&I7I8ImIuIyI�����Ĺ���ĹĹ����������������Ĺ��������Ĺ��������h�X�5�B*\�ph#h�B*CJ
OJQJ^JaJ
phh�X�B*phhlwB*phh�B*phh�5�B*\�phhlw5�B*\�phh�hlwhlwh�mHsHh�h�mHsH#h�h�5�B*\�mHphsH2~H�H�H�H�H&I�I�I�I�I�J�J�J|K�K�K(LcL�L�L�LBMvMwM�M�M�M�M���������������������������gd�
$d�a$gd�yI~I�I�I�I�I�I�I
J.JXJYJ�J�J�J�J�J�J�J�JK7KNKmK|K�K�K�K�K�K�KL(L_LcL�L�L�L�LBMuMvM������ԹԹ��Ԯ����ԹԛԐ��Թ��Ԑ����ԁuh�B*mHphsHh�h�B*mHphsHhlw5�B*\�phh�
B*phh�
5�B*\�phh�X�5�B*\�phh�FB*phh�5�B*\�phhlwB*phh�B*phh�X�h�5�B*phh�X�5�B*phh�X�h�X�5�B*ph)vMwM|M�M�M�M�MNNN!N"N$N%N'N(N*N+NBNCNDNENGNHNINJN���������������������h�W�h�!�mHnHuh�Fjh�FUh�>Bjh�>BUh�;�
h�CJhlwh�h�5�\�h�5�B*\�phh�h�
B*mHphsH�M�M�M�M�M�MNNNNNNNNN	N
NNN
NNNNNNNNNNN�����������������������������gd�NNNNNNNN N!N#N$N&N'N)N*NFNGNHNINJN��������������������$a$gd�Fgd�20p�1����. ��A!��"��#��$��%�������j���������666666666vvvvvvvvv666666>666666666666666666666666666�6666666666�666666666666hH66666666666666666666666666666666666666666666666666666666666666666�62���� 0@P`p������2(�� 0@P`p������ 0@P`p������ 0@P`p������ 0@P`p������ 0@P`p������ 0@P`p��8X�V~ OJPJQJ_HmHnHsHtHX`�X�Normal*$,CJKHOJPJQJ^J_HaJmH	sH	tH:A �:
Police par d�fautVi�V0Tableau Normal�4�
l4�a�2k �2
0Aucune listeN��N
�0Texte de bullesCJOJQJ^JaJf��f�0Texte de bulles Car(CJKHOJPJQJ^JaJmH	sH	tH66
�F0En-t�te

��p#V��!V�F0En-t�te Car(CJKHOJPJQJ^JaJmH	sH	tH@ @2@�F0Pied de page

��p#`��A`�F0Pied de page Car(CJKHOJPJQJ^JaJmH	sH	tHPK!����[Content_Types].xml���j�0E����ж�r�(��΢Iw},��-j��4	��w�P�-t#bΙ{U�����T�U^h�d}㨫��)��*1P�'��	�^��W��0)��T�9<�l�#��$yi}��;�~@��(��H����u�*Dנz��/0�ǰ��$��X��3aZ����,�D0j~�3߶�b��~i>���3�\`�?�/�[���G��\�!�-�Rk.�s�Ի�..���a濭?��PK!�֧�6_rels/.rels���j�0���}Q��%v/��C/�}�(h"���O�
����=������ ����C?�h�v=��Ʌ��%[xp��{۵_�Pѣ<�1�H�0���O�R�Bd���JE�4b$��q_����6L�R�7`������0̞O��,�En7�Li�b��/�S���e��е�����PK!ky���theme/theme/themeManager.xml�M
� @�}�w��7c�(Eb�ˮ��C�AǠҟ����7��՛K
Y,�
�e�.���|,���H�,l����xɴ��I�sQ}#Ր���� ֵ+�!�,�^�$j=�GW��)�E�+&
8���PK!�o��Qtheme/theme/theme1.xml�YOoE�#�F{oc'vGu�رh�F�[��xw�;���jf��7���q�7�P����%PE�W����z'^����������o��^�r/f�Iy��k"����m�ְa�CR�$��'��M��l���e��"����^�T���$}��"OIsc.b��U�K���@7fK˵��R�i��@v��
�9S�x9���z�gb�i�lI	��5BNe�	t�Y�F?�{�CKm�f~����%��-bj��Һ��e�����)�Q���o�.m�
��y\����=���ZY�4��z'�Y��y��Z��p�%�+s2�:�N���b��}l���j���eo@ߜ�7:��7 �_��/�V.ހ"F��9�vh��Q/ cζ+�k_�e�
���.�b��(�b|��>4�aE��)c¸�㑠X3���f�/�4/$}AS��O1�Č��g߽|��zt�ǣ��`	9��q�W����?}��x�Ջ��U�e����ӧ�@H��8�?����Ͽ���oV�7��C�n�C��cP�Xŕ����V#L�+6�P�k.�{*r�7��e�q��ׂ���*���]G�A$&�Vp��p�s���
�4�����$�f.&e��U��8q�ۛ�P7�t�F�s��D�$D!=�	�����]w�/��c��P���$C:r�i�h���i���o�6;�Q��*��ȁ�����B�!a����q�!�Y��ױ���L�_��O��q���Ukn
з��k*V��w�4v�B�*��1�e���F8N���De�{rB�]���;���~��Bwߦ�q����
�f�g&B�J�S�c��]9f걍��+�P���"���B�	{RU&l+��pNjn�����5wO�]a>��-�oK���/���vV[���6ŦE�v�c��@M�.M�,a��0�י�!)NLi�Y]wp��f
\}@U4�p

v��DB��%J��������Ф+{,l������=��
2f�	��3g��	���ʥ�(��*��Z�Ss��L�s�*��U��šЀ h[�ʫp@׬�`�	���ޛ��x�<]$#��GZ�yՍ��X17;>҇��V���d_��i�Tf�X�.���x)��t�KG����%���M�8m{c8��c��ץ�0�f�W†���l�|��V���u���v�Sة��j�Ȇ���B�%����	f=/l���+k��`G׵d<&�*;�4�mg_�R�'��A���=�ס
�T�Մ���Ѵ�͔[���+�^��,�pVnu��l�&��[I<ЭRv���U1)N������O�`%���W`���q�"U(����8���w�0
A��� ���9Kä5��
����H�e�D�	����eI�������2�b��aC]W���B�T����s߳���)�SC����?��d��:l������]o��{oY=1k�yV��V���E8�Vk+֜���\8���0X4D)� ��?*|f�L�
u���"�Р�A�@T_������q��6�4)kڬu�V�7�s�t�nj�%;���h�9s�9�x���,��ڎ-45x�x���8?�ǘoZ�N|t�����	&��$0�������Y����PK!
ѐ��'theme/theme/_rels/themeManager.xml.rels��M
�0���wooӺ�&݈Э���5
6?$Q��
�,.�a��i����c2�1h�:�q��m��@RN��;d�`��o7�g�K(M&$R(.1�r'J��ЊT���8��V�"��AȻ�H�u}��|�$�b{��P����8�g/]�QAsم(����#��L�[������PK-!����[Content_Types].xmlPK-!�֧�6+_rels/.relsPK-!ky���theme/theme/themeManager.xmlPK-!�o��Q�theme/theme/theme1.xmlPK-!
ѐ��'�	theme/theme/_rels/themeManager.xml.relsPK]�
<?xml version="1.0" encoding="UTF-8" standalone="yes"?>
<a:clrMap xmlns:a="http://schemas.openxmlformats.org/drawingml/2006/main" bg1="lt1" tx1="dk1" bg2="lt2" tx2="dk2" accent1="accent1" accent2="accent2" accent3="accent3" accent4="accent4" accent5="accent5" accent6="accent6" hlink="hlink" folHlink="folHlink"/>JFj����	***-�3]DyIvMJN(+-/12�%�B~H�MNJN)*,.034$&-!����t��4R�$�Λ 7e!�4�����b�$r�&bb�������b�$����1bc�������b�$O��� T#u�������b�$���2�+$u�:����b�$��G1�/�����b�$O�1��&�3�i�����@�����������0�(	�
��B
�S����	?�JFCJnuz}������@I���
-8��%0R\��%S\kv*1������R	Z	


mu8
A
L
V
W
c
��$2����x�����	PX����	 (rz����IRgq����������5=��nx��������/8x���<EN[`g����, 9 : A � � � � !!�!�!k#s#u#~#&&e&p&|&�&n'y'J(X(�(�(�(�(u)~)�)�))*/*}*�*�*�*P,[,u-�-..T._.z.�.�.�.�.�.�.///5/?/60@044�4�477�8�8�8�8�8�899999&9L9S9W9^9b9j9o9w9�9�9�9�9�9:%:.:S:^:�:�:�:�:�:�:�:�:�:�:;;;';(;0;2;5;6;<;K;N;X;[;�;�;�;�;�;�;�;�;5<?<@<D<a<h<m<t<�<== =O=X=�=�=�=�=�=�=>> >.>J>S>�>�>�>�>�>�>�>�>-?4?n?u?v?z?�?�?�?�?�?�?�?�?�?@@'@+@1@�@�@�@�@�@AAAWA_A�A�A�A�A�ABB"B�B�B�B�B�B�B�B�B�B�B�B�B�B�BC
C'C0C�C�C�C�C�C�CDD-D5D9D@DNDTDXD_DlDtD�D
EEEMEWEXE\E�E�E�E�E�E�E�E�EFF F F!F!F#F$F&F'F)F*FHFKFj�����		�
�
��Y_�)�)�*�*1-.v2�2o8}899999'9k9n9�9�9:_:�;,<�<=�>�>�>^?_?{?�?�?�@�@�@A�A�A�A�A�A�B�C�C�DAE�E�EFF F F!F!F#F$F&F'F)F*FHFKF3333333333333333333333333333333j��8O�
�
'p�k���n:�:=$=�>�>�?@~@�@�A�A�D�D�EFFF F F!F!F#F$F&F'F)F*FHFKF�������������������8�0��8^�8`�0�-�������^��`���.�p�L��p^�p`�L�..�@����@^�@`���...�����^�`���....	���L���^��`�L�
.....	�������^��`���......	
�������^��`���.......	
�P�L��P^�P`�L�........�������^��`���OJQJ^J-��8����8^�8`���OJQJ^J-��������^��`���OJQJ^J-������^�`���OJQJ^J-��p����p^�p`���OJQJ^J-���	�����	^��	`���OJQJ^J-��@����@^�@`���OJQJ^J-��������^��`���OJQJ^J-������^�`���OJQJ^J-�����������WWNum3����C�
�F�F�>BG	R�2[&ilw�W�mQ��!�5T��;����X�F F�@�����JFp@��Unknown������������
G��* ��Times New Roman5��Symbol3.��* ��Arial]�GulliverRMTimes New Roman7.���{ @�Calibri7���K@�Cambria;��SimSun�[SO5.�*a��Tahoma_�OpenSymbolArial Unicode MSA���� B�Cambria Math"1���������/�
U;#�~�
U;#~!�������0�E�E2����HX	�$P�����������������������2!	xx���Secr�tariatSecr�tariat����Oh��+'��0p��������	
,8
DPX`h�Secr�tariatNormalSecr�tariat8Microsoft Office Word@�ِ@ �&6]�@.{�@]��
U;����՜.��+,��0�hp|�������
���~#�ETitre	

 !"#$%&'()*+,-./012345����789:;<=>?@ABCDEFGHIJKLMN����PQRSTUV����XYZ[\]^��������a����������������������������������������������������������������������������������������������������������������������������Root Entry��������	�F�RA]�c�1Table��������6H0WordDocument��������4jSummaryInformation(����ODocumentSummaryInformation8������������WCompObj������������y������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������
����	�F'Document Microsoft Office Word 97-2003
MSWordDocWord.Document.8�9�q

Youez - 2016 - github.com/yon3zu
LinuXploit