Facial Palsy- diagnosis, treatment planning, reconstruction. images sourced from AO website

1. FACIAL PALSY
DR. DEEISHA
GUPTA

2. The human face is the
organic mix of beauty. It is
the register of value in
development, a record of
experience.
Farnham Eliza

4. CONTENTS

7. NERVE INJURIES

9. MEDICATION

10. GRADING OF RECOVERY FROM FACIAL NERVE
PARALYSIS (HOUSE -BRACKMANN)
GRADE I NORMAL
GRADE II MILD DYSFUNCTION
GRADE III MODERATE DYSFUNCTION
GRADE IV MODERATELY SEVERE DYSFUNCTION
GRADE V SEVERE DYSFUNCTION
GRADE VI TOTAL PARALYSIS

12. TOPODIAGNOSIS OF
FACIAL NERVE
EAR PAIN
Chorda tympani nerve
Auricular branch of vagus nerve

13. Taste test
Drop of sugar or salt on one side of
protruded tongue or electro-gustometer.
Ageusia or atrophied papillae
injury to chorda tympani nerve.

14. Salivation
SUBMANDIBULAR SALIVARY FLOW TEST
This measures functions of chorda tympani
Polythene tubes are passed into both Wharton
ducts and drops of saliva are measured during
one minute period.
Decreased salivation injury to chorda
tympani

15. Tearing
SCHRIMER’S TEST
It compares lacrimation of both sides using a
strip of filter paper hooked in the lower fornix of
the eye
Decreased lacrimation lesion proximal to
geniculate ganglion

16. Stapedial reflex
TYMPANOMETRY
Absence of stapedial reflex when
hearing is normal indicates a lesion
of the facial nerve proximal to the
nerve to the stapedius.

17. Corneal blink reflex
Mediated by sensory fibers of the trigeminal
nerve and motor fibers of the facial nerve
Bilateral blink reflex when cornea of one eye is
touched with a wisp of cotton is known as
consensual reflex
If the depression of the reflex were secondary
to seventh nerve hypofunction, only director
the affected side response would be
depressed, consensual reflex will remain
intact.

18. Electrophysiological
testing
Minimal nerve excitability
test
Maximum stimulation test
Electroneuronography
Electromyography

38. Bell’s Palsy A 54-year-old female reported
to “X” Dental College with a
complaint of missing teeth
and desired replacement of
her missing teeth. Patient’s
appearance was abnormal
and on observation the patient
had facial asymmetry,
involuntary continuous
blinking of the right eye and
twitching of the right cheek.
Patient was provisionally
diagnosed as having right
hemifacial palsy and was
referred to the Department of
Oral and Maxillofacial Surgery
for the management.
HOUSE BRACKMANN GRADE III

39. WHAT CLINICAL FEATURES DID THE PATIENT
PRESENT WITH?
BELL’S PHENOMENON

40. WHAT MUST HAVE
CAUSED IT?

41. WHAT IS THE MOST LIKELY
DIAGNOSIS?
A conclusion of bell’s palsy is arrived usually as a diagnosis of
exclusion

43. HOW DO I MAKE A DIAGNOSIS?

45. WILL IT RESOLVE?
An objective, standardized, quantifiable assessment of facial nerve function serves as
the basis for evaluating the clinical course. The most commonly used system is the
House– Brackmann score.
Many studies have been done which prove that almost 84 percent patients with
Bell’s Palsy have complete recovery especially In HBS I and II and III.

46. WE HAVE MADE A DIAGNOSIS OF ACUTE
BELL’S PALSY . WHAT DO WE DO NOW?
Eyecare
To prevent ulceration or dehydration of
the cornea, apply artificial tears(such as
Hypromellose drops) every one or two
hours during the day. At night,keep the
eye moist by using a thin strip of paraffin
based ointment(such as Lacrilube).
Also refer to the ophthalmologist for
consultation.

47. Corticosteroids
The maximum benefit is seen when steroids are
commenced within 72 hours of the onset of
symptoms. There is no optimum regimen, but in
adults 50–60 mg prednisolone daily for 10 days
has been commonly used. Prednisolone has been
used at a dose of 1 mg/kg/day up to a maximum
of 80 mg in some studies. Doses of more than
120 mg/day have been used safely in patients
with diabetes.
In a randomised controlled trial the recovery rate
at nine months with prednisolone was 94%.

48. Antiviral drugs
The antiviral drugs used in trials were aciclovir
(400 mg five times daily for five days) or
valaciclovir (1000 mg/day for five days).
Combination therapy
A randomised controlled trial found that at nine
months of diagnosis, facial function had
recovered in 94.4% of patients who took
prednisolone alone, 85.4% of those who took
aciclovir alone and 92.7% in patients who took a
combination of both.

49. OUR PATIENT WANTS TO EXPLORE
ALTERNATIVE THERAPIES. WHAT COULD WE
ADVICE?
• Electrical nerve stimulation (electrotherapy)
• Thermal therapies such as heat/ice and exercise
• Massage therapy
• Acupuncture
• Mime therapy

51. SO THE ACUTE MANAGEMENT DIDN’T
WORK. WHAT NEXT?
Basis for the selection of the rehabilitation technique of choice
are the lesion site and the duration of palsy

53. FACIAL REANIMATION

54. INTERPOSITIONAL NERVE
GRAFTS
The repaired nerve begins the regeneration process re-
growing from the site of injury at a rate of approximately
1mm/day or one inch a month. It is imperative that the
nerves are united without tension.
If the gap between the nerve ends is to large to permit a
tension free repair then a interposition graft must be
used to guide the regenerating nerve fibers (axons).
An expendable segment of sensory nerve harvested from the calf (sural nerve graft) or neck (great
auricular nerve) is frequently used to bridge the gap (nerve graft).
Interpostion nerve grafts are frequently utilized to reconstruct the facial nerve after cancer surgery
where complete removal of the tumor necessitates the sacrifice of a facial nerve segment (for example
parotid tumors).

56. Greater auricular nerve
The nerve is located 1cm below the
mastoid tip on the surface of the
sternocleidomastoid muscle.
Add 1 cm to the required graft length
to permit trimming of the ends of the
nerve graft.
The greater auricular nerve has the
disadvantage of not providing a long
length of graft because it divides
quickly (<10 cm). Similarly, it is not
advisable to use it in ipsilateral
parotid or temporal bone cancers
when the nerve is likely to be
affected by the disease.

57. Sural nerve
It is much less accessible and locating it is more
difficult. It requires a 2nd operating field and its
removal must be anticipated.
It has two important advantages: it is a very
fasciculated nerve that is easy to subdivide and
a long length can be harvested as it divides late.
These important benefits make it the preferred
choice when it comes to placing split grafts in
the parotid or temporal bone-to-parotid. It is
located 2cm behind the lateral malleolus,
almost subcutaneously .
It is possible to harvest it via horizontal
incisions along the leg.

58. Postoperatively the patient may have pain in the foot and leg
causing transient functional impairment. It may be necessary
to prescribe anticoagulants to avoid secondary venous
thrombosis. Sensory deficits caused by harvesting the sural
nerve are limited to the lateral edge of the foot and are not
very troublesome.

59. UPPER LID WEIGHTS
Thin profile tantalum implants
Gold implants
Platinum implants

67. Lateral tarsal strip procedure for
ectropion of the lower lid. A lateral
canthotomy incision is shown (A).
Division of the lateral aspect of the
lower lid into an anterior
musculocutaneous layer and
posterior tarsal conjunctival layer
is shown (B). Tarsal strip is
grasped with skin hook (C). Tarsal
strip is positioned inside the lateral
rim of the orbit, which has been
exposed (D). Tarsal strip is sutured
to periosteum inside of lateral
orbital rim (E). Excess skin is
excised and wound closed (F).

68. HYPOGLOSSAL-FACIAL
JUMP ANASTOMOSIS
The very first method of the transposition and end-to-
end-suture of the hypoglossal nerve to the proximal trunk
of the facial nerve was described by Conley et al. in
1979.Because of the lost unilateral tongue function and
atrophy, this method was replaced by an end-to-side
hypoglossal-facial nerve suture. This technique was
modified by use of a free interposition nerve graft, usually
of the great auricular nerve, which was sutured end-to-
end to the distal facial nerve and end-toside to the incised
(1/3 to 1/2) hypoglossal nerve. Today, this method is
favored, but the presence of two anastomosis sites may
influence the reinnervation quality and time..

73. CROSS FACIAL NERVE
GRAFT

80. BABYSITTER TECHNIQUE
v
Shortcomings such as long distances for
regenerating axons to elongate and
prolonged denervation period could be
detrimental, leading to irreversible muscle
atrophy, unless the procedure occurs within
6 months from the onset of facial paralysis
of cross facial nerve grafting lead to the
introduction of babysitter procedure in
1984 by Terriz, which uses a portion of an
ipsilateral powerfulmotor donor nerve
(hypoglossal) to rapidly innervate the
paretic musculature, whereas cross-facial
nerve grafting regenerates across the face.
The procedure involves two stages.

81. In the first stage, 40 percent of the ipsilateral
hypoglossal (minihypoglossal) nerve is coapted
to the denervated facial nerve trunk, and three
or four cross-facial nerve grafts are placed
across the face. The minihypoglossal nerve
promptly provides regenerating motor fibers to
the facial nerve that quickly reach the affected
facial muscles.
At the second stage, 8 to 12 months later, the
distal end of the cross-facial nerve grafts are
connected to selected distal branches of the
affected facial nerve, whereas the
minihypoglossal to facial nerve coaptation
remains undisturbed. This is the original
“babysitter” procedure, and variations have
been reported since its inception

82. TEMPORALIS MUSCLE
TRANSFER

83. Antidromic muscle flap

87. Temporalis mini sling

88. Orthodromic temporalis muscle flap

89. Intraoral approach harvests the
masseter muscle for transfer.
Incision is made along the
gingival sulcus (A). One
muscle is exposed; curved
scissors are used to transect
the muscle in the midportion
(B). Two slips of muscle are
attached to the dermal layers
of the skin for overcorrection of
the smile (C).
MASSTER MUSCLE
TRANSFER

90. MICROVASCULAR TRANSFER
Gracilis free flap transfer is the preferred option for facial reanimation
for patients with irreversible or long-standing facial paralysis.
It offers the best chance of obtaining facial symmetry, voluntary
movement, and natural appearing smile.
Other muscles used are Pectoralis Minor and Latissmus Dorsi muscle.

102. Four fixation points centered around
the commissure are identified in the
following order:
1.Oral commissure
2.Mid lower lateral lip
3.High point of Cupid's bowl
ipsilateral
4.Mid upper lateral lip

108. SLING PLASTIES
Even a dynamic muscle plasty can be
technically impossible in cases of extended
tumour surgery. As third choice static slings are
part of the surgical arsenal. Slings allow
restoration of the resting tone and
improvement of facial asymmetry at rest in
direction of the inserted sling.
Autologic material like fascia lata or the tendon
of the palmaris longus muscle is first choice in
front of alloplastic material. Complications such
as wound healing problems, are seen more
frequently with alloplastic material .

110. Images showing sling plasty done use
Acellular human dermis
(Alloderm).

111. Clinton D. et al in
2007
Vector technique

113. INFERIOR ALVEOLAR NERVE
BLOCK

114. CONDYLAR BONE FRACTURE

116. J Oral Maxillofac Surg. 2016 May;74(5):1013-22. doi: 10.1016/j.joms.2015.12.013. Epub 2016 Jan 7.
A Modified Preauricular Approach for Treating Intracapsular Condylar
Fractures to Prevent Facial Nerve Injury: The Supratemporalis
Approach.
Li H1, Zhang G2, Cui J3, Liu W1, Dilxat D1, Liu L4.
Author information
1
Resident, Department of Oral and Maxillofacial Surgery, West China Hospital of Stomatology, Sichuan University, Chengdu, China.
2
Associate Professor, Department of Stomatology, Xinqiao Hospital, Third Military Medical University, Chongqing, China.
3
Attending Staff, Department of Oral and Maxillofacial Surgery, West China Hospital of Stomatology, Sichuan University, Chengdu, China.
4
Professor, Department of Oral and Maxillofacial Surgery, West China Hospital of Stomatology, Sichuan University, Chengdu, China. Electronic address: drliulei@163.com.

118. SURGICAL LANDMARKS
FOR IDENTIFICATION

122. • If the proximal segment of facial nerve is
obscured, retrograde dissection of 1 or more
of the peripheral branches may be necessary
to identify the main trunk.
• Ramus frontalis is located by a line from
tragus to lateral canthus.
• Ramus buccalis is located by a line from the
tragus towards alae of the nose parallel to the
zygoma but 1 cm below.
• Ramus mandibularis is near the angle of
mandible at a point 4-4.5 cm from the
attachment of the lobule of pinna.

123. MARGINAL MANDIBULAR NERVE
The distance of the marginal mandibular branch of the facial nerve from the inferior
border of the mandible from 1.4 to 1.75 cm.
The marginal mandibular branch of the facial nerve must be looked for in all operative
procedure near the angle of the mandible to a distance of 1.5 cm below the lower margin
of the mandible.
Therefore, in order to avoid damage to the nerve in the submandibular region, the incision
should be made 1.5 cm or more below the lower border of the mandible.
By giving an incision of two fingers breadth below and parallel to the angle of the
mandible, the marginal mandibular branch of the facial nerve can be isolated in the upper
flap.

125. HAYES MARTIN MANEUVER
• The marginal mandibular nerve has available course in relation to
the inferior ramus of the mandible.
• Following its emergence from the anterior border of the parotid
gland, it swings inferiorly to a variable degree before crossing lateral
to the facial vascular pedicle. It remains in a plane lateral to the
superficial layer of the deep cervical fascia enveloping the
submandibular gland.
• Hayes Martin described a now well-known manoeuvre to prevent
injury to this nerve, which involved ligating the facial vein at a level
approximately two finger-breadths below the mandible and then
retracting the superficial layer of the deep cervical fascia with the
subplatysmal plane as far as the mandibular ramus. As a result of
this, the peri-facial nodal groups remain undissected.

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137. THANK –YOU!