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Case Report

Facial nerve paralysis after dental procedure

Melda Misirlioglu, Mehmet Z. Adisen, Alime Okkesim, Yagmur Y. Akyil
Department of Oral and Maxillofacial Radiology, Faculty of Dentistry, Kirikkale University, Kirikkale, Turkey

A B S T R A C T

Peripheral facial nerve palsy (FNP) is a common neuropathy of cranial nerves. However, it is a rare condition in dental treatment
and may be associated with local anesthetic injections. Initial trauma to facial nerve cab is usually minor. In this instance, a complete
and rapid recovery is expected and most cases resolve within 12 hours. If more extensive damage occurs, nerve palsy can be
significant and long lasting. We report a 15yearold female patient with FNP that developed within 8 hours after a dental procedure.
The treatment was continued for 10 days with prednisone and acyclovir. At the end of the 4th day, movement began to return to
her face and the symptoms disappeared within 3 weeks period. In dental practice, it should be considered that iatrogenic factors
may play a direct or indirect role in FNP, as presented in our case. Clarification of the etiology and treatment of FNP requires a
multidisciplinary medical team. Therefore, dentists should be aware of clinical findings along with an essential treatment plan of
FNP in dental office.

Key words: Bells palsy, facial nerve palsy, herpes simplex virus, local anesthetic procedure complications

Introduction This paper describes the diagnosis and treatment of a rare

Peripheral facial nerve palsy (FNP) is a common
neuropathological disorder affecting the branches of the
seventh cranial nerve, causing an inability to control facial
muscles on the affected side.[1] The possible causes are
various and include trauma, infection, pregnancy, diabetes,
and neoplastic infiltration. Involvement of the facial
nerve in varying degrees results in a facial weakness with
a characteristic facial distortion.[2]
FNP is a very rare condition in dental treatment. In most
cases, nerve palsy begins instantly after local anesthetic
injection into the retromolar region and usually resolves
within 12 hours. However, in rare cases, onset of symptoms
may be delayed for several hours to days. Dental infection
or paradental foci is also believed to be responsible for
the insult.[3]
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case of FNP that developed after a dental procedure with
a local anesthetic injection.
Case Report
A 15yearold young girl was admitted to a private dental
practitioner with the complaint of mild pain because of
a decayed mandibular molar tooth in the right side. The
dentist, therefore, applied a block regional mandibular
anesthesia with a disposable regular dental needle using 2%
lidocaine with 1:250.000 epinephrine for dental treatment.
There was no sign of FNP at the end of the treatment,
however, the onset of symptoms was gradual during
the next 8 hours. Within the next 8 hours, she noticed
a weakness in the muscles around the eye and mouth at
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DOI:
10.4103/2321-3841.196356 Cite this article as: Misirlioglu M, Adisen MZ, Okkesim A, Akyil YY. Facial
nerve paralysis after dental procedure. J Oral Maxillofac Radiol 2016;4:80-2.

Address for correspondence: Mehmet Z. Adisen, Department of Oral and Maxillofacial Radiology, Faculty of Dentistry, Kirikkale University,
Kirikkale, Turkey. Email: m_zahit@hotmail.com

80 2016 Journal of Oral and Maxillofacial Radiology | Published by Wolters Kluwer - Medknow
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Misirlioglu, et al.: Facial nerve paralysis
the right side of her face. She developed a typical facial
weakness and could not smile or blink or even close her
eye with maximal effort [Figure 1].
She was due to see an immediate consultation referred to
our Department. Further examination revealed a reduction
of sensation to the lips and a loss of taste at the right
side of the tongue. Panoramic radiographic examination
revealed nothing uncommon [Figure 2]. Treatment with
prednisone (prednisolone, 60 mg per day), and because
of the possible effect of Herpes Simplex Type 1 (HSV1)
in the etiology, antiviral drugs acyclovir (Zovirax, 5 400
mg per day) were administered as a combination therapy.
The treatment was continued for 10 days. At the end of
the 4th day, movement began to return to her face and the
symptoms were disappeared within a 3 weeks period.
Discussion
The mechanism of facial weakness after dental procedure
can be explained as follows; direct anesthesia to the facial
nerve can force a rapid onset that occurs while the anesthetic
agent is being injected, reflex vasospasms of the external
carotid artery can lead the ischemia of facial nerve, and
dental infections may secondarily effect the facial nerve.[4]
Delayed onset of weakness may be associated with viral
infections, especially with HSV1.[5] The virus may remain
in the ganglion latently, and then can be reactivated by the
dental procedure. Other viral infections such as herpes
zoster (Ramsey Hunt Syndrome) affecting the geniculate
ganglion can also been involved in the pathogenesis of
FNP. The difference between Ramsey Hunt Syndrome and
FNP is clinically small vesicle eruptions on the tragus and
aural concha of the ear as well as lesions forming on the
a b
Figure 1: (a) Showing full face of patient. (b) Deviation of mouth to the left
side and failure to close the right eye
Journal of Oral and Maxillofacial Radiology / September-December 2016 / Vol 4 | Issue 3
tympanic membrane, soft plate, and anterior twothirds of
the tongue in Ramsey Hunt Syndrome.[6]
Dental procedure could damage the nerve by three
mechanisms; direct trauma to facial nerve by a needle,
intraneural hematoma formation, and toxic damage due
to local anesthetics. Needle may damage the small blood
vessels around the epineurium that causes hemorrhage
within the nerve caused by compression and fibrosis.
This effect occurs quickly (within 2030 min) that
the damage has been more increased than expected.
Therefore, increasing pressure on the nerve results with
damage.[7]
The local anesthetics containing vasoconstrictor agents may
also act indirectly to sympathetic vascular reflex causing an
ischemic reaction leading to FNP. The mechanic effect of
the needle itself can also stimulate the sympathetic plexus.[8]
Pogrel et al.[8] reported that the amount of the nerve damage
is neither related to any type of local anesthetic agents nor
to the number of injections given at one site. In addition,
they stated, as an interesting example, that the patients
had received multiple dental injections within 3 months
before the nerve damage occurred. They suggested that
the nerve position is an important factor related to nerve
injury by a needle.
Local anesthetic drugs can also be neurotoxic and can
damage the facial nerve itself. Some of local anesthetics
present fewer risks than most local anesthetics. Procaine
and tetracaine cause more damage than bupivacaine or
lidocaine.[7]
The article published by Gray[9] reported patients with
multiple peripheral facial nerve paralyses in dental origin.
He also reported 10 cases with Bells palsy related with
dental and paradental infections. The real mechanism
in those cases was not known, however, toxicity was
considered to be the probable reason.
Figure 2: Panoramic radiography of patient revealed nothing uncommon
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Misirlioglu, et al.: Facial nerve paralysis
Miles[10] suggested that the signs related with trigeminal
neuropathy were impairment of taste, vestibular
insufficiency, hearing disturbance, facial palsy, or
cerebellar lesion signs. These signs led them to suspect
a viral origin. Further, recent studies have shown that
patients treated with an antiviral drug in combination with
prednisolone demonstrated statistically full recovery in a
higher percentage than patients treated with prednisolone
alone.[11]
Conclusion
In dental practice, it should be considered that iatrogenic
factors may play a direct or indirect role in FNP. Onset
of the treatment using prednisolone and antiviral drugs
combined therapy was successful in our case. However,
clarification of etiology and treatment of FNP may require
a multidisciplinary medical team. Therefore, dentists should
be aware of clinical findings and should have an essential
treatment plan of FNP in dental office.
Declaration of patient consent
The authors certify that they have obtained all appropriate
patient consent forms. In the form the patient(s) has/
have given his/her/their consent for his/her/their
images and other clinical information to be reported in
the journal. The patients understand that their names
and initials will not be published and due efforts will be
made to conceal their identity, but anonymity cannot be
guaranteed.
82 Journal of Oral and Maxillofacial Radiology / September-December 2016 / Vol 4 | Issue 3
Financial support and sponsorship
Nil.
Conflicts of interest
There are no conflicts of interest.
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