Specialist article: Face
Facial paralysisWhat training can and cannot do
One half of your face droops, your smile stays one-sided, something runs out when you drink? Here you will learn what lies behind facial palsy, what medicine does in the first few days, what studies show about facial exercises, and how lip closure, swallowing and breathing are trained as well.
Does this sound familiar?
One half of your face no longer cooperates, what now?
What applies to you?
Tap whatever applies to you.
If facial paralysis appears suddenly, it must be checked by a doctor immediately; if there is additional weakness in an arm or leg or speech problems, call the emergency number 112. What remains afterwards in everyday life often affects lip closure, drinking, swallowing and nasal breathing. These functions can be trained.
When it is an emergencyWhat studies show about exercisesThe key points at a glance
- Facial paralysis is a disorder of the facial nerve, the nervus facialis. The most common form is Bell’s palsy with no identifiable trigger; other causes include shingles at the ear (Ramsay Hunt syndrome), Lyme disease, surgery and stroke.
- The disease is treated by medicine, in Bell’s palsy with cortisone within the first 72 hours. Many recover largely; some are left with residual weakness or involuntary co-movements.
- Training does not repair a nerve. It addresses lip closure, swallowing and nasal breathing and can create the conditions for the muscles that are still activated to remain integrated into their functional pattern. Studies on facial exercises are small and predominantly positive; there are none on the FaceFormer in facial paralysis.
Video
Facial paralysis and Ramsay Hunt syndrome: understanding causes and consequences
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Anatomy
The facial nerve: one nerve for all facial expression
When people speak of facial paralysis, they usually mean a disorder of the facial nerve. The technical term is facial palsy.
The nervus facialis is the seventh of twelve cranial nerves. It leaves the brainstem, runs through a narrow bony canal in the petrous bone close to the inner ear, and exits the skull below the ear. In the parotid gland it fans out into branches for the forehead, eyelid, cheek, mouth and chin.
The nerve also carries fibres for taste at the front of the tongue, for tears and saliva, and for a small muscle in the middle ear that dampens loud noise. It is one of six cranial nerves that work together for breathing, swallowing and head balance; another is the vagus nerve.
Without it, no mouth closure.All the muscles that close the lips, press the cheek against the row of teeth and guide the corner of the mouth depend on the facial nerve. At the side of the corner of the mouth they meet in a knot of muscle fibres, the modiolus.
The lip ring has no bone of its own to pull against. It is tensioned from both sides, via the muscles that insert at the modiolus. If one side fails, the healthy side pulls the mouth over towards itself. This is how the typical crooked mouth develops.
A sealed, loosely closed mouth is therefore teamwork between both halves of the face; more on this in the article Lips: a muscle with a job.
Causes
Bell’s palsy, Ramsay Hunt, stroke: where the paralysis comes from
Facial paralysis is a finding, not yet a diagnosis. Very different causes can lie behind it.
The most common form is Bell’s palsy, also called idiopathic facial palsy. The guideline of the American ENT society describes it as a rapidly developing, one-sided weakness or paralysis of the facial nerve with no identifiable cause. However, the guideline also stresses that not every facial paralysis is Bell’s palsy1.
of the 1,989 patients at a specialised facial nerve centre in Boston had Bell’s palsy2
had the paralysis after surgery for a tumour on the hearing and balance nerve, an acoustic neuroma2
was due to the varicella zoster virus, the pathogen of chickenpox and shingles2
Severe and unusual cases tend to end up at a specialist centre, so the distribution does not apply to the general population. It does, however, show the range, extending to tumours, injuries during procedures and Lyme disease after a tick bite2.
Bell’s palsy
Sudden, one-sided, with no identifiable trigger. It is the most common form.
Ramsay Hunt syndrome
Shingles in the area of the ear. In addition to the paralysis there are blisters on the ear or mouth, often also ear noises, hearing loss and dizziness3. More on ear noises in the article Tinnitus.
Lyme disease
After a tick bite, the pathogen can affect the facial nerve, occasionally on both sides.
Stroke
Here the damage is not in the nerve but in the brain. This is referred to as central facial paralysis.
Ramsay Hunt syndrome became widely known in 2022 through the singer Justin Bieber. The paralysis is often more pronounced than in Bell’s palsy and resolves completely less often. The blisters may only appear after the paralysis; in the only prospective study to date, this was the case in 14 % of those affected3.
Context
Central or peripheral: what the forehead reveals
Where the damage lies is often apparent from the forehead. The assessment itself belongs in medical hands.
The forehead muscles receive their commands from both halves of the brain, while those of the lower face receive them mainly from the opposite half. If one half of the brain fails after a stroke, frowning therefore often remains possible, and it is mainly the lower half of the face that is paralysed. If, on the other hand, the nerve itself is affected, the whole half of the face fails, from frowning to closing the eyelid to the corner of the mouth.
Peripheral facial palsy
- Damage to the nerve itself, e.g. Bell’s palsy, shingles or injury
- The whole half of the face is affected, including the forehead
- The eye often does not close completely
- Taste, tears and hearing may also be affected
Central facial palsy
- Damage in the brain, e.g. after a stroke
- Mainly the mouth and cheek are affected
- Frowning often remains possible
- Often together with weakness of an arm or leg and speech problems
The forehead is a clue, not a do-it-yourself test. A stroke can be present even if the forehead can move.
Emergency: If one corner of the mouth suddenly droops and weakness in an arm or leg, or disturbances of speech, vision or balance are also present, call the emergency number 112. Even facial paralysis without any other signs should be seen by a doctor the same day, because treatment of Bell’s palsy is best started within the first 72 hours.
Treatment
What medicine does in the first few days
There is a medical treatment for Bell’s palsy with good evidence. It belongs at the start.
The American ENT guideline explicitly recommends prescribing oral cortisone from the age of 16 within 72 hours of onset. An antiviral drug should not be given on its own; in addition to cortisone, it is an option. If the eye does not close, it needs protection. Anyone who has not fully recovered after three months is re-examined or referred to a specialist centre1.
had regained their facial function after three months if they received prednisolone early, compared with 64 % without4
was the figure after nine months with prednisolone, compared with 82 % without. 551 people in Scotland were studied4
after the onset of paralysis was the latest point at which treatment began there. The antiviral drug aciclovir brought no benefit4
The same guideline makes no recommendation on physiotherapy, either for or against1. The studies on it are small. The training does not replace medical treatment and is no reason to delay it. It works at a different point.
Do not stop prescribed treatments such as cortisone, eye drops, eye ointment or a moisture chamber dressing for the night on your own. Discuss any changes with your practice. The training can be combined with medical treatment, physiotherapy and speech therapy. How we classify other methods is set out under FaceFormer and other treatments.
Progress
What happens next: recovery, residual weakness, co-movements
How facial paralysis progresses without treatment is shown by one of the largest observational studies on the subject.
In Copenhagen, the ENT physician Erik Peitersen followed 2,570 peripheral facial paralyses over 25 years until function returned, for a maximum of one year. No treatment was given. The data therefore show how recovery proceeds on its own5.
showed function again within three weeks; in the rest, it only returned after three to five months5
regained normal facial expression5
were left with co-movements, 17 % with a shortening of the muscles, a so-called contracture5
The figures are encouraging, but they also show the flip side. Some consequences only arise during recovery: when the nerve regrows, not all fibres find their way back to their original muscle. Then the eye moves when you smile, or it waters when you eat. These co-movements are called synkineses.
Residual weakness
The corner of the mouth droops, the smile stays one-sided, the cheek is slack.
Co-movements
When you purse your lips, the eye closes; when you blink, the corner of the mouth twitches.
Shortening
After months, the affected side feels stiff and tense.
Drinking and eating
Liquid runs out at the side, food remains collect in the cheek1.
Eye
The eyelid does not close completely, the eye dries out and needs protection1.
Function instead of symptom
What facial paralysis has to do with breathing, swallowing and head balance
The paralysis itself is a matter for medicine. What it changes in everyday life affects functions that run around the clock. We swallow many hundreds to a thousand times a day.
Our approach does not revolve around the symptom but around the basic functions of breathing, swallowing and head balance. With many complaints, in our view, a disturbed basic function is at the start of the chain. With facial paralysis it is the other way round: the disease disturbs the function, and the body has to adapt to it. This is where the training comes in.
A sealed mouth closure is the prerequisite for the oral cavity to build up negative pressure during swallowing and for the air to take the route through the nose. In people after a stroke, lip strength was clearly associated with swallowing ability; in healthy people it was not6.
In our view, the lips form the front seal of a system in which breathing, swallowing and head balance work together. More on this in the article Swallowing and swallowing disorders.
The nerve fails
One half of the face loses tone, and the lip ring is pulled from one side only.
The mouth closure starts to leak
Something runs out when drinking, food remains stay in the cheek, and the mouth is open more often.
The body compensates
The healthy side works harder, the jaw and tongue help with sealing, and the air takes the route through the mouth more often.
The pattern is stored
In our view, the nervous system files away the compensation as a habit. It can remain even after the nerve has recovered.
In our view, this is where the lever lies. The training does not repair the nerve, but it can create the conditions for the muscles that are still activated to remain integrated into their functional pattern. What is integrated is used and keeps its tension; what is bypassed loses it. Users with partial paralysis tell us about changes in lip closure, drinking and swallowing that they had not expected. This is individual experience and not a promise.
Purse your lips and puff out your cheeks. What happens?
Research
Facial exercises and oral screens: what has been tested
Exercises for the face have been studied, though not as thoroughly as one would wish.
The Cochrane review on physiotherapy for Bell’s palsy found 12 studies with 872 participants. There is no high-quality evidence of a clear benefit or harm. Low-quality studies suggest that facial exercises tailored to the individual can improve function, particularly in moderate and longer-standing paralysis7.
with new paralysis practised for three months. Afterwards, considerably fewer of them developed co-movements than without exercises7
took part in the most meaningful study on electrical stimulation. It brought no benefit compared with a sham treatment7
of high quality among seven randomised studies published since 2011 all reported a benefit of facial exercises8
Mirror training
27 people with complete paralysis, allocated by lot. Those who practised daily for ten months in front of a mirror, keeping their eyes equally open while moving their mouth, developed considerably fewer co-movements9.
Mime therapy
50 people with paralysis that had persisted for more than nine months practised relaxation, coordination and expression for three months. Facial symmetry improved compared with a waiting-list group10.
Closer to the FaceFormer are studies with an oral screen, a shield between the lips and teeth against which the lips work. In Sweden, 30 people after a stroke, 24 of them with central facial paralysis, trained with it for at least five to eight weeks. Their lip strength rose from a median of 7 to 18.5 newtons, and their swallowing ability improved11.
The authors suspect the reason lies less in stronger lips than in sensorimotor stimulation and the adaptability of the nervous system11. In another study, smiling and lip pursing barely changed in seven people with peripheral paralysis. They did, however, report that saliva, drinks and food ran out less often, and six of them were able to suck more strongly12.
The absence of a study does not mean the connection does not exist. It means it has not been tested.None of these studies examined the FaceFormer. The studies with oral screens are small and without a comparison group, and a review considers more studies necessary13. They support the principle, not a device. More under Studies and science.
Training
What FaceFormer training looks like with facial paralysis
Paralysis in the mouth and face area is one of the areas of application named in the FaceFormer exercise instructions. The training complements the treatment.
For background: FaceFormer therapy has its roots in rehabilitation. Klaus and Sabine Berndsen developed it at the ISST Unna, the Institut für Spezielle Systemische Therapie (Institute for Special Systemic Therapy) founded in 1984, among other things in their work with people after a stroke and with nerve damage in the face. What exercises can achieve in facial paralysis and where the limits lie is classified in the sections Studies and Limits.
Every exercise begins with the same starting position. The tip of the tongue rests on the small ridge behind the upper incisors, the starting point of the tongue reference position. The neck is lengthened, the head balanced. The FaceFormer sits in the oral vestibule, behind the lips and in front of the teeth.
In the basic exercise, the lips press the lip wedge together, the back teeth bite down briefly, and you swallow once. The wedge is symmetrically shaped. Both halves of the mouth have to close around the same shape.
Why this can also make sense with paralysis: sensation in the face runs via a different nerve, the trigeminal nerve, and is usually preserved in facial palsy. The pressure and shape of the lip wedge therefore reach the brainstem, even if the muscles still respond weakly. The tongue, palate and neck provide further signals from the same sequence.
The pattern has not been erased, it has been overlaid.That is how our model describes it. In our view, a movement sequence does not come back through insight, but through precise, frequent repetition.
From around week 3, the pull exercise is added. You pull the lip wedge with your thumb and index finger while your lips hold against it, then bite down and swallow. For paralysis in the face, the exercise manual names, in addition to pulling forwards, the directions upwards, downwards and to the side.
With one-sided paralysis, in the pull exercise in varying directions you pull towards the healthy side. The directions and number of sessions are best agreed with a practice.
- From day 1
Basic exercise
Three times a day for a few minutes with the FaceFormer ZERO, with little force and evenly on both sides.
- From around week 3
Pull exercise and night
Pull exercise as described above. At night you wear the ZERO as soon as the basic exercise is established.
- After a few weeks
Switching to the ONE
It is the same size and shape as the ZERO, only made of firmer material.
- From around week 6
Breathing exercise
The breathing exercise combines the training with calm nasal breathing.
- Over months
Patience
The exercise manual expects six to twelve months until new sequences run by themselves.
Safety
Limits and what to watch out for
The training is non-invasive. Even so, there are situations in which you should be careful or consult someone first.
Precision before force
Start with the ZERO and press only firmly enough for both halves of your mouth to hold the wedge.
Keep an eye on the eye
Practise in front of a mirror at first. If the eye closes as well when you press, reduce the force. If this persists, coordinate the training with a practice that treats facial paralysis.
The FaceFormer slips out
Then you are pulling harder than your lips can hold at the moment. Pull more gently.
Protect the eye
If the eyelid does not close completely, the eye needs its own protection. The training does not change that.
Pain and fatigue
If you feel pain, stop. Muscle fatigue and pressure on the teeth are common at first: pause briefly, then continue with fewer repetitions.
Only after consulting a doctor, or not indicated: a new paralysis that has not yet been clarified; acute inflammation in the mouth, throat or airways; a completely blocked nose; recent surgery in the mouth or face, until the practice that operated gives its approval; an acute jaw joint lock with severe pain; degenerative neuromuscular diseases such as ALS, advanced Parkinson’s or bulbar palsy. Facial paralysis on both sides always needs to be thoroughly investigated. Children under 4 train only with expert supervision.
Everyday life
Living with facial paralysis day to day
Drinking
Small sips, head kept upright. Consciously close your lips around the rim of the glass, including on the weaker side.
Eating
Small bites, chew well. If food remains collect in the cheek, the tongue clears them out after swallowing.
Lips closed, nose open
Lips loosely together, tip of the tongue on the palate: this keeps the oral cavity sealed, and the air takes the route through the nose. A mouth that is often open dries out; more under Dry mouth.
Head balance
Balance your head above your body instead of pushing it forward. In our view, this relieves the jaw and neck.
Photos instead of day-to-day impressions
Before you start, photograph your face at rest, smiling and with pursed lips, and repeat this every four to six weeks.
Use the app
The free FaceFormer app guides you through the basic exercises and records your progress. You will find all modules on the exercise pages.
Questions
Frequently asked
What is facial palsy?
A paralysis of the facial nerve, the nervus facialis, which moves the muscles of facial expression on one half of the face. If the damage is in the nerve itself, it is called peripheral facial palsy; if it is in the brain, for example after a stroke, it is called central facial palsy.
How long does facial paralysis last?
It varies greatly. In a large Copenhagen observational study without treatment, function returned within three weeks in 85 %, and after three to five months in the rest. If recovery is incomplete after three months, the guideline recommends a fresh examination.
How can I tell whether it is a stroke?
You cannot reliably tell yourself. If weakness in an arm or leg, or disturbances of speech, vision or balance are also present, call the emergency number 112. Even without any other signs, a new facial paralysis should be seen by a doctor the same day.
Do exercises help with facial paralysis?
The evidence is thin but mostly positive. The Cochrane review found low-quality evidence that tailored facial exercises can improve function and, if started early, reduce involuntary co-movements. Electrical stimulation brought no benefit.
Can the FaceFormer heal facial paralysis?
No. The disease of the nerve is treated by medicine, and the training does not repair the nerve. It addresses lip closure, swallowing and nasal breathing and can create the conditions for the muscles that are still activated to remain integrated into their functional pattern. There is no study on the FaceFormer in facial paralysis.
When can I start training after facial palsy?
Once the cause has been clarified by a doctor and acute treatment has been started; after surgery on the face or in the mouth, only with the approval of the practice that operated. Start with the basic exercise and little force.
In which direction do I pull with one-sided facial paralysis?
Towards the healthy side, as described in the exercise manual. The FaceFormer stays centred in the mouth, and you pull only as hard as your lips can hold it. The combination of directions is best decided together with a practice.
What are synkineses, and can I still train?
Involuntary co-movements after facial paralysis, for example when the eye closes as you purse your lips. You can still train: slowly, with little force and in front of a mirror. If the co-movement increases, coordinate the training with a practice.
More articles from the knowledge section
Where to go next
Sources
- Baugh RF, Basura GJ, Ishii LE, Schwartz SR, Drumheller CM, Burkholder R et al. (2013). Clinical practice guideline: Bell’s palsy. Otolaryngology Head and Neck Surgery 149(3 Suppl):S1-27. PMID 24189771. Source
- Hohman MH, Hadlock TA (2014). Etiology, diagnosis, and management of facial palsy: 2000 patients at a facial nerve center. Laryngoscope 124(7):E283-E293. PMID 24431233. Source
- Sweeney CJ, Gilden DH (2001). Ramsay Hunt syndrome. Journal of Neurology, Neurosurgery and Psychiatry 71(2):149-154. PMID 11459884. Source
- Sullivan FM, Swan IR, Donnan PT, Morrison JM, Smith BH, McKinstry B et al. (2007). Early treatment with prednisolone or acyclovir in Bell’s palsy. New England Journal of Medicine 357(16):1598-1607. PMID 17942873. Source
- Peitersen E (2002). Bell’s palsy: the spontaneous course of 2,500 peripheral facial nerve palsies of different etiologies. Acta Oto-Laryngologica Supplementum (549):4-30. PMID 12482166. Source
- Hägg M, Anniko M (2010). Influence of lip force on swallowing capacity in stroke patients and in healthy subjects. Acta Oto-Laryngologica 130(11):1204-1208. PMID 20443741. Source
- Teixeira LJ, Valbuza JS, Prado GF (2011). Physical therapy for Bell’s palsy (idiopathic facial paralysis). Cochrane Database of Systematic Reviews (12):CD006283. PMID 22161401. Source
- Khan AJ, Szczepura A, Palmer S, Bark C, Neville C, Thomson D, Martin H, Nduka C (2022). Physical therapy for facial nerve paralysis (Bell’s palsy): An updated and extended systematic review of the evidence for facial exercise therapy. Clinical Rehabilitation 36(11):1424-1449. PMID 35787015. Source
- Nakamura K, Toda N, Sakamaki K, Kashima K, Takeda N (2003). Biofeedback rehabilitation for prevention of synkinesis after facial palsy. Otolaryngology Head and Neck Surgery 128(4):539-543. PMID 12707658. Source
- Beurskens CH, Heymans PG (2006). Mime therapy improves facial symmetry in people with long-term facial nerve paresis: a randomised controlled trial. Australian Journal of Physiotherapy 52(3):177-183. PMID 16942452. Source
- Hägg M, Anniko M (2008). Lip muscle training in stroke patients with dysphagia. Acta Oto-Laryngologica 128(9):1027-1033. PMID 19086198. Source
- Wertsén M, Stenberg M (2020). Training lip force by oral screens. Part 3: Outcome for patients with stroke and peripheral facial palsy. Clinical and Experimental Dental Research 6(3):286-295. PMID 32301276. Source
- Fabricius J, Kothari SF, Kothari M (2021). Assessment and rehabilitation interventions for central facial palsy in patients with acquired brain injury: a systematic review. Brain Injury 35(5):511-519. PMID 33645363. Source
Get started
Ready for the training?
The free FaceFormer app guides you through the basic exercises, counts along and reminds you of your sessions. If you wish, a practice from the practitioner directory can support you.
FaceFormer ZERO + ONE
Both material hardnesses for getting started, day and night. The set for adults.
FaceFormer ZERO
The softer FaceFormer for getting started, for children and for the night.
FaceFormer ZERO Children’s Set
ZERO with hygiene box, plush bag and success book with stamp.
FaceFormer training aims to restore the physiological setting of the basic functions of breathing, swallowing and head balance, with lip closure and the tongue reference position, thereby creating the conditions under which symptoms can improve. It does not replace a medical assessment. You can find practitioners near you in the practitioner directory.
