An Eleven-Point Ultrasound-Guided Fascia Hydrorelease Protocol for Non-Odontogenic Toothache and Orofacial Pain: A Clinical Protocol

1. Introduction

Non-odontogenic toothache is defined as pain perceived in the dental region but originating from non-dental tissues. The Japanese Society of Orofacial Pain’s clinical guideline [1] categorizes it into eight types: (i) muscular/myofascial toothache, (ii) neuropathic toothache, (iii) neurovascular toothache, (iv) maxillary sinus-related toothache, (v) cardiac toothache, (vi) toothache associated with psychiatric disorders or psychosocial factors, (vii) idiopathic toothache, and (viii) toothache caused by various other diseases. Among these, category (i) reflects pain of myofascial origin; however, this definition does not address fascia-derived pathology in the broader sense, which encompasses aponeuroses, paraneural sheath and fascia around the nerve, perivascular fascia, spaces between fasciae, and fat pads [2].

In our 2020 Dental Diamond article [3], we showed that fascial abnormalities—including stacking, densification, and adhesion—can act as primary pain generators in non-odontogenic toothache. We described the procedures of ultrasound-guided fascia hydrorelease (US-FHR) in four representative treatment regions (Kimura et al., 2020) [3]: (1) temporalis/lateral pterygoid/masseter, (2) medial pterygoid/fat pad, (3) temporomandibular joint capsule complex, and (4) sternocleidomastoid/levator scapulae. The present article builds upon this foundation, drawing on subsequent clinical experience at the corresponding author’s institution, in which these four regions have been progressively reorganized into a standardized eleven-point protocol (including POINT 11, which addresses vascular and perivascular structures); the rationale for each intervention point is systematically presented from the perspective that fascial pathological changes (densification, stacking, and impaired gliding) are clinically common contributors to such pain.

Newly described POINTs include an intraoral approach to the medial pterygoid, release of the superficial parotid fascia and an integrated approach to the cervical sympathetic ganglion region, the upper posterior cervical region, the digastric muscle, the pterygopalatine fossa, and the perivascular fascia of the facial artery.

The aim of the present article is to present the current standardized eleven-point protocol and to organize it in a form that can serve as a shared operational framework for pain physicians, dentists, physical therapists, and acupuncturists. A focused literature search was conducted in PubMed and Ichushi Web from January 2010 to May 2026, using the keywords “non-odontogenic toothache,” “fascia,” “ultrasound-guided injection,” “masticatory muscle pain,” “trigger point,” and related terms. Relevant articles on the anatomy, referred-pain pattern, and safety of each treatment point were extracted and organized as a clinically grounded synthesis.

The recognition that fascia—a continuous connective tissue system encompassing the muscular fascia, aponeuroses, paraneural sheath and fascia around the nerve, perivascular fascia, and other related structures [2]—can serve as a major source of pain has not been sufficiently addressed in contemporary medical and dental education. As a result, patients with non-odontogenic toothache that has become chronic and labeled as “pain of unknown origin” frequently fall into the following clinical vicious cycle:

(i)

Repeated unnecessary pulpectomy and tooth extraction after the exclusion of odontogenic origins;

(ii)

Transition to pharmacological management labeled as psychogenic or neuropathic pain;

(iii)

Long-term combined use of antidepressants, anxiolytics, and hypnotics;

(iv)

Symptom complexity arising from psychotropic medications and polypharmacy;

(v)

Persistent oversight of fascia as a major source of pain, leading to chronification.

The systematization presented in this article responds to this clinical reality by repositioning fascia as a principal pathological substrate of pain and by aiming for a shared interdisciplinary language for pain physicians, dentists, therapists, and acupuncturists, thereby supporting education and standardization across professions.

Furthermore, in a previous cadaveric study (10 cadavers, 20 injections), the corresponding author and colleagues demonstrated that 1.0 mL of dye solution injected under ultrasound guidance spreads over a wide area between epimysiums, measured as 24.50 cm2 and 18.82 cm2 on the deep and superficial sides, respectively [4]. This finding provides the biomechanical rationale for the small injection volume of 1–2 mL used at each POINT in the present protocol. The same study also identified the out-of-plane (oblique) approach as the most accurate technique for injection between epimysiums, supported by anatomical verification.

A recent anatomical study by Shiwaku, Pirri, Stecco and colleagues [5] provides further support. Using five fresh-frozen cadavers and eight limbs, they demonstrated that 2.5 mL of saline injected under ultrasound guidance mainly distributes into the space between the aponeurotic fascia (APF) and epimysium (EPI). This finding offers an important anatomical foundation for the APF–epimysial targeting strategy adopted in the present protocol. This article integrates these recent findings and organizes them as an eleven-point ultrasound-guided fascia hydrorelease protocol for non-odontogenic toothache and orofacial pain.

2. Background

2.1. Definition of Fascia

Anatomically speaking, fascia is a comprehensive concept (Stecco and Schleip [2]) encompassing myofascia, retinacula, ligaments, tendon sheaths, joint capsules, fat pads, peripheral neural fascia, meningeal fascia, the dura mater–ligamentum flavum complex, and vascular fascia. The Stecco group has proposed the concept of the fasciatome—analogous to the cutaneous dermatome—to organize the functional fascial territories supplied by each nerve root [6].

2.2. Fascial Pain Syndrome (FPS)

Pain of myofascial origin has traditionally been described as myofascial pain syndrome (MPS) (Travell, Simons & Simons’, 3rd ed. [7]). However, pain generators are increasingly recognized in fascial structures other than myofascia. In July 2019, we proposed Fascial Pain Syndrome (FPS) as a successor concept to MPS [8]. FPS is characterized by sensory, motor, and autonomic symptoms caused by fascial abnormalities, and its treatment requires identification of the fascia acting as the pain generator. On ultrasound, the pain-generating fascia is observed as a white, thickened, hyperechoic image referred to as stacking fascia [3].

2.3. Ultrasound-Guided Fascia Hydrorelease (US-FHR)

US-FHR is a procedure in which an abnormal fascia is identified under ultrasound, released with an injection of saline or some other solution, providing analgesia together with improved fascial flexibility (extensibility and gliding). It is a representative treatment technique for FPS [3]. According to fascial adhesion strength, a graded therapeutic hierarchy from Grade 0 (very weak, manual) to Grade 4 (very strong, surgery) has been proposed. US-FHR occupies the Grade 2–3 range and consists of a precise injection of saline or bicarbonate Ringer’s solution through a 27–30 G fine needle.

2.4. Anatomical Rationale for Fascia-Derived Non-Odontogenic Toothache

The masticatory muscles (masseter, temporalis, lateral pterygoid, and medial pterygoid) are innervated by the third division of the trigeminal nerve (mandibular nerve) and are classically known to elicit strong referred pain to the dental region [7]. Wright (2000) [9] quantitatively documented, in 230 patients with temporomandibular disorder (TMD), referred-pain patterns from masticatory muscle trigger points (TrPs) projecting to broad orofacial regions including the teeth. In women with TMD, Fernández-de-las-Peñas et al. (2010) [10] showed that referred-pain areas from TrPs in the masticatory and neck–shoulder muscles were significantly enlarged compared with controls. Svensson and Graven-Nielsen (2001) [11] comprehensively reviewed the mechanisms of craniofacial muscle pain and its referred pain in dental and facial regions. In the cadaveric anatomical study approved by the Nihon University Ethics Committee (approval number 28-8-0), it was shown that the temporalis attaches not only to the tip of the coronoid process but also broadly to the anterior and posterior surfaces of the coronoid process and the lateral pterygoid plate of the sphenoid, wrapping around the mandible; the lateral pterygoid attaches to the surface and posterior margin of the lateral pterygoid plate; the medial pterygoid attaches to the anterior and posterior surfaces of the lateral pterygoid plate and to the maxilla; and fat pads are present between these muscle layers [3]. The broad insertion sites of these muscles and the fat pads between them constitute an anatomical environment in which fascial densification and stacking are prone to develop, providing the anatomical basis by which these TrP/fascial pain sources generate referred pain from the masticatory region to the dental region—that is, fascia-derived non-odontogenic toothache.

The present protocol clinically targets—under ultrasound guidance—the fascial pathologies (such as densification between epimysiums and fat-pad adhesion) that are considered to underlie the referred-pain patterns classically described as TrP-related.

2.5. Anatomical Predilection Sites of Stacking Fascia (Memory Reset Hypothesis)

In our prior paper outlining the Fascial Memory Reset Hypothesis [12], stacking fascia—the macroscopic layered structural phenotype visualized on ultrasound—was interpreted as the mechano-epigenetic structural memory formed under sustained mechanical stress. In Section 3.1 of that paper, eight anatomical predilection sites for stacking fascia were summarized as follows:

• #1 Curved regions of tissues—e.g., curvature of the vertebral artery, facial artery bending, and curvature of the masseter muscle fibers.
• #2 Crossing points of tissues—e.g., crossing of the masticatory and hyoid muscles.
• #3 Convergence zones of multiple tissues—e.g., temporomandibular joint capsule complex (convergence of capsule, ligaments, and muscle attachments) and temporalis insertion.
• #4 Peritubular regions of nerves and vessels—e.g., pterygopalatine fossa (maxillary nerve and artery passage) and carotid sheath.
• #5 Periarticular fat pads—e.g., fat pad between the masseter and lateral pterygoid (buccal fat pad).
• #6 Superficial course of neurovascular structures—e.g., superficial parotid region (the facial nerve and parotid duct run beneath the superficial fascia [the superficial musculoaponeurotic system, SMAS]) and superficial course of the facial artery.
• #7 Ligamentum flavum and epidural space—e.g., C0–1 posterior atlanto-occipital membrane and C1–C2 ligamentum flavum/dural region.
• #8 Predilection sites for accessory muscles—e.g., accessory masticatory muscles.

Each treatment point in the present eleven-point protocol corresponds to one or more of these eight categories (often a combination) and is thereby anatomically grounded. In particular, integrated POINT 3 (lateral pterygoid/fat pad/maxillary artery/pterygopalatine fossa) corresponds to the composite of #1 + #4 + #5 + #6, POINT 11 (upper posterior cervical) corresponds to #7 (PAOM and ligamentum flavum) + #1 (vertebral artery curvature) + #6 (perivascular fascia of the vertebral artery), and POINT 7 (superficial parotid) corresponds to #6 (superficial course of neurovascular structures). The corresponding category is explicitly indicated at each POINT in Section 6.

3. Methods: Protocol Development Framework

This article synthesizes the eleven-point protocol from two complementary sources: (i) a focused literature search of the fascia, orofacial pain, and ultrasound-guided fascia hydrorelease domains, and (ii) the corresponding author’s over-a-decade clinical experience encompassing an estimated 360,000 or more US-FHR procedures across all anatomical regions, of which a substantial portion involved orofacial and cervical structures relevant to non-odontogenic toothache. Rather than a systematic review, this work presents a clinically-grounded synthesis aimed at articulating an actionable intervention framework.

The literature search was conducted in PubMed and Ichushi Web from January 2010 to May 2026, using the keywords “non-odontogenic toothache,” “fascia,” “ultrasound-guided injection,” “masticatory muscle pain,” “trigger point,” and related variants, consistent with the search strategy described in the Abstract. Articles were prioritized when they (a) described relevant fascial anatomy or pathophysiology, (b) reported clinical outcomes of fascial or myofascial interventions, or (c) provided foundational anatomical or histological evidence underpinning the proposed intervention points. Both peer-reviewed publications and authoritative monographs (Travell-Simons, Stecco group, JNOS publications) were included.

The clinical experience component was derived from the corresponding author’s clinical practice at a specialized pain clinic (Kimura Pain Clinic, Maebashi, Japan), encompassing over a decade of practice and an estimated 360,000 or more US-FHR procedures across all anatomical regions (an order-of-magnitude estimate: approximately 150 procedures/day x 20 days/month x 12 months x 10 years; see Kimura et al. [13] for the derivation). Procedures were performed under real-time ultrasound guidance. The eleven-point selection was progressively refined through this accumulated practice, evolving from the original four-region framework described by our group in 2020 (Dental Diamond) into the present eleven-point protocol.

Specific criteria for inclusion in the final eleven-point set were: (a) anatomical correspondence to one or more of the eight stacking-fascia categories described in Section 2.5; (b) reproducible identification of densified (stacking-pattern) fascia at the proposed site on high-frequency ultrasound; (c) consistent clinical responsiveness to US-FHR observed across the corresponding author’s accumulated case experience; and (d) sufficient safety margin given the regional neurovascular anatomy. Sites that did not meet these criteria, or for which clinical responsiveness was inconsistent, were not included in the final protocol.

This synthesis is presented as a clinically grounded clinical protocol article rather than a systematic review. The methodology aims to articulate an actionable framework based on accumulated clinical practice, and does not include formal grading of evidence quality or quantitative synthesis.

4. Diagnosis and Evaluation

This section briefly summarizes the diagnostic reasoning required to provide clinical context for the subsequent treatment protocol. A comprehensive review of differential diagnosis is beyond the scope of this article.

4.1. Clinical Presentation

Non-odontogenic toothache is clinically diagnosed as persistent dental region pain that remains after dental examinations (pulp electric testing, occlusal examination, and imaging) have excluded organic dental disease. According to the classification of the Japanese Society of Orofacial Pain (2019) [1], fascia-derived pain sources should be considered as a major component, especially in cases of refractory pain that is not improved by conventional dental treatment.

Clinical features include (a) an absence of dental abnormality on dental examination, (b) typical referred-pain patterns (masseter → maxillary/mandibular molars; temporalis → maxillary molars and temple; medial pterygoid → mandibular molars and tongue; perivascular facial artery → mandibular anterior region), (c) trigger-point–like tenderness on palpation of the masticatory, parotid, cervical, or perivascular regions, (d) visualization of stacking fascia on ultrasound, and (e) when elicitable, reproduction of the patient’s dental pain by palpation of the candidate pain source is confirmatory.

4.2. Pain Sources Classified by Tooth Location and Referred Pattern

Based on the location of the dental pain and the referred-pain pattern, candidate pain-source muscles and fasciae can be inferred. Classically, Travell, Simons & Simons [7] systematized the dental referred-pain patterns of masticatory muscle trigger points (TrPs). In 230 patients with temporomandibular disorder (TMD), Wright (2000, J Am Dent Assoc) [9] quantitatively documented referred-pain patterns from masticatory muscle TrPs projecting to broad orofacial regions including the teeth. Fernández-de-las-Peñas et al. (2010, J Pain) [10] showed quantitatively, in women with TMD, that the referred-pain areas of TrPs in the masticatory and neck–shoulder muscles are significantly enlarged compared with controls. Svensson and Graven-Nielsen (2001, J Orofac Pain) [11] comprehensively reviewed the mechanisms of masticatory muscle pain and its referred-pain projection to dental and facial regions. Under ultrasound guidance, the present protocol clinically targets the fascial pathologies (such as densification between epimysiums and fat-pad adhesion) that are considered to underlie these referred-pain patterns.

• Maxillary molar region: Masseter (POINT 1), temporalis (POINT 2), medial pterygoid (POINTs 4–5), superficial parotid (POINT 7), and lateral pterygoid/pterygopalatine (POINT 3 integrated POINT).
• Maxillary premolar region: Masseter (POINT 1), medial pterygoid (POINTs 4–5), superficial parotid (POINT 7), and lateral pterygoid/pterygopalatine (POINT 3).
• Maxillary anterior teeth: Superficial parotid (POINT 7) and lateral pterygoid/pterygopalatine (POINT 3).
• Mandibular molar region: Masseter (POINT 1), medial pterygoid (POINTs 4–5), TMJ capsule (POINT 6), and perivascular fascia of the facial artery (POINT 10).
• Mandibular premolar region: Medial pterygoid (POINTs 4–5), digastric (POINT 8), and perivascular fascia of the facial artery (POINT 10).
• Mandibular anterior teeth: Digastric (POINT 8) and perivascular fascia of the facial artery (POINT 10).
• Toothache associated with periarticular symptoms: Lateral pterygoid (POINT 3), TMJ capsule (POINT 6), and medial pterygoid (POINTs 4–5).
• Refractory cases with referred pain from upper teeth to deep eye to temple: Upper posterior cervical (POINT 11, Advanced).
• Toothache with swallowing pain or lingual discomfort: Digastric (POINT 8).
• Toothache with headache or autonomic symptoms: Cervical sympathetic ganglion region (POINT 9).

5. Ultrasound-Guided Fascia Hydrorelease (US-FHR) Procedure

5.1. Principles

In the present protocol, ultrasound-guided fascia hydrorelease (US-FHR) is performed using a linear probe (or, depending on the site, in combination with a convex probe) to identify pathological stacking fascia and to inject 1–2 mL of physiological saline or bicarbonate Ringer’s solution into the space between epimysiums using a 27 G 38 mm needle (30 G is used at POINTs 3, 5, 7, 10, and 11). Based on anatomical evidence of its superior accuracy, the out-of-plane (oblique) approach is used as standard [4].

5.2. Safety Considerations

In the present protocol, safety is supported by (1) the use of fine 27–30 G needles via the out-of-plane technique (30 G at POINTs 3, 5, 7, 10, and 11), (2) Color Doppler identification of vascular structures prior to each release (Doppler is then turned off to optimize B-mode needle visualization), (3) continuous visualization of the needle tip under ultrasound guidance, (4) careful avoidance of intravascular and intraneural injection, and (5) immediate cessation of injection if abnormal resistance is felt. POINT-specific cautions are described in the respective sections.

As listed in our previous article [3], general complications related to this procedure include vascular puncture with bleeding/hematoma, infection at the puncture site, post-injection pain, and delayed muscle soreness. Color Doppler identification of vessels, strict aseptic technique, the use of fine needles via the out-of-plane approach, and minimization of injection volume contribute to risk mitigation.

The standard descriptive format for each POINT is as follows [3]: (1) patient positioning, (2) the injection site indicated by a yellow arrow, and (3) the release area indicated by a yellow dashed line.

5.3. Anatomical Rationale for Needle Technique and Injection Volume [4]

All injections were performed using a 27 G needle via the out-of-plane (oblique) approach (30 G is used at POINTs 3, 5, 7, 10, and 11). The rationale for this selection is supported by the corresponding author’s previous cadaveric study (Kimura H et al., Pain Med 2020 [4]). The out-of-plane approach has the following advantages over the in-plane equivalent:

• Allows the highest accuracy of injection into the space between epimysiums using a fine 27 G 38 mm needle.
• (2) The injection and dispersion origin are close to the puncture site, facilitating anatomical landmark identification during the procedure.
• (3) Avoids the upward spread along the needle path and the distribution accuracy loss that may occur with the in-plane approach.
• (4) Less invasive in clinical practice than the in-plane approach.
• (5) Modern ultrasound devices with simple needle visualization functions provide sufficient needle visibility even with the out-of-plane approach.

Regarding injection volume, the same cadaveric study demonstrated that only 1.0 mL of solution spreads across a wide area between epimysiums (median 24.50 cm² on the deep side and 18.82 cm² on the superficial side; p = 0.033). This provides the biomechanical rationale for the 1–2 mL volume used at each POINT in the present protocol.

6. The Eleven-Point Protocol

This chapter describes the eleven-point standardized protocol by region. Each POINT is described according to the following structure: anatomy, referred-pain pattern, ultrasound technique, and US-FHR procedure.

6.1. Masticatory Muscle Region (POINTs 1–3)

The masticatory muscle region is a further development of POINT 1 from our previous article [3] (temporalis/lateral pterygoid/masseter). Through accumulated clinical experience, the masseter, temporalis, and lateral pterygoid have been recognized as independent pain sources and are described here as three separate POINTs.

POINT 1: Masseter (superficial and deep layers)

The masseter consists of a superficial and a deep layer, separated by a thin fascia between the two epimysial layers. Referred pain involves the upper and lower molars, preauricular region, and cheek [7]. The probe is held perpendicular to the inferior border of the zygomatic arch to image the masseter in the short axis.

• Anatomy: From the zygomatic arch to the lateral surface of the mandibular ramus; innervated by the third division of the trigeminal nerve.
• Referred pain: Upper and lower molars, preauricular region, cheek, and temple.
• Ultrasound: Inferior border of the zygomatic arch; a convex probe is advantageous for an overview.
• US-FHR: 27–30 G needle, 1–2 mL into the space between the superficial and deep epimysiums of the masseter; high safety (Figure 1).

POINT 2: Temporalis (anterior and posterior, integrated)

The temporalis is a broad fan-shaped muscle with anterior, middle, and posterior functional subdivisions. Referred pain involves the maxillary molars, the temple, and the frontal region, and often presents as tension-type-headache-like symptoms [7]. The probe is positioned over the temporal region above the zygomatic arch.

• Anatomy: From the temporal fossa to the coronoid process of the mandible.
• Referred pain: Maxillary molars, temporal headache, frontal region, periorbital region.
• Ultrasound: A linear probe is placed over the temporal region above the zygomatic arch to image the temporalis in the short axis.
• US-FHR: 27–30 G needle, 1–2 mL into the muscle belly and the fascia at the coronoid process insertion (Figure 2).

POINT 3: Lateral pterygoid/fat pad/perivascular maxillary artery/pterygopalatine region (integrated POINT)

The lateral pterygoid has a superior and an inferior head and is the prime mover of mouth opening and lateral mandibular movement. Between the deep layer of the temporalis and the superficial aspect of the lateral pterygoid, there is a continuous fascia between the two muscles containing the fat pad and the maxillary artery (running toward the pterygopalatine ganglion). With a single linear-probe approach, multiple adjacent structures are simultaneously addressed; this is the conceptual core of the integrated POINT.

• Anatomy: Fascia and fat pad between the deep layer of the temporalis and the superficial aspect of the lateral pterygoid and the maxillary artery (running toward the pterygopalatine ganglion); from the lateral pterygoid plate to the articular disc and the condylar process.
• Referred pain: Periarticular region of the TMJ, deep ear pain, occlusal pain, maxillary molars, maxillary sinus and nasal area, and autonomic-related symptoms.
• Ultrasound: A linear probe is placed over the cheek inferior to the zygomatic arch; after confirming the temporalis and the coronoid process, the deep lateral pterygoid, fat pad, and maxillary artery are imaged in the short axis. Color Doppler identification of the maxillary artery is mandatory for safety.
• US-FHR: 30 G needle, 1–2 mL into the fat pad between the lateral pterygoid and the deep masseter, and into the perivascular fascia of the maxillary artery. After confirming the maxillary artery with Color Doppler, Doppler is turned off to maintain clear B-mode visualization during the release (Figure 3).

6.2. Medial Pterygoid and Joint Capsule Region (POINTs 4–6)

POINT 4: Medial pterygoid (extraoral approach)

• Anatomy: The medial pterygoid arises from the maxilla and from both surfaces of the lateral pterygoid plate, inserting on the medial surface of the mandibular ramus. Referred pain involves the periarticular region of the TMJ, mandibular molars, medial cheek, tongue, and palate. The fascia around the masseter and medial pterygoid—and the fat pad between them—function as the pain generator. Insertion points of the temporalis, lateral pterygoid, and medial pterygoid are shown in Figure 4 (Nihon University Ethics Committee approval number 28-8-0).

Precise correspondence of insertion sites:

-

Temporalis: Both surfaces of the coronoid process and the lateral pterygoid plate.

-

Lateral pterygoid: Anterior and posterior margins of the lateral pterygoid plate.

-

Medial pterygoid: Maxilla and both surfaces of the lateral pterygoid plate.

This corresponds to POINT 2 (medial pterygoid/fat pad) in our previous article [3]. To contrast it with POINT 5 (intraoral approach), in the present article, this POINT is explicitly designated as the extraoral approach.

• Referred pain: Temporomandibular joint region, mandibular molars, medial cheek, tongue, and palate. Effective for periarticular TMJ pain.
• Ultrasound: With the mouth half-opened and a convex probe, a panoramic ultrasound view facilitates the identification of the relevant structures. The patient positioning and imaging procedure is as follows:

① Lateral decubitus position with the affected side upward. The operator stands on the patient’s dorsal side.

② Image the temporalis in the short axis using the same imaging approach as for the temporalis/lateral pterygoid/masseter (Figure 2 and Figure 3 in the present article).

③ Slide the probe slightly caudally to display the bony outline of the coronoid process of the mandible.

④ From the oral side of the coronoid process, the structures appear from superficial to deep as follows: masseter, fat pad, and medial pterygoid.

⑤ While imaging with ultrasound, palpate intraorally posterior to the back molars toward the maxilla; medial pterygoid movement can be confirmed.

US-FHR: Release the space between the medial pterygoid and the fat pad, or the fat pad itself (step ⑥).

-

Needle: 27 G 38 mm (using the needle length for the extraoral approach; out-of-plane).

-

Target: The space between the medial pterygoid and the fat pad, or the fat pad itself.

-

Injection volume: 1–2 mL (mainly physiological saline).

-

Injection site: Indicated by the yellow arrow.

-

Release area: Indicated by the yellow dashed line (the fat pad and the surrounding fascia).

Possible complications include vascular puncture with bleeding/hematoma, infection at the puncture site, post-injection pain, and delayed muscle soreness. Color Doppler vessel identification, a strict aseptic technique, the use of fine needles via the out-of-plane approach, and minimization of injection volume contribute to risk reduction.

The following are clinical key points (in addition to the standard procedure of [3], Steps ①–⑥):

-

Have the patient open the mouth widely. This shifts the mandible downward and enlarges the space between the coronoid process and the maxilla, securing a safe access route to the medial pterygoid.

-

Insert the needle from the anterior to the coronoid process. This enables a safe and efficient needle approach to the superficial aspect of the medial pterygoid and the fat pad.

-

These additional clinical tips extend the standard procedure and contribute to safety and efficiency.

POINT 5: Medial pterygoid (intraoral approach)—newly added

The medial pterygoid can also be approached intraorally, particularly in cases of limited mouth opening or pronounced deep fascial densification, where the intraoral approach is advantageous. This POINT is not described in our previous article [3] and was conceived by co-author Dr. Tadashi Kobayashi (Development of Community Healthcare, Hirosaki University Graduate School of Medicine). The anatomical landmarks for ultrasound-guided intervention to the lateral pterygoid muscle have also been detailed by Bae et al. (2025) [14] and Lee et al. (2024) [15] as safety zones for botulinum toxin injection.

• Anatomy: From the intraoral approach, posterior to the maxillary tuberosity, directly into the medial pterygoid muscle belly.
• Referred pain: The same as the extraoral approach.
• Indications: Limited mouth opening, pronounced deep fascial densification, cases complicated by contracture of the lateral pterygoid.
• US-FHR: 30 G needle, 0.5–1 mL via the intraoral route. Collaboration with a dentist is essential for safe execution (Figure 5).

POINT 6: Temporomandibular joint capsule complex

The temporomandibular joint capsule complex consists of the fibrous joint capsule (including ligamentous components) and the muscular insertions such as the lateral pterygoid, which are anatomically continuous without distinct tissue boundaries. As with the shoulder joint capsule, this POINT is treated as a unified structural complex, with the operator releasing this entire complex as a single target.

• Anatomy: Inferior to the zygomatic arch; condylar process of the mandible, articular disc, joint capsule, and lateral pterygoid insertion.
• Referred pain: Periarticular TMJ region, pain on opening/closing, and occlusal discomfort.
• Ultrasound: Probe perpendicular to the zygomatic arch; the condylar process is tracked by sliding the probe, and joint dynamics are confirmed during opening and closing.
• US-FHR: 27–30 G needle, 1–2 mL into the densified periarticular fascia (Figure 6).

6.3. Parotid Region (POINT 7)

POINT 7: Superficial parotid fascia

US-FHR of the superficial parotid fascia is an intervention site first proposed as a treatment target by the authors in the present protocol; it was not included in our previous article [3]. The parotid gland forms a contiguous SMAS (superficial musculoaponeurotic system) layer from the superficial aspect of the masseter to the mastoid process, and the superficial parotid fascia is traversed by branches of the facial nerve, the parotid duct, and the transverse facial artery/vein.

Through clinical experience, densification of the superficial parotid fascia has been observed in patients with (1) non-odontogenic toothache, (2) temporomandibular disorders, (3) referred pain to the submandibular and cervical regions, (4) long-standing facial nerve palsy, post-facial-palsy synkinesis, (5) atypical facial pain, and (6) tinnitus.

• Anatomy: From the zygomatic arch to the anteroinferior region of the mastoid process to the posterior border of the mandibular ramus; continuous SMAS layer.
• Referred pain: Dental pain in general (low site specificity), periarticular TMJ region, cheek, and preauricular region.
• Ultrasound: The probe is moved caudally from the preauricular region; the parotid gland and the superficial layer of the masseter are identified, and the capsule layer is visualized.
• US-FHR: 30 G needle, 0.5–1 mL into the superficial parotid capsule layer; the facial artery and posterior auricular artery must be avoided (Figure 7).
• Related reports: Detailed extensions will be addressed in a separate case report (applications to long-standing facial nerve palsy, synkinesis, atypical facial pain, tinnitus, etc.).

6.4. Cervical Region (POINTs 8–9)

POINT 8: Digastric muscle

The digastric muscle is a two-bellied muscle in which the anterior and posterior bellies are connected to the hyoid bone through an intermediate tendon. It elevates the hyoid bone during swallowing and contributes to mouth opening. The anterior belly is an important landmark of the submandibular triangle, and fascial abnormalities here can produce referred pain to the mandibular anterior region, the tongue, and the pharynx.

• Anatomy: From the mental region to the hyoid bone to the mastoid process.
• Referred pain: Mandibular anterior region, tongue, pharynx, and swallowing pain.
• Ultrasound: Probe placed in the submental region; the hyoid bone and the submandibular gland serve as landmarks.
• US-FHR: 27–30 G needle, 1–2 mL into the fascia around the anterior belly and the intermediate tendon (Figure 8).

POINT 9: Cervical sympathetic ganglion region

Release around the cervical sympathetic ganglion region is a further development of POINT 4 (sternocleidomastoid/levator scapulae) from our previous article [3]. Through accumulated clinical experience, the present POINT was expanded to an integrated approach addressing—in addition to the sternocleidomastoid and levator scapulae—the scalene and longus colli muscles together with the perivascular tissue surrounding the cervical sympathetic trunk, centered on the middle cervical ganglion and extending cephalad and caudad to include the superior cervical and stellate ganglia.

• Anatomy: Fascial planes between the epimysiums of the sternocleidomastoid, levator scapulae, scalene, and longus colli muscles, and the perivascular sheath region.
• Referred pain: Temporal/frontal headache, periorbital pain, dizziness, tinnitus, and swallowing discomfort.
• Ultrasound: Palpate the sternocleidomastoid, place the probe at the tender point, and confirm the internal jugular vein and common carotid artery.
• US-FHR: 27–30 G needle, 1–3 mL into the densified fascia lateral to the carotid sheath (a slightly larger volume than other POINTs is used to ensure spread across multiple cervical fascial planes—between the epimysiums of the sternocleidomastoid, levator scapulae, scalene, and longus colli—and the perivascular fascia). After confirming vascular structures with Color Doppler, Doppler is turned off to maintain clear B-mode visualization during the release (Figure 9).

6.5. Facial Artery Region (POINT 10)

POINT 10: Perivascular fascia of the facial artery

The facial artery crosses the mandibular border and runs obliquely over the buccinator and deep to the platysma. Fascial abnormalities around the artery cause referred pain to the cheek, the corner of the mouth, the lower lip, and the mandibular anterior teeth. The concept of perivascular fascial release is presented here as a novel concept of the present protocol.

• Anatomy: From the inferior mandibular border to the superficial buccinator to the deep platysma.
• Referred pain: Cheek, corner of the mouth, lower lip, mandibular anterior teeth, and mental region.
• Ultrasound: Probe placed at the mandibular border; Color Doppler identification of the facial artery.
• US-FHR: 30 G needle, 0.5–1 mL into the fascia lateral to the arterial sheath. After confirming the facial artery with Color Doppler, Doppler is turned off to maintain clear B-mode visualization during the release (Figure 10).

6.6. Upper Posterior Cervical Release (POINT 11)—Advanced Technique (C0–1 Vertebral Artery Curvature or C1–C2 Ligamentum Flavum/Dural Region; Selected by Tender-Point Dominance)

This section describes an Advanced Technique that the authors have applied to refractory non-odontogenic toothache projecting from the upper teeth to the retro-orbital and temporal regions.

POINT 11: Upper posterior cervical release (integrated POINT, Advanced)

Three structures simultaneously addressed by POINT 11

POINT 11 is not merely a densification release of the PAOM/dura/ligamentum flavum. In a single procedure, the following three structures are simultaneously addressed:

(1)

PAOM/dura densification release: The C0–1 posterior atlanto-occipital membrane and the C1–C2 ligamentum flavum/epidural space are histologically continuous [16], and the densification along this continuum is released through a posterior, out-of-plane needle approach.

(2)

Densification release at the vertebral artery curvature: After passing through the C1 transverse foramen, the vertebral artery makes a sharp curve on the superior surface of the C1 posterior arch. This curvature corresponds to category #1 (curved regions of tissues) among the eight stacking-fascia predilection categories [12] and is a frequent site of densification.

(3)

Perivascular fascia release around the vertebral artery: This is the most important aspect of the procedure. It addresses densification of the perivascular fascia around the vertebral artery (stacking-fascia category #6, superficial course of neurovascular structures [12]). Resulting changes in vertebral arterial hemodynamics may, in turn, affect the perfusion of the brainstem, cerebellum, and upper cervical spinal cord. This aspect supports a hypothesized rationale for applying POINT 11 to non-odontogenic toothache, particularly in the maxillary molar region; further prospective evaluation is required.

In our clinical observations, in patients presenting with occipital pain, dizziness, tinnitus, maxillary molar referred pain, or Crowned Dens Syndrome, POINT 11—used either alone or in combination with other POINTs—has been associated with symptomatic improvement. These observations are not fully explained by the densification release of the PAOM/dura/ligamentum flavum alone; perivascular release around the vertebral artery and its potential effect on arterial hemodynamics may also be considered as a contributing factor, although this requires further investigation.

As shown in Figure 11, the injectate is distributed across the following structures: the PAOM or the ligamentum flavum itself, the epidural space, the perivascular region around the vertebral artery, and the tissues anterior to it. On palpation, the C0–1 (vertebral artery curvature and posterior atlanto-occipital membrane) and C1–C2 regions (ligamentum flavum) are evaluated, and the side with the more prominent tenderness is selected as the target. A single posterior needle approach is used to distribute the injectate across the structures described above. POINT 11 is indicated in refractory pain extending from the upper teeth through the retro-orbital region to the temporal region, accompanied by tenderness in the upper posterior cervical area.

• Anatomy: At C0–1, the perivascular fascia around the vertebral artery at the C0–1 curvature segment (beneath the posterior atlanto-occipital membrane), or at C1–C2, the ligamentum flavum and dura mater. The two structures are histologically continuous [16].
• Referred pain: Refractory pain from the upper teeth (especially the maxillary molars) through the retro-orbital region to the temporal region; refractory headache; and cases with prominent upper posterior cervical tenderness.
• Ultrasound: Based on palpation, the side with dominant tenderness (C0–1 or C1–C2) is selected, and a linear probe is used to image the corresponding level. Color Doppler identification of the vertebral artery is mandatory for safety.
• US-FHR: 30 G needle, advanced from the posterior side, with the tip placed beneath the PAOM; 1–2 mL of physiological saline is injected (direct vascular puncture is strictly forbidden; Color Doppler identification of the vertebral artery is mandatory; Doppler is turned off during the release).
• Treatment Selection Algorithm: The side with dominant tenderness (C0–1, Figure 12; or C1–C2, Figure 13) is selected first; if both are equivalent, C0–1 (more superficial and safer) is preferred.

Advanced Warning: This technique is absolutely contraindicated for novice operators. Because of the risk of vertebral artery injury, it should only be performed by operators fully trained in neurovascular ultrasound anatomy. Direct intravascular puncture must be strictly avoided, and injection should be limited to the surrounding fascial layers.

7. Pathology-Specific Application of the Eleven-Point Protocol

This chapter describes the application strategies of the eleven-point protocol for representative pathological and anatomical patterns of non-odontogenic toothache and orofacial pain. The main POINTs for each category are applied first, and adjunctive POINTs are added when the response is insufficient.

7.1. Masticatory Myofascial Toothache

Non-odontogenic toothache arising from trigger points and fascial densification of the masseter, temporalis, lateral pterygoid, and medial pterygoid. Main POINTs: 1–5. Adjunctive POINTs: 6 (TMJ capsule complex) and 7 (superficial parotid). This category is highly prevalent in clinical practice and is consistent with the referred-pain patterns of trigger points in the masticatory and neck–shoulder muscles in patients with temporomandibular disorders, as classically described by Travell & Simons [7] and Fernández-de-las-Peñas (2010) [10].

7.2. Neurovascular Toothache

Non-odontogenic toothache is attributable to perivascular fascial abnormalities (perivascular facial artery, deep maxillary artery, perivertebral vertebral artery). Main POINTs: 3 (lateral pterygoid/fat pad/maxillary artery/pterygopalatine integrated POINT), 10 (perivascular fascia of the facial artery), and 11 (upper posterior cervical, Advanced). The protocol presents a clinical application of the perivascular fascial release concept proposed here. In support of this concept, a prospective single-arm interventional study, currently available as a preprint, reported pain reduction with ultrasound-guided fascia hydrorelease around the artery for myofascial neck pain [17].

7.3. TMD-Related Toothache

Occlusal discomfort and dental pain are associated with dysfunction of the temporomandibular joint capsule complex and the lateral pterygoid. Main POINTs: 1 (masseter), 3 (lateral pterygoid/fat pad/maxillary artery), 4–5 (medial pterygoid), and 6 (TMJ capsule complex). The protocol comprehensively addresses the pain sources commonly involved in TMD.

7.4. Autonomic-Component Toothache

Dental and orofacial pain with sympathetic hyperactivity originating from the cervical sympathetic trunk (centered on the middle cervical ganglion, extending cephalad and caudad to include the superior cervical and stellate ganglia). Main POINT: 9 (cervical sympathetic trunk region). Adjunctive: POINT 3 integrated POINT (pterygopalatine ganglion region). Detailed extension will be reported in a separate paper on Crowned Dens Syndrome (CDS) focusing on the perivascular release approach.

7.5. Swallowing-Related Toothache

Dental pain accompanied by swallowing pain and lingual discomfort can be attributed to the digastric muscle. Main POINT: 8 (digastric).

7.6. Parotid-Derived Toothache (Novel Concept)

Dental and facial pain attributable to the densification of the superficial parotid fascia has been newly described in the present protocol. Main POINT: 7 (superficial parotid).

7.7. Refractory Referred Pain (Upper Teeth ↔ Deep Eye ↔ Temple)

Refractory referred pain is attributable to structural abnormalities of the upper posterior cervical region (C0–1 PAOM/C1–C2 ligamentum flavum). Main POINT: 11 (upper posterior cervical, Advanced). Through the Treatment Selection Algorithm, the dominant tender site (C0–1 vertebral artery curvature versus C1–C2 ligamentum flavum) is selected. POINT 11 is restricted to operators fully trained in neurovascular ultrasound anatomy.

8. Discussion

8.1. Overall Discussion

The present article systematized the US-FHR (ultrasound-guided fascia hydrorelease) treatment regions for non-odontogenic toothache and related orofacial pain into an eleven-point protocol. The present protocol is the result of long-term refinement of the four sections at the corresponding author’s institution and is presented here as a shared operational framework.

In the present protocol, six new or significantly expanded POINTs were added: POINT 3 (integrated lateral pterygoid/fat pad/perivascular maxillary artery/pterygopalatine region), POINT 5 (medial pterygoid, intraoral approach), POINT 7 (superficial parotid fascia), POINT 9 (cervical sympathetic ganglion region, integrated approach), POINT 10 (perivascular fascia of the facial artery), and POINT 11 (upper posterior cervical release, Advanced). The arrangement into eleven POINTs aims to function as a shared vocabulary for pain physicians, dentists, physical therapists, and acupuncturists.

Notable newly added POINTs include the following:

• POINT 5 (intraoral medial pterygoid): Newly added; this approach was conceived by co-author Dr. Tadashi Kobayashi (Development of Community Healthcare, Hirosaki University Graduate School of Medicine).
• POINT 7 (superficial parotid fascia): Symptomatic improvement has been observed in selected cases of non-odontogenic toothache; these observations are hypothesis-generating and require prospective evaluation.
• POINT 11 (upper posterior cervical release): An integrated technique that simultaneously addresses (1) the histological continuity of the PAOM and dura, (2) the densification at the vertebral artery curvature at C1, and (3) the perivascular fascia of the vertebral artery. Whether this is accompanied by measurable changes in vertebral arterial hemodynamics or downstream perfusion of the brainstem, cerebellum, and upper cervical spinal cord remains a hypothesis to be tested.

The protocol organizes the rationale for each POINT from the perspective that fascial pathological changes (densification, stacking, and impaired gliding) are clinically common contributors to such pain.

Limitations: This article is a clinically grounded synthesis aimed at organizing the literature and clinical experience; it does not present quantitative data on case numbers or treatment outcomes. Quantitative clinical outcome evaluation is left to future prospective studies. The protocol’s development relies on the long-term clinical experience and patient observations at the corresponding author’s institution, and the bias due to the limited number of practitioners and case selection must be acknowledged.

8.2. Anatomical Validity Based on the Eight Stacking-Fascia Categories

The mapping of each POINT in the present protocol to the eight predilection categories of stacking fascia, as proposed in our prior Memory Reset Hypothesis paper [12], demonstrates that the intervention sites cover the major categories (#1 curved regions, #4 peritubular, #5 fat pads, #6 superficial neurovascular course, and #7 ligamentum flavum/epidural space).

The following POINT-specific composite mappings are particularly important:

• POINT 3 (lateral pterygoid/fat pad/maxillary artery/pterygopalatine) = #1 curved regions + #4 peritubular + #5 fat pad + #6 superficial neurovascular course (quadruple composite; integrated POINT).
• POINT 11 (upper posterior cervical) = #7 ligamentum flavum and epidural space (PAOM–dura histological continuity) + #1 curved regions (vertebral artery curvature) + #6 superficial neurovascular course (perivascular fascia of the vertebral artery) (triple composite; integrated POINT, addressing densification across the PAOM/dura/ligamentum flavum together with perivascular release of the vertebral artery; possible downstream effects on brainstem, cerebellar, and upper cervical spinal cord perfusion via altered vertebral arterial hemodynamics remain a hypothesis to be tested).
• POINT 7 (superficial parotid) = #6 superficial neurovascular course (the facial nerve and parotid duct travel beneath the superficial fascia).

The mechanistic validity of POINT 11 is supported by recent evidence on the ligamentum flavum and PAOM as pain sources.

Traditionally, the ligamentum flavum was considered an elastic-fiber-rich structure with sparse innervation [18]. Recent immunohistochemical studies have shown that under pathological conditions, the ligamentum flavum can function as a putative pain generator.

In patients with lumbar spinal stenosis, Benditz et al. [19] demonstrated a significant increase in sensory nerve fiber density (sensory hyperinnervation) in the ligamentum flavum compared with controls, showing that nerve fiber density correlated positively with clinical pain indices and functional impairment [19].

Furthermore, through a histological study of the cervical ligamentum flavum (C3–C7), Wu et al. [20] reported the abundant distribution of sympathetic nerve fibers, providing an anatomical basis for cervical vertigo [20]. This may help explain the potential effects of C1–C2 ligamentum flavum (POINT 11B) release on autonomic symptoms such as dizziness and tinnitus.

In addition, the PAOM is connected to the pain-sensitive dura mater via the myodural bridge [16], and tension here is known to elicit pain signaling originating from the dura. Furthermore, dural afferents at the upper cervical spinal cord converge onto the spinal trigeminal nucleus (trigeminocervical convergence) and may project as referred pain to the head and face. This mechanism supports the anatomical plausibility of POINT 11 in non-odontogenic toothache, particularly in the maxillary molar region, and suggests a possible neuroanatomical pathway for the observed clinical effects.

Taken together, POINT 11 may simultaneously address (1) the ligamentum flavum as a possible pain generator via sensory hyperinnervation, (2) potential dura-derived pain mediated by the PAOM–myodural bridge, (3) maxillary molar referred pain via trigeminocervical convergence, and (4) a possible effect on vertebral arterial perfusion via release of the perivascular fascia of the vertebral artery, suggesting a plausible—but still hypothetical—quadruple mechanism that requires prospective validation.

8.3. A Therapeutic Paradigm Shift from TPI to FHR

The present protocol proposes a treatment paradigm shift from intramuscular trigger-point injection (TPI) to fascia hydrorelease (FHR). Conventional TPI for non-odontogenic toothache and related orofacial pain syndromes targets the muscle belly itself, whereas the present US-FHR targets the space between epimysiums, the fat pad, and the perivascular fascia. This paradigm shift is grounded in the loose connective tissue dysfunction theory advanced by Stecco and colleagues and in our previous cadaveric study [4], demonstrating wide spread between epimysiums of small injection volumes via the out-of-plane approach. Notably, the electrophysiological basis of fascial densification has been discussed by the authors in a separate hypothesis paper [21], and this theoretical framework is consistent with the hyaluronan-LCT dysfunction theory of the Stecco group [22,23,24,25,26]. Furthermore, the efficacy of interfascial injection for myofascial pain syndrome has been demonstrated in prospective, randomized, double-blinded trials [27], providing controlled-trial-level support for the fascia-targeted paradigm adopted in the present protocol, although the eleven-point NDT protocol itself has not yet been evaluated in a controlled trial.

8.4. Position Relative to Existing Related Studies

The fundamental difference between the present protocol and that of Chen et al. [28] lies in the target tissue and treatment paradigm. In line with classical trigger-point injection (TPI), Chen et al. deliver the injectate directly into the muscle belly of the pterygoid muscles. In contrast, the present US-FHR protocol injects 1–2 mL of saline into the space between epimysiums, the fat pad, and the perivascular fascia. This corresponds to a transition from the intramuscular paradigm to the fascia-targeted paradigm.

The work of Chen et al. [28] demonstrated procedural feasibility in a water-phantom model; clinical efficacy in actual patients remains a future research question. By contrast, in a previous cadaveric study [4] the present authors showed that 1.0 mL of injectate spreads broadly along the plane between epimysiums (24.50 cm2 on the deep side and 18.82 cm2 on the superficial side) and that the out-of-plane (oblique) approach is the most accurate technique for such an injection.

Vas et al.’s [29] work on ultrasound-guided dry needling of the masticatory muscles for TGN partially overlaps with the present protocol, in that it targets the masticatory muscles (masseter, temporalis, medial pterygoid, lateral pterygoid, and digastric). However, the target disease in their study was TGN rather than non-odontogenic toothache, and their procedure was dry needling without fluid injection, in contrast to the fascia hydrorelease with saline presented here. The marked clinical effect (NRS 8.9 → 0.6) reported by Vas et al. suggests that ultrasound-guided intervention to the masticatory muscles is effective for refractory pain in the trigeminal territory and may indirectly support the clinical relevance of the FHR approach for non-odontogenic toothache presented here.

The series of studies by the Stecco group [5,22,23,24,25,26] provided multi-dimensional verification for the anatomical basis of hyaluronan aggregation, densification, and fascia-targeted injection. These form the theoretical foundation of the present protocol, although none of them propose a direct clinical application protocol for non-odontogenic toothache or orofacial pain. The present article integrates the theoretical foundation of the Stecco group with the clinical insights of Vas et al., presenting a US-FHR eleven-point protocol for non-odontogenic toothache and orofacial pain together with its clinical applicability.

Importantly, the present protocol introduces the concept of integrated POINTs. POINT 3 (lateral pterygoid/fat pad/perivascular maxillary artery/pterygopalatine region) addresses three adjacent structures in a single linear-probe procedure, while POINT 11 (upper posterior cervical release) individualizes PAOM, dura, and ligamentum flavum treatment by selecting the dominant tender site (C0–1 vertebral artery curvature versus C1–C2 ligamentum flavum). These integrations extend Chen’s individual-muscle approach by incorporating the functional connectivity among adjacent structures into the treatment concept.

8.5. Brief Notes on Related Areas

POINT 11 essentially functions as a vertebral perivascular fascia release and may be relevant to symptoms within the perfusion territory of the vertebral artery, including Crowned Dens Syndrome, dizziness, tinnitus, occipital pain, and referred pain to the upper molar region. Compared with conventional C1–C2 steroid injection for Crowned Dens Syndrome [30], the present technique mechanistically differs in that it directly addresses fascial densification. In addition, perivascular release around the occipital and superficial temporal arteries may be of interest as a related area in the context of post-herpetic neuralgia, and perivascular fascia release of the facial artery (POINT 10) may be of interest as a related area in the context of synkinesis following long-standing facial nerve palsy.

The same principle—organizing region-specific fascial densification into a standardized, point-based US-FHR protocol—can be extended to other anatomical regions. The present eleven-point orofacial protocol is intended as one component of a broader effort to systematize US-FHR applications anchored in fascial densification across body regions.

8.6. Supplementary Materials

Demonstration videos of the US-FHR procedures at each POINT (Videos S1 to S11) are openly available at Zenodo (DOI: 10.5281/zenodo.21318086; https://doi.org/10.5281/zenodo.21318086). POINT 11 is presented as two videos (S11A and S11B), reflecting the selection between C0–1 (vertebral artery curvature) and C1–C2 (ligamentum flavum) based on tender-point dominance, both forming a single conceptual procedure.

• Video S1: POINT 1—Masseter (superficial and deep layers) US-FHR.
• Video S2: POINT 2—Temporalis US-FHR.
• Video S3: POINT 3—Lateral pterygoid/fat pad/maxillary artery/pterygopalatine integrated US-FHR.
• Video S4: POINT 4—Medial pterygoid (extraoral approach) US-FHR.
• Video S5: POINT 5—Medial pterygoid (intraoral approach) US-FHR.
• Video S6: POINT 6—Temporomandibular joint capsule complex US-FHR.
• Video S7: POINT 7—Superficial parotid fascia US-FHR.
• Video S8: POINT 8—Digastric muscle US-FHR.
• Video S9: POINT 9—Cervical sympathetic trunk region (centered on the middle cervical ganglion, extending cephalad and caudad to include the superior cervical and stellate ganglia) US-FHR.
• Video S10: POINT 10—Perivascular fascia of the facial artery US-FHR.
• Video S11A: POINT 11—Upper posterior cervical release (C0–1 vertebral artery curvature, tender-side example) US-FHR.
• Video S11B: POINT 11—Upper posterior cervical release (C1–C2 ligamentum flavum/dural region, tender-side example) US-FHR.

9. Conclusions

The present article systematized the ultrasound-guided fascia hydrorelease (US-FHR) treatment protocol for non-odontogenic toothache and related orofacial pain as a clinical protocol article, presenting an eleven-point standardized framework. POINTs first proposed or significantly expanded by the authors (POINT 3: integrated lateral pterygoid/fat pad/perivascular maxillary artery/pterygopalatine region; POINT 5: intraoral medial pterygoid; POINT 7: superficial parotid fascia; POINT 9: cervical sympathetic ganglion region; POINT 10: perivascular fascia of the facial artery; POINT 11: upper posterior cervical release) substantially extend the original four-region framework. The proposed eleven-point protocol may serve as a practical basis for the standardization, education, and broader dissemination of US-FHR for non-odontogenic toothache and orofacial pain. Prospective observational studies will be required in the future to evaluate the clinical effectiveness of the proposed protocol.