Protracts the outer ear Nerve supply: Facial nerve Arterial supply: Posterior auricular artery Action: Draws the auricle forwards and slightly downwards

1. MUSCLES OF FACIAL
EXPRESSION
Presented by: Dr. Kartik
Pati
Guided by: Dr. Meenaxi
Umarani

2. CONTENTS
• Introduction
• Classification
• Facial Muscles
• Clinical Significance
• Facial Paralysis
• Bell’s Palsy
• Botulinum toxin
• References

3. INTRODUCTION
• Group of muscles in head with common features
• 17 Paired muscles
• Develops from the mesoderm of second brachial arch
• Supplied by nerve of this second arch – Facial nerve

4. CLASSIFICATION
Topographically classified into
 Orbital group
 Nasal group
 Oral group
 Other muscles/ groups
Functionally classified into
 Sphincters
 Dilators

5. PLATYSMA
Covers lateral and anterior
region of the neck
Ant: Sternoclavicular joint to
chin
Post: Acromion to angle of jaw
Lower: Cross clavicle & cover
infra clavicular region
Upper: Lower border of
mandible

6. Origin: Fascia covering upper parts of
pectoralis major and deltoid
Insertion: Lower border of the mandible or
to the lower lip or skin and subcutaneous
tissue of the lower face.
Arterial supply:
• Submental br of facial a
• Suprascapular a. from the thyrocervical trunk
of the subclavian artery.

7. Nerve supply: Cervical branch of the
facial nerve
Action:
Tenses the skin producing vertical
skin ridges.
Facilitates venous flow in the neck
by keeping skin and fascia fairly
taut between mandible and clavicle.

8. MUSCLES OF MOUTH
2 groups:
 Closes the lips – contracts orbicularis oris
 Opens the lips – radial muscles
Superfecial muscles of upperlip
 Zygomatic minor
 Levator labii superioris Quadratus labii superioris
 Levator labii superioris alaeque nasii
 Zygomaticus major muscle

9. Deep layer of upper lip: Levator anguli oris / caninus
Superfecial layer of lower lip:
 Depressor labii Inferioris
 Mentalis
Corner of the mouth:
 Supefecial – Risorious
 Deep - Buccinator

10. QUADRATUS LABII SUPERIORIS
Origin: Long line from frontal process of
maxilla lateral to Zygomatic bone
3 heads – 3 muscles
1. Levator labii superioris aleque nasii:
 Levator of upper lip & nasal wing ( Angular head)
 Arise from frontal process of maxilla at level of
medial palpebral ligament

11. 2. Levator labii superioris:
 Levator of upper lip (Infraorbital head)
 Arise from maxillary body parallel to infra orbital
rim
3. Zygomaticus minor:
 Zygomatic head
 Arise from prominent part of zygomatic bone
Insertion: All fibers descend & interlace
with orbicularis oris

12. Arterial supply:
•Facial artery
•Infraorbital branch of the maxillary artery
Nerve supply: Zygomatic and buccal
branches of the facial nerve.
Action: Elevates and everts the upper lip.
 Acting with other muscles, it modifies the
nasolabial furrow. Depicting sadness or
seriousness
 Creates Nasolabial fold.

13. ZYGOMATICUS MAJOR
Origin: Temporal process of zygomatic
bone just ahead of FZ suture
Insertion:
Superficial fibers: Insert into corner of
the mouth
Deep fibers : Insert into mucous
membrane of upper lip

14. Arterial supply: Superior labial branch
of facial artery
Nerve supply: Zygomatic and buccal
branches of the facial nerve
Action: Draws the angle of the mouth
upwards and laterally as in laughing.

15. RISORIUS
Origin: Fascia of masseter muscle
behind its anterior border
Insertion: Skin & Mucous membrane of
upperlip, MM lateral to corner of the
mouth.

16. Arterial supply: Superior labial branch of
facial artery
Nerve supply: Buccal branches of the
facial nerve
Action: Pulls the corner of the mouth
laterally (smiling, grinning, laughing)

17. LEVATOR ANGULI ORIS MUSCLE
Origin: Anterior surface of maxillary body
from the canine fossa below the
infraorbital foramen.
Insertion: Skin and mucous membrane of
lower lip.

18. Arterial supply:
•Superior labial branch of facial artery
•Infraorbital branch of the maxillary artery
Nerve supply: Zygomatic and buccal
branches of
facial nerve.
Action: Raises the angle of the mouth in
smiling,
contributes to the depth and contour of

19. DEPRESSOR ANGULI ORIS /
TRIANGULARIS
Origin: Outer surface & above the lower
border of the mandible in a line from
mental tubercle to a plane below the 1st
molar.
Insertion: Blends at the angle of the
mouth with orbicularis oris and risorius.
Skin of the corner of the mouth.

20. Arterial supply:
•Inferior labial branch of the facial artery
•Mental branch of the maxillary artery.
Nerve supply: Buccal and mandibular
branches of the facial nerve.
Action: Pulls the corner of the mouth
downward and inward

21. DEPRESSOR LABII INFERIORIS
Origin: Uppermost level of the rough
line of origin of platysma and
triangularis muscle.
Insertion: Skin of the lower lip above
the mentolabial fold.

22. Arterial supply:
•Inferior labial branch of the facial artery
•Mental branch of the maxillary artery.
Nerve supply: Mandibular branch of the
facial nerve.
Action: Draws the lower lip downwards.

23. MENTALIS
Origin: Oval area in the
depth of mental fossa.
Insertion: Skin of the chin

24. Arterial supply:
•Inferior labial branch of the facial artery
•Mental branch of the maxillary artery.
Nerve supply: Mandibular branch of the
facial nerve
Action: Raises the lower lip, wrinkling
the skin of the chin. Protrusion and
eversion of the lower lip in drinking and
also in expressing doubt or disdain
Its contraction renders lower vestibule
shallow.

25. BUCCINATOR
• Mobile and adaptive substance of the cheak
Origin: Horse shoe shaped line.
Base of alveolar
process from upper 1st
molar to suture
between maxilla &
palatine bone.
Lower surface of
pyramidal
process of
palatine boneLower end of retro
mandibular fossa &
follows oblique line
downward and forward
till mesial end of lower
1st molar

26. Insertion:
• Mucous membrane of cheek in & around tendinous
node and tendinous line.
• Interlace with neighbouring muscles and terminate
into skin near oral commisure

27. Arterial supply:
•Branches from the facial artery
•Buccal branch of the maxillary artery
Nerve supply: Buccal branch of the facial
nerve
Actions:
• Pulls corner of the mouth laterally and
posteriorly
• Keeps the cheek taut during all phases of
opening and closing the mouth

28. ORBICULARIS ORIS
• No direct attachment to skeleton.
Origin: Medial maxilla and mandible; deep surface of
perioral skin; angle of mouth (modiolus)
Insertion: Mucous membrane of lips
Medially:
• Upper – Densely woven connective tissue strip –
depressor of nasal septum
• Lower – Interlace in midline & also with depressor of
lower lip
Laterally:
• Cross each other at acute angle & end in tendinous
trip & node.

29. Arterial supply:
•Superior and inferior labial branches of facial artery
•Mental and infraorbital branches of maxillary artery
•Transverse facial branch of superficial temporal artery
Nerve supply: Buccal and mandibular branches of facial
nerve
Action: Tonus closes rima oris; phasic contraction
compresses and protrudes lips (kissing) or resists
distension (when blowing)

30. INCISIVUS
• 2 muscles – upper and lower
Origin: Alveolar process
•Upper – Alveolar eminence of canine
•Lower – height of canine alveolus just above mentalis muscle
Insertion: Tendinous node
• Due to its close relation to orbicularis oris they are
called as accessory skeletal heads.

31. Arterial supply:
•Superior and inferior labial branches of facial artery
•Mental and infraorbital branches of maxillary artery
•Transverse facial branch of superficial temporal artery
Nerve supply: Buccal and mandibular branches of
facial nerve
Actions: Press on the fornix of vestibule & make it
shallow

32. NASALIS
• Origin: Alveolar eminence of lateral incisor
& canine of upper jaw at the base of alveolar process.
• 2 parts: medial F – Posterior end of mobile
septum
• Alar part: Musculus dilator naris
Lateral F – Skin of nasal wing
• Transverse part: Musculus compressor naris – Sling like band
across cartilaginous part of the nasal bridge.

33. MUSCLES OF EYELIDS &
EYEBROWS
• 4 muscles
•Orbicularis occuli
•Depressor supercilli
•Corrugator supercilli
•Procerus muscle

34. ORBICULARIS OCULI
• 2 parts
•Palpebral – Eyelids
•Orbital – Forehead, Temporal region and cheek
Origin: Inner canthus
•Frontal process of maxilla & lacrimal bone
•Wall of lacrimal sac & medial palpebral ligament
•Lacrimal part ( Horner’s Muscle) - Posterior lacrimal crest of
the lacrimal bone behind the lacrimal sac

35. Insertion:
• Palpebral part – Skin of lateral corner of the eye
• Orbital part – Diverge into neighboring muscles and into
skin.
Arterial supply: Branches of the facial, superficial temporal,
maxillary and ophthalmic arteries.
Nerve supply: Temporal and zygomatic branches of facial
n.
Action: Closes eyelids: palpebral part does so gently;
orbital part tightly (winking).

36. DEPRESSOR SUPERCILLI MUSCLE
Origin: Lacrimal part of maxillary
frontal process
Insertion: Skin of head of eyebrow
Arterial supply: Branches from the
superficial temporal and
ophthalmic arteries
Nerve supply: Temporal branches of
the facial nerve
Action: Pull the eyebrow downward

37. CORRUGATOR SUPERCILLI
• Wrinkler of the eyebrow
• Horizontal muscle
Origin: Frontal bone at the medial end of the
superciliary arch
Insertion: Skin above the middle of the supraorbital
margin.
Arterial supply: Branches from the superficial
temporal and ophthalmic arteries
Nerve supply: Temporal branches of the facial nerve
Action: Draws eyebrow medially and inferiorly, creating
vertical wrinkles above nose (demonstrating concern
or worry)

38. PROCERUS NASI
Origin: Fascial aponeurosis covering the
lower part of the nasal bone and the
upper part of the lateral nasal cartilage.
Insertion: Skin of the head of the brow
& forehead in the glabella region
between eyebrows

39. Arterial supply: Branches from the facial
artery
Nerve supply: Temporal and lower
zygomatic branches from the facial
nerve
Action: Depresses medial end of
eyebrow; wrinkle skin over dorsum of
nose (conveying disdain or dislike)

40. MUSCLES OF OUTER EAR
• Vestigial in man
•3 muscles
•Auricularis anterior – Protractor of outer ear
•Auricularis superior – Elevator of outer ear
•Auricularis posterior – Retractor of outer ear

41. AURICULARIS ANTERIOR
Origin: Aponeurotic tendon of the scalp
in the temporal region
Insert: Cartilage of outer ear at its
anterior border & medial surface above
auditory passage
Action: Protracts outer ear
Its small and weak

42. AURICULARIS SUPERIOR
Origin: Above the ear in a broad
line from aponeurotic tendon of
scalp
Insertion: Medial Surface of
articular cartilage
Action: Elevates the outer ear
Largest of the group

43. AURICULARIS POSTERIOR
Origin: Lateral part of superior nuchal
line & base of mastoid process
Insertion: Medial surface of cartilaginous
outer ear
Actions: Retracts the outer ear

44. MUSCLES OF SCALP
• 4 muscles: Paired
•Frontal Epicranius
•Occipital Muscle
•Common tendon – Galea Aponeurotica

45. FRONTALIS
Origin: Anterior border of galea
aponeurotica
Insertion: Skin of the eyebrow &
root of the nose
Fibers interlace with adjacent
muscles
•Procerus nasii
•Elevators of upperlips & nasal wing
•Frontalis of opposite side

46. OCCIPITALIS
Origin: Supreme nuchal line from
base of mastoid process to point
close to midline
Insertion: Posterior border of
galea aponeurotica

47. GALEA APONEUROTICA
• Common tendon of occipitofrontalis muscle
• Consists mostly of Sagittal fibers
• Transvers fibers – Lateral part of Galea
• Laterally – No sharp boundary, it thins out gradually &
above the Zygomatic arch it fuses with superficial
fascia.
• Galea is loosely fixed to periosteum but tightly
adherent to skin.

48. Actions:
• Lift Eyebrow
• Fold skin of forehead into horizontal creases

49. MODIOLUS-
• Fibromuscular mass ,bluntly cone shaped
• Modiolar base - kidney-shaped
• 4x10x20mm
• The musles attached are:
1. Levator labii superioris alaeque nasi
2. Levator labii superioris
3. Zygomaticus major and minor
4. Levator anguli oris
5. Risorius
6. Depressor labii inferioris
7. Depressor anguli oris
8. Orbicularis oris
9. Buccinator

50. APPLIED ANATOMY

51. SKIN FOLDS
• Tendons are attached to skin in small concentric
areas – Dimple
• Creasing of skin along certain lines due to muscle
attachment forms permanent folds – Nasolabial &
Labiomental folds
• Folds become deeper and sharper with advancing age
because of loss of elastic tissue
• Inconsistent folds- by habitual wrinkling
• Horizontal folds on forehead
• vertical folds between brows
• Crows feet at corner of the eye

52. SIGNIFICANCE IN INFECTIONS
• The relation of apices to the origins
of buccinators muscle determines
whether the infection exists intra
orally in the buccal vestibule or
expands deeply into buccal space
• Molar infections exiting superiorly to
the maxillary origin of the muscle or
inferiorly to the mandibular origin
enter the buccal space

53. FACIAL PARALYSIS –
ETIOLOGY
• Central or intracranial region
•Vascular abnormalities
•CNS Degenerative diseases
•Tumors of Intracranial Cavity
•Trauma to the brain
•Congenital abnormalities & agenesis

54. • Temporal bone region
•Bacterial and viral infections
•Cholesteatoma
•Trauma
•Longitudinal and horizontal # of temporal bone
•Gunshot wounds
•Tumors invading the middle ear, mastoid, and facial nerve
•Iatrogenic causes – surgical injury

55. • Parotid gland region
•Malignant tumors
•Trauma – Lacerations and gunshot injury
•Iatrogenic factors
•Primary tumors of the facial nerve
•Malignant tumors of ascending ramus of the mandible, the
pterygoid region and the skin

56. DIAGNOSTIC EVALUATION OF
FACIAL PALSY
• History
• Physical Examination
• Observation: Muscle tone and symmetry
Twitches and spasms
Lines of facial expression
• Test Motor function: Wrinkle the forehead
Close eyelids tightly
Show the teeth
Pucker the lips
Grimace
Draw lower lip & corner of the mouth downward

57. •Topognostic tests
•Hearing and balance tests
•Schirmer test
•Stapes reflex
•Submandibular flow test
•Taste test

58. • Electrical tests
•Maximal stimulation test (MST)
•Evoked electromyography (EEMG)
•Electromyography (EMG)
• Radiographic studies
•Plain views of Mastoid and internal auditory canal
•Pluridirectorial tomography of temporal bone
•CT of brain stem, cerebellopontine angle, temporal bone, skull base
•Sialography of Parotid
•Chest radiographs to detect Sarcoidosis, lymphoma, Carcinoma.

59. • Surgical exploration
•Spl laboratory test
•Lumbar puncture
•Complete blood count
•Monospot test
•Heterophile titre
•ESR
•Urinary and feacal examination
•Serum cryoglobulins & immune complexes
•Serum globulin levels
•Serum and urinary calcium determinations

60. LOCATION OF LESION
• Supra nuclear Paralysis :
• Involve upper motor neuron or
corticobulbar pathways
•Preservation of function of orbicularis
occuli and frontalis muscle on the
side of the lesion
•Paralysis of lower facial muscle on the
contralateral side of the lesion
• Infra nuclear:
•Weakness of entire ipsilateral half of
the face including forehead

62. BELL’S PALSY-
• It is defined as an idiopathic paresis or
paralysis of facial nerve of sudden onset
(unilateral lower motor neuron paralysis of
sudden onset not related to any other disease in
the body).
• Sir Charles Bell (1821)- demonstrated
separation of motor and sensory innervation of
face.
• Incidence-15-40cases per 1 lac cases.
• Women predilection (pregnant 3rd trimester)
• Unilateral involvement
• At any age

63. ETIOLOGY -
• Rheumatic
• Cold
• Ischaemic
• Immunological
• Viral (herpes)

64. CLINICAL FEATURES
• Sudden onset, patient gives a history of
occurrence on awakening early in the morning.
• Unilateral involvement of entire side of face
• Inability to smile, close the eye or wink on affected
side
• Whistling is impossible
• Corner of the mouth droops down with drooling of
saliva
• Inability to wrinkle the forehead or elevate upper
or lower lip
• BELLS SIGN-in attempt to close the eyelid, eyeball
rolls upwards so the pupil is covered and only the
white sclera is visible.

65. DIAGNOSTIC EVALUATION
• History
• Physical examination
• Electrical and topognostic tests
• Other investigations –
•CT scan-to rule out skull base fracture.
•MRI-detect any intracranial lesions.

66. Test Indication
Nerve conduction testing
Electroneurography
Degree of denervation in
1st week after trauma
Intensity duration curves 15 days after trauma
Nerve Excitability Test
Maximum stimulation Test
Early evaluation of nerve
injury
Electromyography Degree of re-innervation

67. TOPOGNOSTIC TESTS
The principle behind topognostic testing is that lesions
distal to the site of a particular branch of the facial nerve
will spare the function of that branch.
Moving distally from the brainstem, these tests include:
• Schirmer test for lacrimation (GSPN),
• Stapedial reflex test (stapedial branch),
• Taste testing (chorda tympani nerve),
• Salivary flow rates and pH (chorda tympani).

68. TOPOGNOSTIC TESTING
Schirmer Test
• Greater superficial petrosal nerve
• Filter paper is placed in the lower
conjunctival fornix bilaterally
• 3- 5 minutes
• Value of 25% or less on the involved side or
total lacrimation less than 25 mm is
considered abnormal.

69. TOPOGNOSTIC TESTING
Stapedial Reflex
•Most objective and reproducible
• A loud tone is presented to either the ipsilateral or contralateral ear 
evokes a reflex movement of the stapedius muscle  changes the
tension on the Tympanic membrane (which must be intact for a valid test)
resulting in a change in the impedance of the ossicular chain.
• If the tone is presented to the opposite ear (normal hearing) and the
reflex is elicited, the seventh nerve is considered to be intact up to that
point.
• If intact stapedial reflex, complete recovery can be expected to begin
within six weeks
• Absence of the stapedial reflex during the first two weeks in Bell’s Palsy
is common

70. TOPOGNOSTIC TESTING
Taste Testing
• Chorda tympani
• Its function is tested by galvanic current.
• Metallic taste on normal side
• Sensation of electric shock on affected side
• A more reliable indicator of interruption of the chorda tympani nerve
involves microscopic detection of the absence of taste papillae on the
involved side of the tongue.
• Examination of the middle 1/3 of the tongue is most indicative,
because the anterior 1/3 may receive bilateral input.
•Application of bitter solution is not perceived by a tongue lacking
chorda tympani innervation.

71. TOPOGNOSTIC TESTING
Salivary flow rates
Chorda tympani
Cannulation of Wharton's ducts bilaterally
5 minute measurement of output
Significant if 25% reduction in flow of the involved side as
compared to the normal side
Salivary pH  Flow Rate

72. HOUSE- BRACKMANN FACIAL NERVE
GRADING SYSTEMGrade Description Characteristics
I Normal Normal facial function in all areas
II Mild dysfunction Slight weakness noticable on close inspection
At rest- normal symmetry and tone
Motion- forehead- moderate to good function, eye-
complete closure with minimum efforts, mouth- slight
asymmetry
III Moderate
dysfunction
Obvious but no disfiguring difference between the two
sides
At rest- normal symmetry and tone
Motion- forehead- slight to moderate movement, eye-
complete closure with effort, mouth- symmetrical with
maximal effort
IV Moderately severe
dysfunction
Obvious weakness and / or disfiguring asymmetry
Motion- forehead- none, eyes- incomplete closure,
mouth- asymmetric with maximum effort
V Severe dysfunction Only barely perceptible motion. asymmetrical at rest
VI Total paralysis No movement

73. CONSERVATIVE MANAGEMENT
• Medicinal
•Steroids -- Prednisolone 1mg /kg/day for 10 day
•Vit B1,, B6 & B12
• Physiotherapy
•TENS
•Exercises, massage, hot application
• Eye protection
•Glasses
•Lubricating eye drops (methylcellulose drops)

74. SURGICAL MANAGEMENT - GOALS
• Normal appearance at rest
• Symmetry with voluntary motion
• Restoration of oral, nasal & Ocular sphincter control
• Symmetry with involuntary motion & controlled
balance in expressing emotion
• No loss of significant Functions

75. • 2 essential elements of facial expression
•Intact Facial nerve
• Healthy facial muscles
• Nerve
• Viable ipsilateral facial nerve nucleus
• Proximal nerve segment capable of supporting axonal
regeneration
• Distal nerve segment through which axons may regenerate to
the facial muscles.
• Muscle
• 18 - 24 months: Muscle seeks reinnervation by retaining its
motor end plate substructure & elaborating substances that
attract axons

76. SURGICAL MANAGEMENT -
INDICATIONS
• Injury and repair: 3 stages
• Immediate – 0 to 3 weeks
• Delayed – 3 weeks to 2 yrs
• Late - > 2 yrs

77. • Immediate:
• Lacerations and iatrogenic injuries
• Best repaired immediately
• Nerve decompression
• Best chance of recovery
• Delayed:
• Endoneural tubules are present and they can
guide regenerating axons to facial muscles
• Procedures – Nerve grafting / Nerve Cross over

78. • Late:
• Muscle atrophy and fibrosis occurred
• Extent is evaluated by EMG
• Biopsy – absence of muscle fibers
• Treatmant: Regional muscle transfer
Distant microvascular muscle transfer

79. FACIAL DISSECTION PLANES
• These are various planes in subcutaneous layers
employed for dissection & flap development
• Supraplatysmal Plane – SMAP
• Subplatysmal plane
• Periosteal Plane
• Subperiosteal Planes
• Combinations

80. SMAS - SUPERFICIAL MUSCULAR
APONEUROTIC SYSTEM
• Extends from platysma to galea aponeurotica & is
continues with temperoparietal fascaia & galea
• Its connected to dermis via Vertical septa
•The superficial musculoaponeurotic plane (SMAP) is a
utility plane that is excellent for
•Facial rhytidectomy
•Parotidectomy
•Placement of free flaps in facial volume defects
•Development of local flaps to repair defects from facial
tumors.

82. BOTULINUM TOXIN
• Botulinum toxin is a protein produced by the
bacterium Clostridium botulinum, and is known to be
highly neurotoxic
• Seven distinct antigenic botulinum toxins
• Botox is manufactured by allergan inc (u.s.) for both
therapeutic as well as cosmetic use.

83. MOA

84. BOTOX
• 50 Units of Clostridium botulinum type A neurotoxin complex,
0.25 mg of Albumin Human, and 0.45 mg of sodium chloride
• 100 Units of Clostridium botulinum type A neurotoxin
complex, 0.5 mg of Albumin Human, and 0.9 mg of sodium
chloride
• 200 Units of Clostridium botulinum type A neurotoxin
complex, 1 mg of Albumin Human, and 1.8 mg of sodium
chloride in a sterile, vacuum-dried form without a preservative.

85. THERAPUTIC USES
• Cervical dystonia(spasmodic torticollis) (a neuromuscular
disorder involving the head and neck)
• Blepharospasm (excessive blinking)
• Strabismus (Squints)
• Achalasia (failure of the lower oesophageal sphincter to
relax)
• Chronic focal painful neuropathies. The analgesic effects
are not dependent on changes in muscle tone.
• Migraine and other headache disorders, although the
evidence is conflicting in this indication

86. • Hemifacial spasms
•Tremors
BOTOX® injections reduce facial lines caused by
hyperfunctional muscles. They also are used to contour
aspects of the face such as the brows.

87. •Exocrine gland hyperactivity
•Focal hyperhidrosis: It is defined as excessive
sweating of the palms, soles, axilla or face.
•Relative sialorrhoea
•Frey's syndrome: Areas of skin are targeted that show
gustatory sweating due to aberrant innervation of
facial nerve secretomotor fibers to sweat glands
following parotidectomy.
•Crocodile tears syndrome: Lacrimal glands are
targeted in gustatory lacrimation due to aberrant
innervation of facial nerve secretomotor fibers.

88. CONTRAINDICATIONS
• Prior allergic reaction,
• Injection into areas of infection or inflammation,
• Pregnancy or breastfeeding.
• Diseases of the neuromuscular junction (eg, myasthenia gravis)
• Some medications decrease neuromuscular transmission and
generally should be avoided in patients treated with botulinum toxin.
These include aminoglycosides, penicillamine, quinine, and calcium
channel blockers.
• Avoid intravascular injections because diffuse spread of large
amounts of toxin can mimic the symptoms of botulism.

89. TREATMENT OF BOTULINUM
POISONING
• Equine antitoxin
• Use of enemas
• Extracorporeal removal of the gut contents .
• Antitoxins-
•Trivalent (A,B,E) Botulinum Antitoxin
•Heptavalent (A,B,C,D,E,F,G) Botulinum Antitoxin

90. REFERENCES
• Gray’s anatomy for students- Richard Drake, wayne
Vogl, Adam Matchell
• McCarthy Plastic Surgery Vol 3 The Face Part 2
• Sicher & Dubrul Oral Anatomy
• Richard Topazian Oral & Maxillofacial Infections