Botulinum toxin A and/or soft tissue fillers for facial rehabilitation.

Botulinum toxin A and soft tissue fillers are cornerstones of facial rejuvenation procedures. They can also be of benefit in facial rehabilitation. We report on three female patients who were treated with botulinum toxin A and/or hyaluronic acid-based fillers, one after orthognathic surgery, two after Bell's palsy, to correct facial asymmetries and loss of volume to restore facial attractiveness and improve their self-esteem and quality of life. These minimally invasive procedures are safe and effective. However, they need to be repeated for the long-term rehabilitation.

Distracción ósea y cirugía ortognática en paciente previamente radiado / Bone distraction and orthognathic surgery on previously irradiated patients

Introducción. Presentamos a un paciente que recibió tratamiento radioterápico en la infancia por un retinoblastoma. Como principal secuela presenta una severa hipoplasia ósea hemifacial, alteración de la dentición y atrofia muscular. Se realiza cirugía correctora facial mediante distracción ósea, cirugía ortognática y lipoescultura facial con un resultado estético y funcional excelente y estable hasta el momento actual. Caso clínico. Varón de 15 años con hipoplasia témporo-parieto-frontal, orbitaria izquierda y del tercio medio facial con un plano oclusal inclinado, resalte de más de 25 mm y múltiples piezas dentales con microdoncia y rizólisis. A los 19 años, inicia ortodoncia prequirúrgica y la colocación de distractores tipo Zurich en el maxilar superior. Se consigue un avance maxilar de 25 mm. A los 21 años se realiza cirugía ortognática bimaxilar y lipoescultura facial. Resultados. Paciente con mejoría de la simetría facial, oclusión en clase i con plano oclusal alineado. Resultados estables hasta el momento actual, con 23 años. Continúa con ortodoncia posquirúrgica y rehabilitación dental. Discusión. Se obtuvo una buena consolidación, con una calidad ósea excelente desde el punto de vista clínico y radiológico, sin presentar complicaciones. Otro beneficio de la distracción es el efecto expansor de los tejidos blandos. La distracción ósea y la cirugía ortognática bimaxilar son métodos prometedores en la reconstrucción del territorio maxilofacial en pacientes radiados con una deformidad dentofacial como secuela oncológica (AU)

Introduction. We report the case of a patient who received radiotherapy in childhood for retinoblastoma. The main sequelae of this was, severe bone hemifacial hypoplasia, abnormal dentition, and muscle atrophy. Corrective facial surgery was performed through bone distraction, orthognathic surgery, and facial liposuction, with excellent and stable aesthetic and functional results to date. Case. report A 15 year-old patient with left temporo-parieto-frontal and orbital hypoplasia and midface hypoplasia with an inclined occlusal plane, overjet more than 25 mm and multiple teeth with microdontia and rhizolysis. At 19 years old, presurgical orthodontics and placement of Zurich type maxillar distractors were started. An advancing of 25 mm was achieved. At 21years old, bimaxillary orthognathic surgery and facial liposuction was performed. Results. Patient improvement in facial symmetry, occlusion type i of Angle classification with inclined occlusal plane. Stable results to date on a 23 year-old patient. Continues with post-surgical orthodontic and dental rehabilitation. Discussion. Good bone consolidation was obtained, with excellent bone quality from a clinical and radiological point of view, with no complications. Another benefit is the distraction expanding effect of the soft tissue. Osteogenesis distraction and bimaxillary orthognathic surgery are promising methods in maxillofacial reconstruction on irradiated patients with dentofacial deformity as oncology sequelae (AU)

Rehabilitation and functional recovery after masseteric-facial nerve anastomosis.

BACKGROUND: After masseteric-facial nerve (V-VII) anastomosis, a new neurological circuit oversees the facial muscles and patients should learn to activate the facial movements using the masseteric function. AIM: To monitor the rehabilitative protocol of facial muscles activation through teeth clenching and to assess the clinical evolution after V-VII anastomosis in terms of facial symmetry and functional recovery. DESIGN: Case series. SETTING: Outpatients clinic. POPULATION: Eleven patients undergone V-VII anastomosis for complete unilateral facial palsy. METHODS: After surgery, patients underwent a needle electromyography (EMG) and a rehabilitative training with mirror feedback to learn how to reach the symmetry at rest and during facial movements through teeth clenching. The rehabilitative protocol at the first clinical evaluation has been monitored through the Italian version of Sunnybrook Facial Grading System (SFGS) and the Software Facial Assessment by Computer Evaluation (FACE). Functional limitations and quality of life have been evaluated using the Italian version of Facial Disability Index (FDI). The clinical evolution at 18 months was evaluated with EMG, SFGS, biting evaluation and FDI. RESULTS: At the first clinical evaluation after reinnervation, through teeth clenching patients displayed an improvement of symmetry at rest, symmetry of voluntary movement, symmetry of smile and composite score of SFGS. Objective measurement of facial structures with FACE system demonstrated an improvement of symmetry at rest and during smile through teeth clenching. At 18 months patients displayed a good reinnervation with a further improvement of SFGS scores and reduction of functional disability. No biting deficit has been observed. CONCLUSIONS: After V-VII anastomosis, at the first rehabilitative visit, patients learn to activate the reinnervated facial muscles through teeth clenching. Eighteen months after the anastomosis, patients display a further improvement of voluntary control on facial symmetry and smile and a reduction of disability. CLINICAL REHABILITATION IMPACT: Our study illustrates the rehabilitative protocol after V-VII anastomosis and analyzes the clinical evolution after this intervention in terms of recovery of facial symmetry and reduction of disability. This will be instrumental to standardize the rehabilitative protocol among different centers and to choose the best patient-tailored surgical approach for subjects affected by complete facial palsy.

Influence of maxillary obturator prostheses on facial morphology in patients with unilateral maxillary defects.

STATEMENT OF PROBLEM: Facial asymmetry is prominent with individuals with unilateral bone resorption and can lead to decreased quality of life. PURPOSE: The purpose of this study was to investigate the influence of maxillary obturator prostheses on facial morphology of individuals with unilateral maxillary defects by using 3-dimensional digital stereophotogrammetry. MATERIAL AND METHODS: The facial data of 8 participants with unilateral maxillary defects were acquired with a noncontact 3-dimensional digitizer, both with and without maxillary prostheses. The mid-facial plane was established by overlapping an original facial image with its mirror image. Displacement at 18 measurement points, including 7 bilateral pairs, was compared between the 2 sides, with and without the prostheses. Asymmetry indices of these 7 pairs also were calculated. Multivariate repeated-measures ANOVA was used to determine differences. RESULTS: Displacements of the lateral and inferior points at the ala of the nose were significantly greater on the defect side than on the normal side. The distances between the ideal and defect side points at the superior ala, the upper lip, and the angle of the mouth decreased significantly with the prosthesis. No significant differences were found in asymmetry indices, but the angle of the upper lip line to the mid-sagittal plane increased significantly with the prosthesis. CONCLUSIONS: The 3-dimensional analyzing method developed in this study can be useful in evaluating facial reconstruction with maxillary obturator prostheses with individuals with unilateral maxillary defects. The prostheses affect the region of the nasal ala, the upper lip, and the angles of the mouth.

Orthopaedic splint treatment can reduce mandibular asymmetry caused by unilateral temporomandibular involvement in juvenile idiopathic arthritis.

Unilateral temporomandibular joint (TMJ) arthritis in juvenile idiopathic arthritis (JIA) patients often induces asymmetric dentofacial growth. This study evaluates the effects of an orthopaedic functional appliance worn full time to reduce asymmetric mandibular growth in JIA patients. Twenty-two JIA patients with unilateral TMJ involvement were included in the study (mean age 7.5 years, range: 3.8-13.8 years). They all received orthopaedic treatment with a functional appliance, a so-called distraction splint (mean treatment time 57 months). Panoramic tomograms or cone beam-computerized tomograms were taken before and within 12 months after treatment cessation. At both time points, the ratio between the healthy and the affected side of the mandible was evaluated in terms of inter-side differences in condylar height, ramus height, and total vertical mandibular height. Orthopaedic functional treatment reduced mandibular asymmetries in terms of ramus height and total vertical mandibular height (P < 0.05). Mandibular growth rates in the affected and the non-affected sides were comparable in most patients. Our study finds evidence to support that a distraction splint can normalize mandibular vertical growth in the affected side. We therefore suggest implementation of distraction splint therapy in the treatment of JIA patients with unilateral TMJ arthritis.

Establishing gingival symmetry when placing anterior direct nanohybrid composite restorations.

Restoring the beauty of patients' smiles requires clinicians to incorporate both tooth and gingival esthetics. When gingivectomies and crown-lengthening procedures are required, opting for direct nanohybrid composite restorations can help enable dentists to achieve harmonious blending of the gingival architecture and the anticipated restoration by allowing for tissue healing and subsequent modifications to the gingival portions of restorations. This article presents two cases in which anterior nanohybrid direct composite restorations provided a means to enhance tooth esthetics simultaneous to improving gingival harmony.

Tortícolis muscular congénita en fase de adulto / Congenital muscular torticollis in adults

La tortícolis muscular congénita (TMC) es una enfermedad frecuente, que debido a su fácil reconocimiento y exitoso tratamiento en los primeros meses de vida no suelen mostrar alteraciones clínicas en edades infantiles tardías o adultos. El escaso número de casos que prevalecen por encima de los primeros años de vida hace que exista una menor información sobre las decisiones terapéuticas a seguir. Básicamente se relegan, tras fracasar la fisioterapia, al uso de toxina botulínica o de una cirugía específica. Presentamos el caso clínico de una paciente diagnosticada finalmente, ya en edad adulta de TMC, y que fue tratada mediante sección unipolar de la porción clavicular del esternocleidomastoideo seguida de una rehabilitación específica, intensa y precoz, con muy buenos resultados estéticos y funcionales (AU)

Congenital muscular torticollis is a common condition. Because it is easy to recognize and its successful treatment during the first months of life, clinical changes are not usually found in the late childhood or adult age. As few cases prevail after the first years of life, there is less information about treatment decisions to follow. When physical therapy fails, these treatments are basically relegated to botulinum toxin or specific surgery. We report the case of a patient who was finally diagnosed in adulthood of congenital muscular torticollis. This patient was treated by unipolar sectioning of the clavicular portion of the sternocleidomastoid muscle. This was followed by specific, early and intense rehabilitation, with very good esthetic and functional results (AU)

Recovery pattern of mandibular movement by active physical therapy after bilateral transoral vertical ramus osteotomy.

PURPOSE: The purpose of the present study was to evaluate the effect of an active physical therapy (PT) protocol after transoral vertical ramus osteotomy and to investigate the rehabilitation patterns of mandibular movement. MATERIALS AND METHODS: The study included 187 patients diagnosed with mandibular prognathism with or without facial asymmetry who had undergone bilateral transoral vertical ramus osteotomy from 2001 to 2009. The subjects were evaluated preoperatively and 1, 3, 6, 12, 18, and 24 months postoperatively in terms of the periods of PT and range of mandibular movement. The data were analyzed using 1-way analysis of variance (significance level, P < .05). RESULTS: Of the 187 patients, 108 (57.8%) did not receive repeat intermaxillary fixation (IMF) during the PT period, 58 (31.0%) received it once, 15 (8.0%) twice, and 6 patients more than 3 times. The average PT period for all was 10.9 days (range 5 to 45). The mean maximal mouth opening was 50.7 mm before surgery, decreasing to 33.9 mm at 1 month postoperatively. This was followed by an increase to 46.3 mm at 6 months postoperatively, with the maximal mouth opening thereafter showing 93.9% to 95.7% recovery compared with the preoperative state. CONCLUSIONS: About 88% of the patients with transoral vertical ramus osteotomy responded well to the reduced IMF duration and active PT protocols, receiving repeat IMF less than twice. It required about 6 months to recover 90% of the preoperative maximal mouth opening and 12 months to recover near preoperative levels statistically. The benefits of reduced IMF duration and the PT protocols seem to promote rehabilitation of the masticatory muscles and prevention of mandibular hypomobility.

A comparison of three methods to evaluate the position of an artificial ear on the deficient side of the face from a three-dimensional surface scan of patients with hemifacial microsomia.

PURPOSE: Patients with hemifacial microsomia may have a missing ear on the deficient side of the face. The fabrication of an ear for such individuals usually has been accomplished by directly measuring the ear on the normal side to construct a prosthesis based on these dimensions, and the positioning has been, to a large extent, primarily operator-dependent. The aim of the present study was to compare three methods, developed from the identification of landmarks plotted on three-dimensional surface scans, to evaluate the position of an artificial ear on the deficient side of the face compared with the position of the natural ear on the normally developed side. MATERIALS AND METHODS: Laser scans were undertaken of the faces of 14 subjects with hemifacial microsomia. Landmarks on the ear and face on the normal side were identified. Three methods of mirroring the normal ear on the deficient side of the face were investigated, which used either facial landmarks from the orbital area or a zero reference point generated from the intersection of three orthogonal planes on a frame of reference. To assess the methods, landmarks were identified on the ear situated on the normal side as well as on the face. These landmarks yielded paired dimensional measurements that could be compared between the normal and deficient sides. Mean differences and 95% confidence intervals were calculated. RESULTS: It was possible to mirror the normal ear image on to the deficient side of the face using all three methods. Generally only small differences between the dimensional measurements on the normal and deficient sides were observed. However, two-way analysis of variance revealed statistically significant differences between the three methods (P = .005). CONCLUSIONS: The method of mirroring using the outer canthi was found to result in the smallest dimensional differences between the anthropometric points on the ear and face between the normally developed and deficient sides. However, the effects of the deformity can result in limitations in relation to achieving a precise alignment of the ear to the facial tissues. This requires further study.

Correlação entre eletromiografia e índice de inabilidade facial em pacientes com paralisia facial de longa duração: implicações para o resultado de tratamentos / Correlation between electromyographic data and facial disability index in patients with long-term facial paralysis: implications for treatment outcomes

INTRODUÇÃO: Apesar de o movimento facial e de a atividade muscular poderem ser quantificados por meio de diversas técnicas e de a inabilidade facial poder ser quantificada por meio de questionários de autoavaliação, a relação entre essas medidas objetivas e subjetivas ainda não foi investigada. O objetivo do presente trabalho foi correlacionar dados eletromiográficos dos músculos elevadores do ângulo da boca com o índice de inabilidade facial em pacientes com paralisia facial de longa duração. A hipótese do estudo foi de que indivíduos com maior assimetria facial apresentariam escores menores no índice de inabilidade facial. MÉTODO: A avaliação consistiu na aplicação de uma escala clínica para avaliação da mímica facial, de duas subescalas do Índice de Inabilidade Facial e da realização do exame de eletromiografia de superfície (EMGs). Foram analisados 17 pacientes com paralisia facial de longa duração e os resultados foram comparados ao grupo controle, composto por 17 indivíduos saudáveis pareados por gênero e idade. RESULTADOS: Os participantes do grupo pesquisa apresentaram diferenças significantes entre as hemifaces nas tarefas de repouso e sorriso. O mesmo não foi observado para os participantes do grupo controle. A análise estatística indicou correlação fraca entre os dados da EMGs (assimetria facial) e o Índice de Inabilidade Facial. CONCLUSÕES: O uso de técnicas científicas modernas de análise de dados, como a EMGs, combinadas a medidas de autoavaliação oferece grandes possibilidades para clínicos e seus pacientes. A combinação de diferentes medidas em estudos randomizados que verifiquem o tipo de tratamento que oferece melhor resultado aos pacientes com paralisia facial deverá ser abordada em estudo futuro.

BACKGROUND: Several techniques are available for the assessment of facial movement and activity, and facial disability can be evaluated through self-administered questionnaires. However, the relationship between these objective and subjective measurements has not been examined to date. The present study examined the relationship between electromyographic data of the levator anguli oris muscle with the facial disability index in patients with long-term facial paralysis. We hypothesized that individuals with greater facial asymmetry have lower facial disability index scores. METHODS: Patients were assessed using a clinical scale for the evaluation of facial expression, 2 facial disability index subscales, and the results of surface electromyography (sEMG). Seventeen long-term facial paralysis patients were analyzed and compared to 17 age- and gender-matched healthy controls. RESULTS: Significant differences between right and left hemifaces during smiling and at rest were detected in the experimental group, but not in the controls. Statistical analyses also indicated a weak correlation between sEMG (facial asymmetry) and facial disability index. CONCLUSIONS: The use of modern data analysis techniques such as sEMG in combination with self-reported data is of great benefit to clinicians and their patients. The identification of a combination of measurements from randomized trials that can best determine the most effective treatment for patients with facial paralysis should be the objective of future studies.

Prosthetic rehabilitation of hemimandibular hyperplasia: five-year follow-up.

Hemimandibular hyperplasia is a rare asymmetrical mandibular malformation, characterized by enlargement of the condyle, the condylar neck, the ramus, and the body of the mandible. This condition results in laterognathia, dental articulation disorders, and functional defects. Therapy largely depends on the patient's age and the desired esthetic and functional results. This clinical report describes the prosthetic rehabilitation of a 50-year-old woman with hemimandibular hyperplasia. During the diagnostic phase, facial asymmetry was observed, as was the chin midline shifting to the unaffected side and three-dimensional enlargement of one side of the mandible, the condyle, the condylar neck, and the ramus. No biomechanical or functional problems were seen at a five-year follow-up visit, except for physiological wear to the artificial teeth.

Functional results after condylectomy in active laterognathia.

INTRODUCTION: Mandibular asymmetry due to overgrowth has two main forms, hemimandibular hyperplasia and hemimandibular elongation. It is necessary to distinguish between inactive and active forms, since surgical treatment of the latter, with a solely morphological aim, could lead to recurrence of further condylar growth. In these cases orthognathic surgery is performed in association with high condylectomy to interrupt the hyperactivity of the condyle. Condylectomy alone in growing patients stops the progression of deformities and sometimes achieves facial symmetry at the end of growth. Some authors have viewed condylectomy as a dangerous procedure, with the possibility of compromising articular function. We aimed to verify immediate and long-term results of condylar function after high condylectomy. MATERIALS AND METHODS: Between 1998 and 2007, 15 patients underwent high condylectomy for active laterognathia. All but one patient underwent postoperative Delaire functional rehabilitation. Long-term articular function was evaluated using subjective and objective criteria. RESULTS: In 14 patients, articular function was subjectively satisfactory. In one case, this did not occur because the patient refused postoperative functional rehabilitation. DISCUSSION AND CONCLUSIONS: Some authors have advised against condylectomy because of the possibility of temporomandibular joint dysfunction. High condylectomy in active laterognathia seems to be the procedure of choice in both adults and growing patients. In our experience, functional alterations of practical relevance are rare if the operation is followed by successful functional rehabilitation.

The restoration of function and esthetics of a patient with amelogenesis imperfecta using a combination of orthodontic and prosthodontic treatment: a case report.

AIM: The purpose of this case report is to present the esthetic and functional rehabilitation of the teeth in a 20-year-old patient with amelogenesis imperfecta (AI), facial asymmetry due to functional mandibular shift, and unilateral posterior crossbite. BACKGROUND: AI is a group of hereditary defects of enamel unassociated with any other generalized defects. AI results in poor development or the complete absence of the enamel of the teeth caused by improper differentiation of ameloblasts. CASE DESCRIPTION: This report describes the diagnosis and treatment of a young female patient with AI and facial asymmetry using a combined orthodontic-prosthodontic approach. Initially, the posterior crossbite, mandibular shift, and facial asymmetry were treated orthodontically. Later, metal-ceramic crowns for posterior teeth and all-ceramic crowns for anterior teeth were fabricated for final restorations. SUMMARY: Coordinated orthodontic and prosthodontic treatment, with careful consideration of patient expectations and requests, were critical for a successful outcome and patient satisfaction. CLINICAL SIGNIFICANCE: The complexity of the management of patients with AI supports the suggestion that the dental profession should have appropriate methods for the rehabilitation of rare dental disorders.

Biomaterial implantation in facial esthetic diseases: ultrasonography monitor follow-up.

Facial deficit diseases are corrected by biomaterial implantation. The ideal biomaterial should be easy to implant and remove and simple to be identified by a low-dose radiation and low-cost radiologic technique. The purpose of this work was to evaluate ultrasonography (US) as a technique in monitoring biomaterial status after operation. In the last 3 years, for this study we used polyethylene porosus and polyacrylamide. Our study included 300 patients grouped accordingly as follows: malformative syndromes, degenerative syndromes, and esthetic problems, results of skull-facial traumas, and whether they are treated in the early phase and or the late phase. In this paper, we describe the better 15 clinical cases for their excellent result and for their variety of US images. Ultrasonography has been shown as an excellent way to visualize clinical features and a possible pathologic process of an implanted biomaterial; it is a noninvasive, low-radiation and low-cost dose radiologic technique. Reconstruction in facial deficit diseases needs adequate biomaterial to implant and a careful patients observation, that is, both clinical and radiologic. Ultrasonography is a fundamental component of the follow up of implanted biomaterial patients.

Operative treatment of congenital torticollis.

There were 47 patients with congenital muscular torticollis who underwent operative release. After a mean follow-up of 74 months (60 to 90), they were divided into two groups, one aged one to four years (group 1) and the other aged five to 16 years (group 2). The outcomes were assessed by evaluating the following parameters: deficits of lateral flexion and rotation, craniofacial asymmetry, surgical scarring, residual contracture, subjective evaluation and degree of head tilt. The craniofacial asymmetry, residual contracture, subjective evaluation and overall scores were similar in both groups. However, group 2 showed superior results to group 1 in terms of the deficits of movement, surgical scarring and degree of head tilt. It is recommended that operative treatment for congenital muscular torticollis is postponed until the patient can comply successfully with post-operative bracing and an exercise programme.

[Algorithm of comprehensive treatment of adult patients with TMJ ankylosis and concomitant deformations of face skeleton].

There was offered an algorithm of optimal tactics of treatment and rehabilitation of adult patients with TMJ ankylosis and concomitant deformations of face skeleton.

Effect of facial neuromuscular re-education on facial symmetry in patients with Bell's palsy: a randomized controlled trial.

OBJECTIVE: To determine the effect of facial neuromuscular re-education over conventional therapeutic measures in improving facial symmetry in patients with Bell's palsy. DESIGN: Randomized controlled trial. SETTING: Neurorehabilitation unit. SUBJECTS: Fifty-nine patients diagnosed with Bell's palsy were included in the study after they met the inclusion criteria. Patients were randomly divided into two groups: control (n = 30) and experimental (n = 29). INTERVENTIONS: Control group patients received conventional therapeutic measures while the facial neuromuscular re-education group patients received techniques that were tailored to each patient in three sessions per day for six days per week for a period of two weeks. MAIN MEASURES: All the patients were evaluated using a Facial Grading Scale before treatment and after three months. RESULTS: The Facial Grading Scale scores showed significant improvement in both control (mean 32 (range 9.7-54) to 54.5 (42.2-71.7)) and the experimental (33 (18-43.5) to 66 (54-76.7)) group. Facial Grading Scale change scores showed that experimental group (27.5 (20-43.77)) improved significantly more than the control group (16.5 (12.2-24.7)). Analysis of Facial Grading Scale subcomponents did not show statistical significance, except in the movement score (12 (8-16) to 24 (12-18)). CONCLUSION: Individualized facial neuromuscular re-education is more effective in improving facial symmetry in patients with Bell's palsy than conventional therapeutic measures.

A comparison of prosthetic ear models created from data captured by computerized tomography, magnetic resonance imaging, and laser scanning.

PURPOSE: To compare the dimensional measurements and surface topography of stereolithographic models generated from computerized tomography (CT), magnetic resonance imaging (MRI), and laser scanning (LS) data with the same subjects' natural ears and ear casts. MATERIALS AND METHODS: Stereolithographic models were manufactured from images of the subjects' ears and ear casts recorded by CT, MRI, and LS, and dimensional measurements were compared. In the second part of the study, all stereolithographic models were CT scanned and reconstructed in an STL file format. A comparison of the surface topography of the CT, MRI, and LS model ears was made. RESULTS: Intraclass correlation coefficients indicated that dimensions could be reliably measured on the CT, MRI, and LS stereolithographic models. A 2-way analysis of variance revealed no statistical differences between the various sources of data (P = .991). The smallest differences of surface topography were observed on the MRI/CT superimpositions. CONCLUSION: The dimensional measurements on the stereolithographic models were similar to those from the original source. Only small differences were apparent between the surface topography of the CT, MRI, and LS models. MRI may be particularly appropriate to fabricate a prosthesis because it involves no radiation for the patient and internal form can be reproduced. The use of this technique in clinical practice requires further study.

Prosthodontic treatment of a patient with hemimandibular elongation: a clinical report.

This clinical report describes prosthodontic treatment of a patient with hemimandibular elongation that resulted in significant dentofacial asymmetry. A maxillary metal-ceramic fixed dental prosthesis and crowns were fabricated. To eliminate the negative horizontal overlap, 3 mandibular teeth were reduced to the gingival level. The mandibular prosthetic restoration was completed with metal and composite resin using an electroforming technique.

Mime therapy improves facial symmetry in people with long-term facial nerve paresis: a randomised controlled trial.

QUESTION: What is the effect of mime therapy on facial symmetry and severity of paresis in people with facial nerve paresis? DESIGN: Randomised controlled trial. PARTICIPANTS: 50 people recruited from the Outpatient department of two metropolitan hospitals with facial nerve paresis for more than nine months. INTERVENTION: The experimental group received three months of mime therapy consisting of massage, relaxation, inhibition of synkinesis, and co-ordination and emotional expression exercises. The control group was placed on a waiting list. OUTCOME MEASURES: Assessments were made on admission to the trial and three months later by a measurer blinded to group allocation. Facial symmetry was measured using the Sunnybrook Facial Grading System. Severity of paresis was measured using the House-Brackmann Facial Grading System. RESULTS: After three months of mime therapy, the experimental group had improved their facial symmetry by 20.4 points (95% CI 10.4 to 30.4) on the Sunnybrook Facial Grading System compared with the control group. In addition, the experimental group had reduced the severity of their paresis by 0.6 grade (95% CI 0.1 to 1.1) on the House-Brackmann Facial Grading System compared with the control group. These effects were independent of age, sex, and duration of paresis. CONCLUSION: Mime therapy improves facial symmetry and reduces the severity of paresis in people with facial nerve paresis.