| Abstract|| |
Patients afflicted with Bell's palsy are faced with both functional and esthetic impairment. Prominent among these are the inability to close the eyelids and abnormal facial appearance, with concomitant difficulty in eating, drinking and speaking. Rehabilitation of such patients can be achieved by a multispecialty approach, with the prosthodontist functioning as an integral part of the treatment team.
This article describes a simple and effective approach to restore the blinking reflex of the upper eyelid with custom gold implant and facial esthetics with cheek support prosthesis.
Keywords: Bell′s palsy, cheek support prosthesis, gold eyelid implant, lagophthalmos
|How to cite this article:|
Somani P, Nayak AK. Restoration of blinking reflex and facial symmetry in a Bell's palsy patient. Indian J Dent Res 2011;22:857-9
Bell's palsy is a self-limiting non-fatal and spontaneously remitting disorder of acute onset due to non-suppurative inflammation of the facial nerve within the stylomastoid foramen. Although idiopathic by definition, some attribute it to cold, trauma, infection, nerve ischemia and autoimmunity. 
|How to cite this URL:|
Somani P, Nayak AK. Restoration of blinking reflex and facial symmetry in a Bell's palsy patient. Indian J Dent Res [serial online] 2011 [cited 2019 Oct 24];22:857-9. Available from: http://www.ijdr.in/text.asp?2011/22/6/857/94686
It affects the muscles of facial expression that are unilaterally supplied by the seventh cranial nerve, causing partial or complete paralysis. The face is drawn up to the normal side, affecting eating, drinking and speech. 
Paralysis of the orbicularis oculi from the facial nerve results in upper lid elevation due to unopposed action of the levator palpebrae superioris muscle that is supplied by the oculomotor nerve. Prolonged exposure of the cornea, associated with poor tear film movement and increased tear evaporation, puts the patient at risk of exposure keratitis, corneal abrasion and, in worst cases, blindness. ,
| Case Report|| |
A 42-year-old female patient reported with the chief complaint of missing upper and lower teeth since 1 year and deviation of the angle of mouth to the left side since the past 20 years. She also complained of inability to close her right eye completely, recurrent episodes of irritable eye with redness, watering and pain.
The patient was diagnosed to be having lower motor neuron facial palsy of the right side with reduced forehead wrinkles, lagophthalmos, loss of nasolabial fold and weakness of buccinators muscle on the right side [Figure 1]. An intraoral examination revealed favorable, completely edentulous maxillary and mandibular ridges.
Custom gold implant for eyelid reanimation
Weight necessary to pull the paralyzed upper eyelid closed during blinking and restore full "normal blinking reflex" was measured, 1.6 g in this case, with a wax mould that was hung by a string from the middle one-third of the upper eyelid with the patient seated and looking straight forward. 
The eyelid was closed passively with a tissue tape and an impression was made of the eyelid region with irreversible hydrocolloid impression material (Tropicalgin, Zhermack, Italy) and was poured with dental stone. The cast was then duplicated in auto-polymerizing acrylic resin (DPI-RR Cold Cure Dental Products of India, India) to mold the gold implant to appropriate contour.
1.6 g of 24 karat was swaged to the contour of the acrylic cast to get an implant 15 mm in length, 5 mm in width and 1.5-mm thick. Three holes were drilled in the implant, one at each end and one in the middle third, to facilitate suturing [Figure 2]. Polished prosthesis was tested pre-operatively by stabilizing it to the upper eyelid with a tissue tape, ensuring adequate weight for eyelid closure and not excessive to impede opening.
Till the date of surgery, the patient was given a training appliance measuring about 1.6 g to be taped to the upper eyelid three- to four-times a day intermittently so that the muscles and the patient get accustomed with the weight of the implant.
The implant was placed surgically in the upper eyelid under local anesthesia. A horizontal skin incision was placed along the superior lid crease. Orbicularis muscle fibers were split along the length of the incision and a submucosal pocket was created with blunt dissection, exposing the outer surface of the tarsal plate. Sterilized gold implant was positioned in the pocket and was sutured with five interrupted 6-0 vicryl sutures [Figure 3]. The skin incision was closed with interrupted 6-0 silk sutures that were removed 7 days post-surgically. Patient's complete eyelid closure and restoration of blink reflex were obtained at post-operative examination.
Cheek support prosthesis to restore facial symmetry
Complete dentures were fabricated by the conventional technique. The patient was followed and, after the initial adjustment phase, she did well with the dentures. Because of good retention and stability, it was decided to attach cheek support prosthesis to the maxillary denture. 
Maxillary denture was duplicated in dental stone. The denture was then waxed up to provide adequate support to the cheeks and restore facial symmetry. A loop of 0.8 mm stainless steel wire with about 5 mm extraoral extension was attached to the wax mold to retract the lip.
Wax molds were then transferred from the dentures to the duplicated stone cast and were invested. After dewaxing, the wax shim was adapted in the mold space to create the roof, lateral wall and base of the cheek plumper. A 50:50 mix of Plaster of Paris and pumice was filled in the space to get a three-dimensional spacer. The wax shim was dewaxed and the space was filled with dough consistency of heat-cured denture base resin (DPI Heat Cure, Dental Products of India) cured and deflasked. The cheek support prosthesis was then trimmed, finished and polished and sealed to the maxillary denture with an autopolymerizing acrylic resin [Figure 4]. The denture was inserted and the extraoral wire extension was adjusted for passivity [Figure 5].
At 3, 6 and 18 months follow-up, the patient was able to close her eye and was pleased with the cosmetic result. The patient was also satisfied with the cheek support prosthesis due to improvement in esthetics, mastication and speech.
| Discussion|| |
The primary concern in the treatment of a Bell's palsy patient is to restore the esthetics, function and comfort. Lagophthalmos due to facial nerve palsy leading to exposure keratitis has been traditionally treated with Tarsorraphy and Canthoplasty. Although effective, these procedures lead to disturbance in vision and visual field in addition to cosmetic defect. Implanted devices to counteract the action of the levator include silicone bands, palpebral springs, gold weight and platinum-cobalt magnets. Silicone bands and palpebral springs have the disadvantage of being difficult to calibrate against the pull of levator, and this can be adjusted in springs, and a second surgical procedure is required. Springs are associated with extrusion risk as well. , Magnets have the potential disadvantage of slow blink response, foreign body reaction and extrusion. 
Gold weight implant has the advantage of being relatively inert, high density and providing good color match for the overlying skin.  Commercially manufactured gold implants are available in several weights and are usually used, but may create a "brick-like" appearance within the eyelid. Custom-made weights that produce a much more esthetic result can be fabricated by the dental professionals. Although rare, the complications associated with the lid-loading technique, like excessive ptosis (15-25%), residual lagophthalmos (8-15%), implant migration (8-10%), extrusion (3-7%), wound infection (7-10%) and astigmatism (7-24%) have been reported. ,, But, these complications can be overcome by the gold weight trial procedure, proper suturing of the implant and by following proper surgical procedures to prevent infection, respectively.
Surgical approaches to improve permanent facial paralysis include facial nerve graft, hypoglossal nerve crossover and regional muscle transfer with varying success. But, these procedures require hospitalization, general anesthesia and extensive rehabilitation. 
The non-surgical approach for facial reanimation with intra-extraoral cheek support prosthesis improves esthetics and function by providing support to the paralyzed musculature and retracting the lip to a more normal position with small extraoral extension.  A hollow design of the prosthesis aids in increased retention due to decreased weight.
| References|| |
|1.||Muralidhar M, Raghavan MR, Bailoor DN, Kamath VV. Bilateral Bell's palsy: Current concepts in aetiology and treatment. Case report. Aust Dent J 1987;32:412-6. |
|2.||Fogg RA, Radell MH. A removable oral prosthetic appliance for Bell's palsy: Report of case. J Am Dent Assoc 1977;94:1169-72. |
|3.||Lavy JA, East CA, Bamber A, Andrews PJ. Gold weight implants in the management of lagophthalmos in facial palsy. Clin Otolaryngol Allied Sci 2004;29:279-83. |
|4.||Grisius M, Hof RL. Treatment of lagophthalmos of the eye with a custom prosthesis. J Prosthet Dent 1993;70:333-5. |
|5.||Sela M, Taicher S. Restoration of movement to the upper eyelid in facial palsy by an individual gold implant prosthesis. J Prosthet Dent 1984;52:88-90. |
|6.||Larsen SJ, Carter JF, Abrahamian HA. Prosthetic support for unilateral facial paralysis. J Prosthet Dent 1976;35:192-201. |
|7.||Baker C Daniel. Facial paralysis. In, Carthy M Joseph, May W James, Litter J Williams Editor. Plastic surgery, Volume 3, The Face, Part 2, Philadelphia, WB Saunders 1990. p. 2307-15. |
|8.||Townsend J Daniel. Rehabilitation of paralysed eye. In, Cheney M.L Editor. Facial surgery Plastic and reconstructive, 1 st Edition. Maryland, Williams and Wilkins, 1997. p. 685-94. |
Department of Prosthodontics, KLEVK Institute of Dental Sciences, Belgaum, Karnataka
Source of Support: None, Conflict of Interest: None
[Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5]