FACIAL NERVE

FACIAL NERVE

DR. C.S. AARTHY

Ist YEAR POST GRADUATE STUDENT
DEPARTMENT OF PUBLIC HEALTH DENTISTRY
CONTENTS
 INTRODUCTION
 EMBRYOLOGY
 NUCLEI OF ORIGIN
 COURSE AND RELATIONS
 BRANCHES OF FACIAL NERVE
 FUNCTIONAL COMPONENTS
 GANGLIA ASSOCIATED WITH FACIAL
NERVE
 BLOOD SUPPLY
 VARIATIONS OF NERVE
 FACIAL NERVE LESIONS
 PUBLIC HEALTH SIGNIFICANCE
 CONCLUSION
 FACIAL NERVE
 7th Cranial Nerve
 Mixed Nerve - * Motor root
*Sensory root
 It emerges from the Brain stem between the
Pons and the Medulla

 Function – Conveys taste sensation from

anterior 2/3rd of tongue and oral cavity and
also, controls the muscles of facial expression.

 Supplies- Pre ganglionic parasympathetic

fibres to several head and neck ganglia
 EMBRYOLOGY

DEVELOPMENT :-

 Mesoderm of 2nd
pharyngeal arch
 FACIAL NERVE EMBRYONIC DEVELOPMENT

 Facial nerve course, branching pattern, and

anatomical relationships are established
during the first 3 months of prenatal life
 The nerve is not fully developed until about 4
years of age
 The first identifiable FN tissue is seen at 3rd
week of Gestation-

FACIOACOUSTIC
PRIMORDIUM
 4th WEEK

 By the end of 4th week ,the facial

and acoustic portions are more
distinct.

 The facial portion extends to

placode.

 The acoustic portion terminates on

otocyst.

 The CHORDA TYMPANI will be

discerned from the main branch.
 5TH WEEK

 Early 5th week, the geniculate ganglion forms

from distal part of primordium.

 Nervous intermedius, and greater superficial

petrosal nerve are visible by the fifth week.
 6TH WEEK

 Near the end of the 5th week ,the

facial motor nucleus is
recognizable.

 The motor nuclei of 6th and 7th

cranial nerves initially lie in close
proximity.

 The internal genu forms as

metencephalon elongates and 6 th
nerve nucleus ascends.
 7TH WEEK

 Early 7th week, geniculate ganglion is well developed and facial nerve roots are
recognizable.
 Motor root fibers pass mainly caudal to ganglion.
8TH WEEK
 Muscles of facial expression
 Terminal branches evident
10TH TO 12TH WEEK
 Facial nerve makes 2nd genu
 Peripheral branches are completely developed
NUCLEI OF ORIGIN
 NUCLEI OF ORIGIN

• It lies in the lower part of the

Motor nucleus of pons
facial nerve (SVE): • muscles of facial expression

• lies in the pons lateral to the

Superior salivatory main motor nucleus of VII
nucleus (GVE) • gives rise to secretomotor
parasympathetic fibers

• lies in the medulla

Nucleus solitarus • recieves the taste sensation from
(SVA): the anterior 2/3 of the tongue
 COURSE AND RELATIONS
COURSE

 Internal course:-
Motor fibres passes dorsally and
medially forming a loop around the
abducent nucleus in the floor of 4 th ventricle
forming facial colliculus
 Superficial origin:-
At the pontomedullary angle above
the inferior cerebellar peduncle
 COURSE
Facial Nerve is formed mainly of two parts:-

 Facial nerve proper:-

arising from facial motor nucleus
in pons
 Nervus intermedius:-
It lies between the facial proper
and vestibulcochlear nerve in the
pontocerebellar angle
COURSE AND RELATIONS:-

 INTRACRANIAL (intrapetrosal)
COURSE

 EXTRACRANIAL COURSE
COURSE

 INTRAPETROUS COURSE:- The nerve passes laterally with the

vestibulocochlear nerve to the internal auditory meatus.At the
bottom ofmeatus the nerve enters the facial bony canal where it
runs laterally above the vestibule of inner ear
 Reaching the medial wall of the middle ear, it bends sharply
backwards above the promontory where the geniculate ganglion
is found.
 It then arches downwards in the medial wall of the middle ear to
reach the stylomastoid foramen.
16
EXTRACRANIAL COURSE :-
As it emerges from the stylomastoid foramen, it
runs forwards in the substance of the parotid gland crosses the
styloid process, the retromandibular vein and the external
carotid artery.
It divides behind the neck of the mandible into its
terminal branches which come out of the anteromedial surface
of the gland.
BRANCHES :-
INTRACRANIAL :-
Greater petrosal nerve
Nerve to stapaedius
Chorda tympani

EXTRATEMPORAL:-
Intrameatal
Labyrinthine
Tympanic
Mastoid nerve
EXTRACRANIAL BRANCHES :-
Posterior Auricular Nerve
Digastric nerve
Stylohyoid nerve
TERMINAL BRANCHES:-
Temporal
Zygomatic
Buccal
Marginal mandibular
Cervical
 BRANCHES

TEMPORAL

 Comes out through the upper pole

TEMPORAL
of parotid gland
 Cross zygomatic arch
 Muscles supplied
 Auricularis anterior & superior
 Frontalis
 Corrugator supercilii
 Procerus
 Upper orbicularis oculi
 Action – Raising eyebrows
ZYGOMATIC

 Also called Upper Zygomatic

 Cross zygomatic bone
 Muscles supplied
 Lower Orbicularis oculi
 Action – Tight shutting of eye

ZYGOMATIC
BUCCAL

 1 cm below zygomatic arch

 2 in number -Upper deep buccal & Lower deep
buccal
 runs along with parotid duct
 Muscles supplied :-
 Buccinator
 Zygomatic major and minor
 Levator Labii Superioris Alaque Nasi
 Levator Anguli Oris (soft smile)
 Nasalis &Upper Orbicularis Oris BUCCAL
 Action – Showing Teeth
MARGINAL MANDIBULAR

 Comes out through the ant. border of parotid

gland
 Runs 1-2cm below the ramus of mandible
inferiorly
 Supplies muscles of lower lip & chin
 Lower Orbicularis Oris
 Depressor anguli oris
 Depressor labii inferioris
 Mentalis
 Actions – Whistle & Puckering of Lips

MARGINAL
MANDIBULAR
CERVICAL

 Comes out through the lower pole of parotid

gland.
 Muscle Supplied – Platysma
 Action – Contraction of Platysma

CERVICAL
FUNCTIONAL COMPONENTS :-

Special visceral Efferent Facial expression

General visceral Efferent Para sympathetic, secreto motor to

lacrimal glands, sub mandibular &sub
lingual glands.

Special visceral Afferent Taste sensation from anterior2/3rd of the

tongue

General visceral Efferent Carries impulses from lacrimal

glands,sub mandibular &sublingual
glands.
 GANGLIONS :-

GENICULATE GANGLION :-

Main ganglion of facial nerve

Receives fibres from the respective nucleus

Send fibres to corresponding glands /muscles

 SUBMANDIBULAR GANGLION
LANGLEY’S GANGLION
Parasympathetic pre ganglionic fibres

Superior salivatory nucleus

Facial nerve

Chorda tympani nerve

Lingual nerve

Sub mandibular ganglion

Post ganglionic fibres

Sub mandibular& sub lingual glands

 MECKELS GANGLION PTERYGOPALATINE GANGLION
SPENOPALATINE GANGLION
Pre ganglionic fibres

Sup.salivatory nucleus

Nervous intermedious/facial nerve

Geniculate ganglion

Greater petrosal nerve

Nerve of pterygoid canal

Pterygopalatine ganglion

Post ganglionic fibres

Lacrimal gland/nasal/palatine glands

BLOOD SUPPLY :-
 Anterior inferior
cerebellar artery Stylomastoid artery
– at the – mastoid segment
cerebellopontine angle

BLOOD
SUPPLY
Superficial petrosal
Labyrinthine artery
artery
– within internal
– geniculate ganglion
acoustic meatus
and nearby parts
VARIATIONS OF NERVE :-

Buccal branch: Marginal mandibular

usually single, two branches branch – 20-50% cases pass
in 15% cases below the lower border of
mandible

Katz and Catalano:

Cervical branch – 20% (3%) cases presenting the
cases, two branches major and minor trunks of
facial nerve

Baker and Conley:

trifurcation, quadrifurcation, plexiform
branching pattern of the trunk of the
facial nerve
 AGE CHANGES :-
Child Adult

Chorda tympani may exit through Chorda tympani exit proximal to

Stylomastoid Foramen Stylomastoid Foramen

2nd genu is more acute and lateral 2nd genu is less acute and medial

Nerve trunk is more anterior and lateral Nerve trunk is less anterior and deeper
on exit through Stylomastoid Foramen

Nerve very superficial over angle of Nerve less superficial over angle of
mandible mandible
FACIAL NERVE LESIONS

• Upper Motor
Neuron Lesion
Central facial • Involves Supra
paralysis nuclear&nuclear
segments
• The Frontal And
Upper Orbicularis
Oculi- Spared

• Lower motor neuron

lesion
Peripheral
paralysis • BELL’S PALSY
Etiology of Facial Nerve Paralysis

1. Idiopathic: Bell’s palsy

Melkersson Rosenthal syndrome
2. Temporal bone trauma: Road traffic accident
3. Infection: Herpes Zoster
4. Neoplasm: Parotid tumors
Glomus tumors
5. Congenital: Moebius syndrome
6. Iatrogenic: Parotid surgery
7. Metabolic: Diabetes mellitus, Hypertension
 CLINICAL TESTING OF FACIAL NERVE

Patient is asked:
ACTION MUSCLE TESTED
1. Raise the eye brows Frontal head of
Occipitofrontalis
2. Wrinkle the brow Nasocilliary
3. Close the eye Orbicularis oculi
4. Show the teeth; pronouncing Orbicularis oris
several labial consonants
5. Blow out the cheek Buccinator
6. Retract the chin Platysma
EVALUATION OF FACIAL NERVE

• Physical examination
• Topognostic testing
• Hearing and balance tests
• Taste test
• Electrical tests
• Maximal stimulation tests (MST)
• Evoked electromyography (EEMG)
• Electromyography (EMG)
EVALUATION OF FACIAL NERVE

Radiographic studies
 CT and MRI of brain stem, temporal
bone, skull base,
 Contrast sialography of parotid gland.
Surgical exploration
Special laboratory tests.
 Lumbar puncture, Monospot , ESR, CBC,
urine and stool tests, Lyme titres etc.
 BELLS PALSY

 Lower motor neuron palsy

 Charles bell , 1821
 Women > Men
 Unilateral in nature
 Bilateral rare
 Right side=left side
BELLS PALSY :-

ETIOLOGY:
INFECTIONS Bacterial
Viral
Otitis media
TRAUMA Fractures
Gunshot wounds
TUMOURS
IATROGENIC Parotid gland surgery
Orthognathic surgery
TMJ surgery
Injection of LA in parotid capsule
COLD HYPOTHESIS.
Clinical features
Inability to smile
Unable to close the eyes
Absence of wrinkles
Drooping of corner of mouth
Drooling of saliva
Obliteration of nasolabial fold
BELLS SIGN
Mask like appearance
Slurring of speech
Alteration of taste
 MANAGEMENT :-

 REASSURE THE PATIENT-

spontaneous recovery- 85% in 3 weeks to 6months
 Physiotherapy maintain muscle tone via
 Galvanism
 Gentle massage
 Facial exercises
 MANAGEMENT

 Medication
If patient is seen within 2-3 weeks
 Tab.prednisolone 1mg/kg 10-14 days
 Vitamin B1,B6,B12- supplementary
 Anti viral drugs - Acyclovir -400 mg 5 times per day X 7days ys
 Artificial lubricants
 Artificial saliva
 MANAGEMENT

SURGERY
 If patient is seen after 3-4 weeks
 STEROID THERAPY- no use
 ELECTRO NEURO GRAM should be
performed
 EYE CARE

Placement of springs
Gold weight /tarsorraphy
Botax(clostridium
botilinum)
GOLD WEIGHT PLACEMENT
 MELKERSSON-ROSENTHAL SYNDROME

Fissure tongue

Facial swelling
paralysis involving lips
 CROCODILE TEAR SYNDROME

 Injury to nerve near

geniculate ganglion
 Misdirection of nerve to
lacrimal gland instead to
submandibular gland through
greater petrosal nerve
 Patient lacrimate while
eating-crocodile tear
Treatment
Dividing the greater petrosal
nerve
 RAMSAY HUNT SYNDROME

Facial nerve
paralysis

Herpitic Eighth nerve

lesions involvement
PUBLIC HEALTH SIGNIFICANCE :-

 Public Health professionals need to have a sound and firm

understanding of the basic and applied anatomy of the facial nerve as it
helps us in early diagnosis and treatment of patients in the field setting.

 The detection of the early signs and symptoms are pertinent to

proper treatment and rehabilitation of the patients. Since many of the
patients are unaware and ignorant about the nerve disorders, public
health professionals play an important role in re-assurance and
management of the disorders afflicting the facial nerve.
CONCLUSION

 The best means of reducing iatrogenic facial nerve injury, remains in a

clear understanding of the anatomy, good surgical technique with the use
of multiple anatomic landmarks.

 Furthermore, the patient has to be informed about the cosmetic sequelae

of any surgery involving the facial nerve and have to be told that facial
nerve paralysis or paresis is possible and can be partial or total, temporary
or permanent.
REFERENCES

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 Brad W. Neville, Douglas D. Damm, Carl M. Allen. Oral And Maxillofacial
Pathology. 2nd Ed. Usa: W.B. Saunders Company; 2002.
 Chaurasia BD.Human anatomy: Regional and Applied. vol 3.3rd Ed. New
delhi.CBS Publishers;1996.
 Neelima A. Malik. Textbook of oral and maxillofacial surgery.3rd Ed. New
delhi. JP Publishers;2012.