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.