Understanding Oral Motor Disorders: Synkinesis

Older Geriatric Dental Patient with Synkinesis Experiencing Eye Pain


A variation of hemi-facial spasm is the motor abnormality called synkinesis. This disorder occurs after a viral or traumatic paralysis of the seventh nerve. The nerve injury produces sprouting and the new motor connections cause inappropriate motor activations to occur, thus the name synkinesis. A variation of synkinesis is when there is also hyperlacrimation along with synkinesis. Some cases report that eye tearing occurs with chewing or other activities involving the orofacial muscles. [1]

Synkinesis Treatments

The management of facial synkinesis consists of a combination of facial biofeedback routines, facial physical therapy, the chemodenervation of affected muscle groups using botulinum toxin type A injections, and surgical modification of the offending muscle group if possible. [2]

1. Biofeedback

To improve facial muscle’s function, the use of ​biofeedback ​has been used, promoting a more conscious movements and facial expressions. Some examples are mirror feedback (performing exercises to prevent eye closure during mouth movements) and the use of tape around the mouth (to increase sensation of oral movements). [3], [4]

2. Physical Therapy

The purpose of the ​physical therapy in synkinesis is to prevent significant deterioration. The therapy may include biofeedback using a mirror or electromyography.

Fujiwara et al (2017) reported on 37 patients with peripheral facial nerve palsy receiving physical rehabilitation (application of hot packs, massage and stretching by hand, mirror biofeedback and eyelid motion using the levator palpebrae superioris muscle). They concluded that females and younger patients had higher possibility to prevent muscle deterioration with physical therapy.​ [5]

3. Botulinum Neurotoxin (BoNT) Injections

A report in 1994 first described the treatment of synkinesis with BoNT-A, and was followed with another clinical report on the use of ​BoNT-A injections in 10 patients with post-peripheral facial nerve palsy synkinesis. [6] Since then, multiple reports have shown efficacy of BoNT-A for patients with synkinesis. [7] If synkinesis is accompanied by hyperlacrimation or epiphora, BoNT-A may be used to reduce lacrimal secretion of the principal lacrimal gland in its palpebral portion. [8]

4. Surgical Options

The ​surgical techniques that improve individual symptoms aim to restore and/or inhibit movement. Some surgical options include upper eyelid loading, unilateral orasymmetric brow lift, selective neurectomy, muscle transection and free tissue transfer. [9]

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[1] Cooper, L., Izard, C., Harries, V., Neville, R., Venables, Malhotra, & Nduka. (2018). Paradoxical Frontalis Activation: An Underrecognized Consequence of Facial Palsy. Plastic & Reconstructive Surgery, 141(2), 263e-270e.

[2] Thomas, A., Larson, M., Braden, S., Cannon, R., & Ward, P. (2017). Effect of 3 Commercially Available Botulinum Toxin Neuromodulators on Facial Synkinesis: A Randomized Clinical Trial. JAMA Facial Plastic Surgery, JAMA facial plastic surgery , 2017.

[3] Kasahara, T., Ikeda, S., Sugimoto, A., Sugawara, S., Koyama, Y., Toyokura, M., & Masakado, Y. (2017). Efficacy of Tape Feedback Therapy on Synkinesis Following Severe Peripheral Facial Nerve Palsy. The Tokai Journal of Experimental and Clinical Medicine., 42(3), 139-142.

[4] Nakamura, K., Toda, N., Sakamaki, K., Kashima, K., & Takeda, N. (2003). Biofeedback rehabilitation for prevention of synkinesis after facial palsy. Otolaryngology and Head and Neck Surgery., 128(4), 539-543.

[5] Fujiwara, K., Furuta, Y., Yamamoto, N., Katoh, K., & Fukuda, S. (2017). Factors affecting the effect of physical rehabilitation therapy for synkinesis as a sequela to facial nerve palsy. Auris Nasus Larynx., Auris nasus larynx. , 2017.

[6] Laskawi R; Damenz W; Roggenkamper P; Baetz A. Botulinum toxin treatment in patients with facial synkinesis. European Archives of Oto-Rhino-laryngology. Supplement, 1994:S195-9.

[7] Husseman, J., & Mehta, R. (2008). Management of synkinesis. Facial Plastic Surgery, 24(2), 242-249.

[8] Girard, B., Piaton, J., Keller, P., Abadie, C., & Nguyen, T. (2017). Botulinum neurotoxin injection for the treatment of epiphora in nasolacrimal duct obstruction. Journal Français D’ophtalmologie., 40(8), 661-665.

[9] Markey, J., & Loyo, M. (2017). Latest advances in the management of facial synkinesis. Current Opinion in Otolaryngology & Head and Neck Surgery, 25(4), 265-272.

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