THE VALIDITY AND RELIABILITY OF A RANGE OF MOTION ASSESSMEM' OF SMILE FOR CHiL,DREN WITH FACIAL PALSY

Shawna Elise Wade

A thesis submitted in conformity with the requirements for the degree of Masters of Science

Graduate Department of the Institute of Medical Science University of Toronto

Q Copyright by Shawna Elise Wade, 2000

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TEE VALiDITY AND RELIABILITY OF A RANGE OF MOTION ASSESSMENT OF SMDLE FOR CHILDREN WITH FACIAL PALSY

Shawna Wade Masters of Science

lnstitute of Medical Science University of Toronto

2000

Injury to the VI1 craaial nerve may resuit in a condition know as facial palsy, paralysis of the

muscles of facial expression. For children with long-standing paralysis, re-animation surgery

has provided them with the ability to smile. In order to assess the child's progress, the

efficacy of therapeutic interventions and the long-term outcomes, it is important to estabiish a

range of motion (ROM) assessment that is valid and reliable. The important amibutes to

rneasiue in the ROM assessment of srnile were identified and the content vdidity established.

The inter-rater reliability of the clinically derived measures of smile was determined using

three measurement tools: the modified hand held caliper (MCT), the d e r and the

goniorneter. The most clinically appropriate of the three tools was selected to cornpiete each

facial measurement. For clinicd activities the MCT appeared to be reasonably consistent in

the documentation of distance measutements in the assessment of smile. The d e r and

goniorneter were not found to be as reliable although the rneasurements of, lip droop and

direction of srnile are important in the assessment of smile. The results of this investigation

have produced a ROM assessment that will reliably measure most of the gross motor

components of srnile deemed important in the clinical setting: cornmisure movement, upper

lip movement, symmetry of the upper and lower Iips and symaietry of the philtnim. To

capture the smaller facial movements the community of researchers need to continue to

perfect the cornputer d y s i s of facial movement.

Appreciation and thanks are extended to my Master's Degree s u p e ~ s o r y cornmittee, Dr. R.

Manktelow, Dr. R Zuker, Dr. L. Mainwaring and Dr. C. Graveline. 1 am grateful to Dr.

Manktelow for consenting to provide me with passage into the graduate program of The

Institute of Medical Science and his ongoing mentorship throughout my graduate expenence.

1 continualiy admire the vision and slcili of both Dr. Manktelow and Dr. Zuker in their

treatment of children with facial palsy and the devotion they have in improving the quality of

Iife for this group of individuals. Dr. Mainwaring has been my lighthouse. 1 appreciate her

astuteness, her sense of clarïty, and sensitivity to my growth as a young researcher. Causaiity

is afforded to Dr. Graveline for daring me to begin this venture. I am indebted to her for

recognizing my potentiai.

Thank you to all the staff of Rehabilitation Services who supported me and the development

of this project. Special recognition is given to the Academic and Clinical Research

Committee for their insightfbi critique of this proposai and to Tara Muir, the second rater in

this study. 1 would also like to thank an exceptional group of individuals at Sick Kid's for

providing the polish to this project: Andrew Baziw - Medicai Engineering, Derek Stephens -

Biostatictics, Rob Tetemck, Eimer Cruz and Bili Fox - Graphic' s Department and Frank

Ferrari and Sam Mendolia - Audio-Visual Department In addition, 1 would aiso like to

acknowledge The Hospital for Sick Chiidren's Seed Grant Comrnittee for funcihg this

research study.

A profound thank you to the extraordinary children and families who participated in the

research study. Their interest and devotion to improve the outcornes for children undergohg

facial re-animation procedures needs to be commended.

A heartfelt thanks is also owed to my biends and family for their support, encouragement

and perseverance. In particular, my parents Murray and Chns Wade for al1 that they have

done for me in making this possible.

1 would now finaily thank rny husband Morgan Robinson for his never falling support and

patience with my graduate work and this research project. He is an excellent editor and 1 his

number one fan.

Appendix A Table Al : The Houe Brackmann Facial Nerve Grading Scale From: Facial nerve grading system by J.W. House and D E Brackmann. 1985, Oto lameolo~ Head and Neck Sur~ew, 93 (2), 146. (permission pending)

Table A 2 The Fisch Detailed Evaluation of Facial Symmetry From: Comparative value of facial nerve grading systems by Rickenmann, J., Jaquenod, C., Cerenko, D., Fisch, U. 1997, Otolamgolog~ Head and Neck Sur~ery, 1 17(4), 323. (permission pending)

Figure Al The Suonybrook Facial Grading System From: Development of a sensitive clinicd facial grading system by Ross, B.G., Fradet, G., & Nedzelski, J.M. 1996, Otolamaolo~ Head and Neck Surperv, 114(3), 382. (permission pending)

Appendix B

Figure B 1 : Landmarks for The Maximal Static Response Assay (Figure 1) From: Simultaneous quantification of facial movements: The maximal static response assay of facial nerve function. Johnson, P.C., Brown, H., Kuzon, W.M., Balliet, R, Ganison, J.L., & Campbell, J., 1994. Annals of Plastic Sureerv, 32(2), 1 72. (permission pending)

Figure B2: Landmarks for The Three Dimensional Tracking S ystem in Sensitivity of a method for the analysis of facial mobility: vector displacement. Trotman, C., Faraway, J.J., Silverster, KT., Greedee, G.M., & Johnston, L.E.

Reprinted with pennission from m e American Cleft Palate-Craniofacial Association &iginaily pubrished in The CZe fi PaZute-Cranio facial JoutnuI, 1998; 35(2), 133. bending author permission)

Figure B3: Interlandmark Separation for The Three Dimensional Tracking System in Sensitivity of a rnethod for the analysis of facial rnobility: Landmark separation. Trotman, C., Faraway , J. J.

Reprinted with permission from The Americun CIeft Palate-Craniofacial Association OriginaZZy published in The Clef? PaZate-Cranidacial Joum~Z, 2000; 35(2), 1 43. @ending author permission)

TABLE OF CONTlENTS

TABLE OP CONTENTS ...aa...a.a.a............................................................................................... vi

LIST OF FIGURES AND TABLES ........................................................................................... i~

................................................................................................... LIST OF SREVL4TIONS * . s s ~

S ~ E C T I E ASSESSMENTS ............................................................................................................................................ 6 ENtXFtEn OBECTNE GRADING SYSTEMS ...................................................................................................................... 8

........................................................................................... Hotue- Brackrnann Facial Grading Scaie (HBFGS) - 9 ...................................................................................... Fisch Detaifed Evafuation @Facial Symmetry (DEFS) 13

................................................................................................ The Sunnybrook Facial Grading System (SFGS) 15 .................................................................... .............................. Critical Anaiysis of Indirect Grading Sysrems ,.. 17

CHARACTERISTICS OF ïHE WICAL S m .................................~~..~.......................................................................... 1 8 OBJEC~~VE MEASUREMMT SYSTEMS ......................................................................................................................... -22

Liner Memurement Index (LM?) ......................................................................................................................... -25 Faciorneter by Frey ................................................................................................................ ,... ................... .., 27

..................................................... Cornputeriked Quantitative Assessrnent ofRynamic Facial Motion (QAFM 29 ................................................................................................... The Maimal Static Rtsponse Assay (UTR4) 3 1 ...................................................................................................... Three Dimensional Tracking System (TDTS) 34

....................................................................................... Critical Analysis of Objective Meanrtement Systems ... 35 SUMMARY OF LITERATURE REVIEW ............................................................................................................................. 36

......................................................................... RATIONALE FOR THE CURRENT STUDY 38

............................................................................................................................ OBJECTIVES .*40

....................................... PHASE ONE: DEVELOPMEElT OF THE ROM ASSESS MENT ..41

DESIGN .....................................................................................~..............~.......~.....................~...................................... 42

............................................................. PHASE TMrO: PRIMARY RELlABILITY STllDY *43

S ~ J E ~ S E L E ~ O N ........... .. ..................................................................................................................................... 43 RATERS ....................................................................................................................................................................... -44 -mmNG pROCEDURES ................................................................................................................................................. 44 THE MEASUREMENTT00I.S ....................................................................................................................................... 45 DESIGN .................................................~...............~.............................~.............~.................~.......................................~~ 46 POWERAND SAMPLE SIZE ............................ ,., .......................................................................................................... 47 ANALYSES .................................................................................................................................................................... 47

................................................... PHASE: ONE: DEYELOPMENT OF THE .4 SSESSMENT 53

................................................... PHASE THREE: FOLLOW-UP RELIABILITY STZTDY ..66

DEVELOPMENT OF m ASSESSMENT ........................................................................................................................... 70 INTER-RATER RELLABIL~~Y .......................................................................................................................................... 71

Hypothesrlr One ................................,................................................................................................................. 73 Hypothesis Two ................................................................................................................................................... 75 HypothesrS Three ................................................................................................................................................ 76 Hypothests Four .................................................................................................................................................. 77

CONTRI~U~ONS OF ms -1s ................................................... .............................................................................. 79 Lwrr~no~s ................................................................................................................................................................ 80 F m D B C ~ ~ O N ................................................................................................................................................ 8 1

CONCLUSIONS ....................................................................................................... 0........0.0.....0083

APPENDICES

APPENDDC A: IND~RECT O B E ~ FACIAL GRADMG SYS- .................................................................................. I Table A l . The Howe B r o c h m Facial Nerve Grading Scale Table A2 . The Ftsch Detailed Evdurrtion of Facial Symmetry Figue A I . The Swi.ybrook Facial Grading &stem

APPENDK B: Dmcr OB JE^ FACIAL GRADING S Y S ~ .................................................................................... IV Figure 81 . Facial Landmmks for the Maximal Static Respome As* Figure B2 . Facial Landmarks for the Three Dimensional Tracking System Jector Displucement Figure B3 . Facial Lcrndmorksfor the Three Dimensional Tracking System Sepuration of

Lu.MharRF

vii

APPMDR C: MEAS- TOOLS... ..................................................................................................................... VU Figure CI. The Modified Hand Held Coliper Tool with Coronal Plane Level Figure C2. The Transparent Goniorneter

&PENDE D: INFORMATION SENT TO FAMILLES ........-............-................................................................................... IX Recruitment Letter Infiormation for Familier Letter of Responre

APPENDIX E: CONSENT FORMS ........................................-....................................................................................... XI Corsent form for partic@ants I6 years and older Consent-fbrm f i r participants Zms than 16 years of age Assent form

APPENDE F: ASsESSMENT PROCEDURES ......~................-.......................................................................................... XX Standard Protocol for the Administration of the Assesment Tobie FI. Data Base: ROM Assessmeni ofSrnile

LIST OF TABLES AND FIGURES

Table 1:

Figure 1:

Table 2:

Figure 2:

Figure 3:

Figure 4:

Table 3:

Table 4:

Figure 5:

Figure 6:

Table 5:

Table 6:

Table 7:

Critical Analysis of Indirect Facial Grading Systems: H o u e Brackmann Scale, Fisch Detailed Evaluation, The Sunnybrook Facial Grading System

Facial Landmarks based on the investigations by Burres (1985); Paletz, Manktelow & Chaban (1 994); Frey, MY, Giovanoli & Stussi (1 994)

Cntical Analysis of Direct Facial Grading Systems: Linear Measurement Index, Faciorneter, Cornputerized Quantitative Assessment of Dynamic Facial Motion, The Maximal Static Response Assay, Three Dimension Trac king

Facial Landmarks -primary study

Range of Motion Assessment of Smile -pnmary study

Direction of Cornmisure Movement

Inter-rater Reliability of Facial ROM Measurement -primary study (distance measurements and direction of cornmisure movement)

Inter-rater Reliability of Facial Range of Motion Measurement -primary shidy (depth measurement)

Follow-up Study: Shifting of the Philtrum Revised

Follow-up Study: Depth of the Nasolabid Fold Revised

Inter-rater Reliability of Facial Range of Motion Measurement -follow-up study (distance measurement)

Inter-rater Reliability of Facial Range of Motion Measurement -follow-up shidy (direction of cornmisure movement and depth measurement)

Proposed Facial Assessment Data Base

Page 9

Page 20

Page 24

Page 56

Page 60,6 1,62

Page 63

Page 65

Page 65

Page 67

Page 68

Page 69

Page 69

Page 84

LIST OF ABBREVLATIONS

ROM

MCT

B F G S

DEFS

SFGS

LM

QAFM

MSRA

TDTS

HSC

ICC

ANOVA

ROM

Modified hand held caliper tool

House-Brackmann Facial Grading Scale

Fisch Detailed Evaluation of Facial Symmetry

The Sunnybrook Facial Grading System

Linear Measurement Index

Computerized Quantitative Assessrnent of Dynamic Facial Motion

The Maximal Static Response Assay

Three Dimensional Tracking S ystem

The Hospital for Sick Children

Interclass Correlation Coefficient

Analysis of Variance

LNTRODUCTION

Injury to the W cranial neme can result in a condition bown as facial palsy. This is

rnanifested by a unilateral or bilateral paralysis of the muscles of facial expression. Ln

children, facial nerve palsy can be classified into three major groups. The first group,

congenital or developmental facial nerve palsy presents at bkth and is a result of an error

intrinsic to embryogenesis; for example, Moebius Syndrome. The second category, prenatai

acquired facial nerve palsy, occurs as a result of extrinsic factors during fetai development;

for exarnple, pressure and infections. The third group, postnatal acquired facial nerve

paralysis, is the most diverse group of disorden, wbich includes inflammation, infection,

trauma, and diseases of the sM1 as well as intracranial and extracranial causes (Orobello,

199 1).

The incidence of facial paralysis in children has not been adequately reported. However, two

large studies with divergent results have docurnented the incidence of facial palsy in the

newbom. Hepner (1 95 1) reported a rate of occurrence of 7% where as McHugh, Sowden

and Levitt (1 969) ascertained a kequency of 0.23%. The reasons for this incongruity are

unclear, yet one can conclude the incidence of facial palsy in the newbom is a rare event

(OrobeiIo, 1 99 1). Nevertheless, as a tertiary center, the Hospital for Sick Children (HSC)

evaluates over 100 children with facial nerve p d y s i s through the plastic surgery clinic each

year (Dr. R Zuker, personal communication, 2000).

Paralysis of the facial muscles can have a significant impact on a child's physical, social and

psychologicaf developrnent Physicaily, children with facial newe palsy can present with

facial asymmetries and motor difficulties in tasks such as eating, drinking and speaking.

Socially these children will have the challenge of conveying emotions through facial

expression; for exarnple, happiness, sadness and surprise. The social effects of coping with

facial paralysis may lead to problerns in school and leisure activities. These children often

have to contend with cruel teasing from their peers and this can have a devastating impact on

their seit-esteem. Al1 of these factors can have consequences in the psychosociai adjutment

of the child.

To date, there has been no published research on the psychosocial adjustment of children

who present with facial pdsy. A few researchers have d e d the social psychology in

children who present with facial differences. These investigations typically included a small

sample group of children with a variety of craniofacial diagnoses that may or may not

include facial palsy. The results indicated children with craniofacial anomalies, when

evaluated against match cornparison groups, present with a number of psychosocial

limitations: the children were more introverted, have a poorer self-concept and experience

more negative social interaction (Pope & Wood, 1 997; Padwa, Evans, & Pillemer.F.C., 199 1 ;

Pertschuk & Whitaker, 1985).

Occupational Therapy is involved in the assessrnent and follow-up of children who present

with long-standing facial palsy. The majority of these children have undergone facial re-

animation surgery at HSC. In these chiIdren there is often a functional or anatomical absence

of the facial nerve and muscles (Dr. R Zuker, personal communication, 1999). This

population of children would be classified pre-operatively as having grade IV or grade V

facial function using the House-Brackmann facial grading scale. Grade IV ninction is

defined as obvious weakness andor facial disfigurement indicating moderate to severe

dysfunction. Grade V function is defined as only barely perceptible motion demonstrating

severe dysfunction (House & Brackmann, 1985).

For ciiildren who present with a uniiaterai faciai paisy, facial re-animation surgery is a two-

part procedure. The first stage involves a cross-face sural nerve gr& in which the unaffected

facial neme is evaluated and three to five fascicles from the zygomatic and buccal branches

are selected for repair with the nerve graft. The sural nerve graft is then placed in a

previously dissect tunnel across the face and the end is anchored close to the ear on the

paralyzed side. This technique allows for facial nerve input from the non-paralyzed side of

the face yet leaves adequate innervation of the musculature on the normal side.

Once the nerve graft has regenerated to the paralyzed side (6 to 12 months later) the surgeon

can proceed with the second phase; the muscle =fer. A section of the gracilis muscle with

its neurovascular bundle is transferred to the recipient side of the face. The origin of the

muscle is attached to the temporal fascia as well as the area in fiont of the tragus of the ear

and the insertion of the muscle to the commissure of the mouth and upper lip. The

neurovascular repairs then foilow. The goals of this procedure are: to have the mouth in

balance at rest, to assist in oral cornpetence, to improve speech patterns, to facilitate

voluntary and spontaneous active elevation of the corner of the mouth, and hal ly, to mate a

symmetrical d e (Dr. R Zuker, personal communication, 1 999; Frey, Jenny, Giovmoli, &

Stüssi, 1994; Zuker t Manktelow, 1993). Occupational Therapy interventions in children

with facial paisy address severai areas. In terms of motor function, the children may need an

exercise program to skengthen the transferred muscle andor re-training to gain a

symmetrical smile.

The assessment and treatment of children with facial palsy does present a significant

challenge to the multidisciplinary team. The clinical changes as a result of therapeutic

intervention can be significant but when measued objectively the changes are small. For

example, Goldberg & Zuker (in press) investigated the fiuictional outcomes of facial re-

animation surgery in children who presented with Moebius Syndrome (bilateral facial

paralysis of the VI and VI1 cranial nerves). Ln regards to facial motion these investigators

estimated the movement at the cornmisure corner of the mouth improved on average 15 mm

with a range of 6 mm - 28 mm. Elevation of the upper lip improved on average 7 mm with a

range of 4 mm - 13 mm. With the advances made in the surgical treatment of facial palsy

the curent measurement systems are either not sensitive enough to document the detailed

functional changes or too complex to be usefùl in the clinical setting. It is important to

establish a reüable and valid outcome assessment to quantify srnile in order to assess the

chid's progress, the efficacy of therapeutic interventions, and the long-tem functional

outcornes. The reliabiliq of an assessment refers to the consistency and stability of a

meanirement whereas validity refers to the assessments ability to measure what it is designed

to meastue (Law, 1987). The overall objective of this study is to develop a valid and reliable

assessment that will mûasure the range of movement for s d e in children with facial palsy

and is suitable for &y to day clinicai use.

LITERATW REVIEW

The intent of this review is to examine the accumulated empiricai evidence to determine if

there is a reliable, valid and clinically usefil assessment that wouid evaluate modest yet

signincant changes in the ROM of a child's smile. Several assessments currently used in

clinical practice are critiqued. Emphasis is placed on the scientific ngor and clinicai utility of

these instruments. The overd construction of the assessment is considered with particular

importance placed on the ROM evaluation of smile. Operational issues such as clhical

usefulness, scoring, cost and acceptability are reviewed. As well, the reliability, vaiidity and

responsiveness of the test are reported. Responsiveness is a fonn of vaiidity that it refers to

the tests ability to document changes within an individual over time (Law, 1987). The

review concludes with an evaluation of the existing rneasurement systems, followed by a

discussion of the specific research questions and hypotheses suggested by the review and

exsunined in this thesis.

Facial nerve palsy is a cornplex phenornenon to characterize. The multiple variables that can

be evaluated and how these variables are prioritized make it difficult to document findings.

As a result, there is a myriad of facial grading scales available and each scaie presents its

own hadequacies (House, 1983; Smith, Murray, Cd, & Slattery, 1992). For several years,

facial grading systems have been compared to one another, yet a universally accepted

grading system for facial rneasurement that is reliable, valid, responsive and clinically useful

continues to elude the investigators of facial nerve palsy (Burres & Fisch, 198613; House,

1983; Muw, Diver, Kelly, ODonoghue, & Bradley, 1994; Ross, Fradet, & Nedzelski, 1996;

Rickenmann, Jaquenod, Cerenko, & Fisch, 1997; Smith et al. 1992).

Facial measurement systems cm be classified into three categories: subjective, indirect

objective, and objective assessments. Subjective assessments that describe the clinical

outcomes following facial re-animation surgery include case reports that are typically written

by the surgeon who has performed the surgery and patient self-report questionnaires.

Indirect objective assessments are grading scales that have a set of criteria for making

jucigements, and objective assessrnenu use direcr measuremenr rechniques thar foilow the

principles of physics and mathematics.

SUBJECTIVE ASSESSMENTS

Throughout the facial palsy literature there are a number of published case reports. Zuker

and Manktelow (1 993) illustrated the fiuictional and aesthetic results following facial re-

animation surgery with two case reports. They described the outcomes for a 27-year-old as

follows:

the patient developed spontaneous contraction of the muscle, which provided a

pleasing lift to her mouth and obtained good soft tissue reconstruction of the cheek.

The muscle provided symmetry at rest and near syrnmetry with srnile. The patient

was very pleased and no longer felt that she was deformed. (p. 63)

Equaily positive results were achieved in a 9-year-old girl.

Suficient range of movement was accomplished and was reasonably symmetrical.

Most important, the activity was spontaneous and synchronous with emotional

expression. Her ability to handle social situations, her self-confidence and her

interpersonal relationships were greatly aided by her improved facial appearance.

@.64,65)

Kumar (1995) demonstrated the fiinctional results following facial re-animation surgery with

three case reports. A 23-year-old woman was described as having "good movements of the

transferred muscle, with good elevation but some asymmetry of the upper lip during smiling"

(p. 84). A 56-year-old man demonstrated "good movement symmetry on rest and animation.

Some asymmetry persisted on smiling. He had independent movement on both sides. He no

ionger has dificuities in eating and drinking" (p.85j. AI i i-yearsid boy was reponed to

have improved tone and symmetry of the face and does not drool. The elevation of his lip is

weak and the two sides of the face do not move independently. The scar on the left

cheek was hypertrophie. Although this settled down, the scar was stretched. His

results was assessed as fair. (p.85)

Case reports are descriptive studies that involve a detailed investigation of a number of

variables on a single subject (Hemekens & Buring, 1987, p. 18). This strategy allows for the

reporting of new therapeutic techniques and the presentation of individual clinical outcomes.

Case reports are helpful in the formulation of hypotheses; however, the results are not

generalizabie and are subject to bias since it is often the attending surgeon who is interpreting

the results (Burns & Grove, 1997, p. 256).

Selforeport questionnaires allow for the documentation of the patient's appraisal of the

surgical outcomes. O'Brien et al (1 990) and Sassoon, Poole and Rushworth (1 99 1) both used

patient questionnaires to cornplement their methods of assessrnent Some items in the

questionnaires included appraisal of symmetry in smiling, satisfaction with resuits, and

identification of complications such as pain and functional difnculties. Both investigations

reported the majority of patients had a hi& satisfaction post-operatively and felt the surgical

procedure was worthwhile and their appearance was improved. To evaluate the child's

perceptions of surgical outcornes, the questionnaire needs to be developmentally sensitive to

the issues of children. Unfominately, these researchers do not supply the reader with the

methods of administration or a sample of the questionnaires. This makes it impossible for the

reader to evaluate the validity of their methods.

I~JDIREC~ OBJECTIVE GRADING SYSTEMS

Indirect objective measurement systems use an ordinal grading scale with multiple

categories. The categones have a rank order but the interval between the ranks is not

necessarily equal. The patient's progress is evaiuated by set cnteria, thereby ailowing for

increased objectivity (Burns & Grove, 1997, p. 325). Ordinal grading scales can be M e r

classified into gross and regional grading scales. Gross grading scdes are descriptive scdes,

which consider the overall function of the face and give one grade for the degree of facial

paralysis. Regionai grading scales delineate separate areas of facial function, which are

observed and scored independently then added together for a total score (House, 1983). For

the purposes of this review three indirect objective grading scales are critiqued: House-

Brackmann Facial Grading Scale (Houe & Brackmann, 1985), Fisch Detailed Evaluation of

Facial Symmetry (Fisch, 198 1) and the Sunnybrook Facial Grading System (Ross, Fradet, &

Nedzelski, 1996). For a summary of the critical d y s i s of indirect objective grading scales

see Table 1. The taxonomy for this table is based on the research by Law (1987) as well as

the practical clinical requirements of this investigator. The acceptable test qualities have

been highiighted.

paisai ION paisai ION paisai ION 1 s a i a ~ - i s a ~ paisai ION 66'0 sL4-0. 1 3 1 8 J - l l ) U I

paisai WN pasai ION paisai ION ra i~~ -or iu l paisai ION %L8 %E6 wauiaa~%e J O laha1

pa1uauin3op iou a i s y d o ~ d d y a8v-

Conmittee of the American Academy of Otolaryngology adopted the HBFGS as the

international standard method for reporting results (Pearson, 1985).

In 1983, as his candidate's thesis to the Arnerican Laryngological, Rhinological, and

Otological Society, John Houe developed a six-point facial grading scale. He completed an

extensive analysis of eigh~ orchal masurement scales that had bcen developed ard used

between the years 1955 to 198 1. AU of the scales reviewed were successful in distinguishing

patients with varying degrees of nerve function. However, patients with moderate to severe

dysfunction are difncult to classify and it is this group which deterrnined the competence of

the scale. House theorized that the intent of a measurement scale was to rate the patient

according to general categories and not give specific details about facial fùnction. He

concluded that overall gross grading scales are preferred by dinicians and have the potentiai

to be just as reliable as the more detailed scales (House, 1983).

House (1983) developed a gross facial gradhg scale that M e r defined the moderate to

severe ranges of facial palsy and included secondary deficit. Secondary deficits are

described as contractures of the facial muscles, hemifacial spasm, andlor synkinesis.

Synkuiesis is an involuntary muscle contraction associated with facial movement (Ross et ai.

1996). Grade I on the HBFGS depicts norrnd facial function. Grade III indicates disfigurllig

clifFerences between the two sides of the face, the secondary deficits are minimal, there is

normal symmetry at rest and facial motion is weak. Grade VI indicates total paralysis

(House, 1983).

Brackrnann and Barn (1984) devised a facial grading system in a patient questionnaire

format to assess the degree of facial nerve recovery following acoustic neuroma surgery. The

objective h e m measurements (raise eyebrows and smile) were used in the development of

the HBFGS. In this study there was no evaluation of the insrniment itself to determine its

reliability, validity or responsiveness. The landmarks for the linear measurements were not

clearly defïned and the patient evaluated their own movements. The linear rneasurements

have added littie scientific value to the HBFGS and subsequent investigations refer

exclusively to the ordinal-scaie of measurement. The scaie continues to be referred to as the

HBFGS (see Appendix A, Table 1 for the complete scale).

Evans, Hanies, Baguley, and Moffat (1 989) tested the inter-rater reliability of the HBFGS

grading scale. Forty patients representing a complete range of unilateral facial palsy were

reviewed and tested on the same day by three skilled observers. The frequency of responses

was assessed and of the one hundred and twenty judgements, eight were in dispute by a

maximum of one grade resulting, in a level of agreement of 93%. These investigatoa

concluded that the HBFGS is a simple robust method of assessing facial function. The

limitation in this analysis is that level of agreement does not necessarily relate to the

reliability of the measurement scale and has the potential to overestimate the reliability of the

measure (S treiner & Norman, 1 995, p. 1 07). A superior statistical test of reliabiliv uses a

correlational design (Streiner & Norman, 1995, p.328) that takes into account agreement by

chance, such as Cohen's weighted kappa (Burns & Grove, 1997, p. 1 17).

Smith et al. (1992) compared nine facial grading systems (the grading scales examined by

House in 1983 as well as the HBFGS) to determine the reliability and constmct validity of

these scales. Construct validity was defined as the ability of the gradhg scale to differentiate

the degree of seventy of facial palsy.

This sniciy by Smith et ai. (1992) involved the assessrnent of ien subjrcts who reflectrd the

cornpiete range of recovery one-year subsequent to the onset of facial palsy by four

independent observers. Infra- and inter-rater reliability was estimated by the quadratically

weighted kappa statistic; an acceptable level is greater than .60. For each grading system

there was a reasonable degree of infra- and inter-rater reliability.

The accuracy of each grading scale to describe the degree of severity was evaluated and \

compared to the overall impression of facial function and there was no significant difference

between systems. The average Kappa value for al1 the systems was 0.74, suggesting that

most systems offer a reasonable level of construct validity (Smith et al. 1992). Although,

clinical judgement and overail impression is a poor test of construct validity (Ross et al.

1996). No single experiment can prove the constnict vdidity of a test. This is an ongoing

process that is satisfied over multiple investigations (Streiner & Norman, 1995, p. 152).

Smith, et al. concluded that gross grading systems are the most convenient to use, and

although the HBFGS did not give superior results, it was the grading system preferred by

most cihicians.

The development of the HBFGS was based on an excellent systematic review of the facial

grading systems in clinical use at that the . The HBFGS is an ordinal scale of measurement

that provides a good gross classification of facial nerve palsy. Clinically this measurement

tool is easy to use and is reported to have a good degree of inter-rater reliability (Evans et al.

1989; Smith, et al. 1992; Johnson et al. 1994; Ross et al. 1996).

The disadvantages of the HBFGS are that it is a discontinuou scale that inadequately

considers secondary deficits such as synkmesis. It is also questionable if the scale will

detect small yet clinically important change within a patient (Ross et al. 1996). This is a

gross grading scale therefore the properties of the test do not allow for the specific movement

analysis required to assess the range of movement of &le (Murty et al. 1994; Johnson et al.

1994).

Fisch Detailed Evaluation ofFacial Symmetry (DEFS)

The DEFS is a regionai evaluation of 5 standard facial poses: face at rest, raising eyebrows,

closure of eye with minimal effort and maximal effort, smiling, and pursing the lips. Patients

are given a percentage of function score: 0% = total paralysis, 30% = facial movement closer

to total paralysis than to normal symmetry, 70% = facial rnovement doser to normal

syrnmetry than to total pardysis and 100% = normal symmetry. The percentages of bc t ion

scores are then converted to a weighted point scale, with higher weighting given to eye

closure and smiling (see Appendix A, Table 2 for the complete scale) (Fisch, 1% 1).

Rickenmann et ai. (1997) compared the DEFS and the HBFGS grading scales with the intent

of determinhg whether the DEFS allowed for reliable sub-classifications of facial

rnovements to supplement the HBFGS. The major difference between these two systerns is

the division of facial movements; the 6 grades of the HBFGS, versus the percentage scale of

the DEFS. The DEFS reduces the number of assijped options, is weighted to emphasize the

esthetics and function of the mouth, and represents a more accurate sub-classification of

overall facial movement. The HBFGS scale has a wide numeric range within certain grades

and does not allow for M e r differentiation.

Rickenmann et al. (1 997) concluded that both systems have good reliability, minimal inter-

observer variability and reasonable agreement. Although both scales are a reliable grading of

facial movement, the DEFS is a finer scale. The investigators recommend a combination of

the nuo systems for a more accurate evaluation of facial palsy, particdarly after a facial

nerve repair.

The benefits of the DEFS are that it is a regional grading scale that is weighted to emphasize

the importance of the mouth. Overail this scale provides a good gross classification of facial

nerve palsy, is easy to use and is reported to have a good degree of inter-rater reliability

(Rickenmann et al. 1997).

The disadvantage with the DEFS is that synkinesis is assessed as a mass movement only

when it affects facial motion (Rickenmann et al. 1997). Furthemore, tests of validity and

responsiveness have not been completed. Again, this is a gross grading scale, therefore the

properties of the test do not allow for specific ROM analysis.

The Sunnybrook Facial Grading Sysfern (SFGS)

Ross et al. (1996) recently studied the literature regarding facial grading systems and

identified that the questions of validity and responsiveness have not been aciequateiy

addressed. This group of investigators set out to develop a clear, well-defined grading

system that provided an accurate description of facial motor function and that is responsive to

change. The necessary components of a facial grading system were identified, a measure

constructed, and its validity and responsiveness tested.

The SFGS is a regional gradmg scde that is based on resting symmetry, the degree of

voluntary excursion of facial muscles and the de gree of synkinesis associated with speci fic

voluntary movement. Resting symmetry is evaluated by comparing the resting position of

the eye, nasolabid fold and corner of the mouth to the nomai side. Symmetry of voluntary

movement and the degree of synkinesis associated with the movement are regionally

examined with 5 standard expressions: forehead wrinkle, gentle eye closure, mouth open

smile, snarl and lip pucker. These items are evaluated on a point scale and a cumulative

composite score is tabulated: 100 for nomai facial function and O for complete facial

paralysis (see AppendYt A Figure 1 for the complete scale) (Ross et al. 1996).

Content validity was established through a judgmental process. A review of the Iiterature

identified important content areas to measure dong with appraisal by expenenced chicians.

The construction of h a 1 measure was achieved after use with a broad spectnim of patients

with facial nerve paral ysis and informai exchange with physicians, facial phy siotherapists

and patients. To determine the constnict vaiidity of the SFGS these researchers elected to

compare the SFGS with the HBFGS (House, 1983) and a linear measurement system (Burres

& Fisch, 1986b). The responsiveness of this assessrnent was also investigated (Ross et al.

1996).

For the validation study, the SFGS was used to score the pretreatment and post treatment

videotapes of patients by an independent blinded assessor. The Pearson correlation

coefficient test detennined the inter-relationship between the individual components of the

SFGS. The components are independent and each component demonstrated an equally

significant correlation to the composite score. Each component of the SFGS is sensitive to

change and contributes to a change in the composite score. Significant correlation between

linear meamremeats and the voluntary movements occurred with forehead movements only.

The student t-test detected highly signûicant changes with pre- and post-test scores for each

component of the SFGS as well as the composite score. No statistical significance was found

with the IIBFGS (Ross et al. 1996).

In conclusion the SFGS reported results in a more continuous manner, had a wider response

range than the HBFGS and was sensitive to the severity of dyshction. Change was

detected in the individual components of the facial grading system and these were reflected

in the composite score. This facial grading system was shown to be a valid rneasure that was

responsive to cbically important change (Ross et ai. 1996).

The psychometric analysis of the SFGS was well designed and executed. This ordinal scale

provides a good clinical description of facial function and secondary deficits. The

measurement scale is easy to use and the validity and responsiveness of the measure has been

established. The disadvantages for the SFGS are that reliability of the scale has not yet been

tested and being a gross gradhg scale specific ROM analysis is not included.

Critical Analysis of Indirect Gruding Systems

House (1983) believed the purpose of a measurement scale was to rate the patient according

to generai categories and not give specific details about facial function, thus the development

of the HBFGS. Regional gradhg scales are a refinement of the gross gradhg systems.

Regional scales delineate separate areas of facial function so that the scores can be weighted

to reflect importance of facial function. This is usually based on the researchers' preference.

For example, the DEFS places higher weighting on the region of the mouth in contrat to

Ross, et al. (1996) who place a different emphasis on resting symmetry, voluntary

movement, and synkmesis.

Indirect grading scales rely on observer interpretation. Clinician may overrate or underrate

with respects to each other when evduating patients (Burres & Fisch, 1986b). Another

potentid difficuity in using these types of scdes is that the gradation of change that can be

detected is limited. Burres (1985) contends that observers are not able to discriminate arnong

more than three or four gradations of dysfunction. More specifically, grading scales have

been criticized for not being sensitive enough to document the changes in facial palsy as a

resdt of surgical intervention (Rickenmann et al. 1997). It therefore seems necessary to find

a system that limits observer interpretation (Smith et al. 1992) and cm detect finer gradations

of change in order to increase accuracy of evaluation.

The surgical re-animation for patients with facial palsy has becorne more sophisticated with

the introduction of the surgical fiee-muscle transfer. With these surgical advances the

methods used to clinically analyze facial motion are undergohg a rekemenr Born indirect

grading scales to objective measurement techniques.

The next section examines the characteristics of a typical srnile. The intent of this review is

to gain an understanding of the typicai srnile in order to make reasonabie judgements as to

what landmarks on the face should be analyzed with this facial motion. This knowledge base

is a prerequisite to the critical analysis of objective grading systems.

CHARACTERIST~CS OF THE TYPICAL SMILE

Facial expressions are a way of communicating our emotional condition to one another.

Srnihg to express happhess has been described as an intrinsic response that is culturaily

universai. Darwin (as cited in delatanzaro, 1999, pages 2 19-221) in 1872 documented one

of the original description of srnile. This scientist described a strong srnile as involving the

raising of the upper Lip that cause the cheeks to be drawn upward which in tum cause

wrinkles to form in the lower eye lids. As well the skin on the bridge of the nose becomes

wrinkled and the eyes becorne bnght and sparkling.

In 1974 Rubin proposed a qualitative description of a srnile that is based on the number of

teeth exposed. He determined that srnile cm be classified into three categories: the corner of

the mouth srnile, the canine srnile and the full denture smile. Although this classification is a

u s e M descriptor of smile, the quantitative analysis of movernent is overlooked.

Paletz, Manktelow and Chaban (1 994) investigated the shape of the nomal srnile. Eight

points dong the vermilion cutaneous boarder of the mouth were identified: each commisure

corner and the center and mid-Iateral points of the upper and lower lips. As well, two other

points were identified: the infenor border of the alar rim, and a point on a 45degree angle

fiom the oral commisure on the nasolabial crease (see Figure 1, page 20). The direction and

extent of movement of the upper and lower lips, nasolabial fold and the nasal base during

smile were analysed using stop h m e analysis with a 16-mm movie projector.

F i m 1 . Facial Landrnarks. 1 : Central nose point. 2 and 3: Right and left tragus. 4: Centrai chin point 5 and 6: Right and Ieft commisure corner of the mouth. 7 and 8: Right and lefi mid-lateral point of the upper lip. 9 and 10: Right and lefi rnid-lateral points of the lower lip. 1 1 : Nasin. 12: Midline of the mouth. 13 : Center point of the upper lip @hiltrum). 14: Center point of the lower lip. 15 and 16: uifenor boarder of the dar Rm. 1 7: Point at a 45" angle fiom the oral commisure on the n a d labial fold.

The results of this investigation demonstrated several patterns of movement during maximum

spontaneous d e . The cornmisure movement demonstrated the greatest variability; with an

average ROM of 14 mm. The side to side comparison of the cornmisure movement withh

each subject was notably different. The average direction of the cornmisure movement was

at a 40" angle and the side to side comparison was less remarkable. An interesting fincihg

was the amount of vertical movement in the mid-laterd portion of the upper lip, an average

of 1 1 mm (Paletz et al. 1994). These movements - elevation of the upper lip, commisure

movement and direction of the commisure movement - are valuable objective measurements

to document in the analysis of s d e .

Frey et al. (1994) also identified specific points (static and dynamic) on the face in order to

quanti@ facial movement. As well, this group explored the distances and the movements

that wouid be the most representaUve of the 3 regionai areas of the face jiiontal, eye, an8

nose/mouth). The VICON three dimensional, computer-assisted measurement system was

used for the motion analyses. For this review, discussion will be limited to the results

associated with the mouth region.

Three static reference points were required for three-dimensional motion analyses; the left

and right tragus of the ear and a central nose point were favored. Paletz et al. (1994) had

identified the centrai chin point as a static reference point and this was also tested in this

study. The dynamic points investigated were as follows: the commisure corner of the mouth?

the philtrum, and the mid-Iaterai points of the upper and lower lip (see Figure 1 .) (Frey et al.

1 994).

The resuits indicated that the most reliable static points were the tragus of the ear and the

cenaal nose point. In the mouth region, a greater number of points were required to reflect

the complexity of motion in this area. The commisure corner of the mouth showed the

greatest excursion and the philbxm point described the aesthetic of middle upper lip.

Symmetry of the mouth is an important parameter to measure in order to assess the quality of

therapeutic intervention. The mid-lateral points of the upper and lower lips best assess

symmetry (Frey et al. 1 994)

Once the static and dynamic points were identified the relevant distances for measurernents

were determined. For the nose and mouth, 6 relevant distances were identified. To assess

lateral movement in the mouth, measurements are taken fiom the tragus and cornmisure

comer of the mouth. The central nose point and the mid-lateral point of the upper lip descnbe

the upward movement of the mouth. The centrai nose point and the mid-lateral point of the

lower lip describe the asymriletry in the lower lip. The distance between the ph i l tm and

tragus give a clear picture of the shifting of the philtrum, and the distance between the comer

of the mouth and the philtnim provide information on the intrinsic movements of the lips

(Frey et al. 1994).

Throughout this last section the normal patterns of movement dwhg srnile have been

examined including a review of suitable reference points and distance measurements to

quantify smile. Prior to cntiquing the objective grading systems it is beneficial to have an

understanding of these concepts.

OBJECTIVE MEASUREMENT SYSTEMS

Over the past decade there has been a shift in focus fiom grading scales to detailed objective

data collection systems. Many investigators have attempted to quanti@ facial movement by

using a variety of direct measurernent techniques and computer technologies. These systems

have been developed in reaction to the perceived weakness of indirect grading scales and

other observer-dependent systems. The purpose of quantitative systems is to reduce observer

bias, reduce rater variability and detect h e r gradations of change.

Objective measurement systems use a ratio measurement scale and have the ability to present

a Iess biased and more sensitive assessment. Ratio level of measurement refers to the use of

a quantitative variables with a meaningful zero point (Law, 1987). For the purposes of this

review five objective measurement systems will be cntiqued: Linear Measurement Index

(Bures, 1985), Faciorneter (Frey et al. 1994), Computerized Quantitative Assessrnent of

Dynamic Facial Motion (Neely, Cheung, Wood, Byers, & Rogerson, 1992), The Maximal

Static Response Assay (Johnson et al., 1994) and Three Dimensional Tracking (Trotman,

Stohler, & Johnston, 1997). For a summary of the critical anaiysis of objective grading scaies

see Table 2. The acceptable test qualities have been highlighted.

l~able 2. Criticai Anaivsis of Direct Facial Gradhg &stems 1

Insbiunent Construct'n Items w11 Developed Levei of Meamemnt Wes Weipfrting

1 -Age Appropriate 1 not doCumaNd Ion one 1 l y.0. lonane 16 y.0.

I

> 1 Hour -i-i

Memurement Index

use ~nchil~-- not documentai

Clinical Application Format cos

by Frey

Acapdiiiiy -Ti to Complete > 1 Hour > 1 Hour > 1 Hour

Use on children Documented .Docuniented

Good Uear

Moderate.

Limited Cornplex &

Xes .:.-. . -; -. .-

-Rtdi"oY- Xo Yes

Limited Cornplex

Escpensive

Measurement of Smile L

Comniisure

Computerized QAF.M.

Not correct vector (Tested . . 1 Not testeci Elevation of upper lip M o n of CM Shifüng of thephiltnrm LOW I ~ D

Tested Not tested C a l a Tested Not tested

L I

Responsiveness INot testecl lNot tested ~Y&L ' . - L [ Y ~ - I~otte~ted *Ratio level of cneasuremer9 a w v e IeveI of measuremait with a sxwhgiFiil zero point (Law, 1987).

Max. Static Resp Assay

Yi= Ratio* Ys I

No

Yes-. bYes.. ' . . 11Yes -

l

Tested UncIear cdoulM Unc Iear Tested

Not correct vector Not tested Not tested N0t tested

Valid@ Coldent Construct

Tracking by Trotman

. W o * .

Ys No

Ratio* No No

Not correct vedor Not testeci Tested 'ks&!d

: Yes Yes

Not tested Nat tested Not tested Not tested

Not descn'bed fiPgelliiiél/el~@ '

In deue1opm't Not tested

Not descri i In developm't Nottested

Not described In âevelopm't

Desgibe In developm't

Not tested lNot tested

Liner Memurement Index (LM)

To quanti@ motor function, Burres (1985) proposed a LM1 in which a hand held caliper tool

is used to assess facial ROM. Linear measurements (distance measurements) are defined as

the distance between each of the facial landmarks at rest and at maximum rnotor capacity for

specinc facial expressions. in the preliminary investigations tàcial expressions were

evaiuated in normal subjects by linear measurements and integrated electromyography. This

inqujr is limited to the linear measurements that characterize srnile.

Burres (1985; 1986a) related the amount of displacement of facial landmarks to the motor

recovery of the muscles. Through his own review of the literature and his own study using

integrated electromyography, he concluded that skin displacement, force and electrical

activity are ail related and codependent. To determine the reliability of the measurements, a

coefficient of variance score was caiculated (a cornparison of the distance moved with the

variation of displacement). In total eight measures were classified as the most reliable to

esthate the total facial motion. To depict smile, three facial landmarks were identified and

two distances measured. They are as follows: the midine of mouth to the cornmisue comer

of the mouth and fiom the nasin to the comer of the mouth (see Figure 1, page 20). Based on

these measurements Burres proposed a linear measurement index for maximum voluntary

facial motion.

Bmes (1986a) studied subjects with facial paralysis using the LMI. To account for the

pathology of facial palsies such as: negative displacement, comed exposure and resting

asymmetry, the L M required significant revisions. The raw scores continue to be converted

to a percentage of displacement followed by a minimum of seven mathematical steps to

arrive at the h a 1 score. He concluded that it was impossible to establish an absoiute

standard measure due to the fact that with the facial palsy group, the displacement of the

paralyzed side of the face was fiequently in the range of the normal side of the face.

Although, significant clifferences are documented when an individual side to side cornparison

was made.

The L M has been compared to the DEFS and HBFGS indirect grading scales which were

discussed earlier (Burres & Fisch, 1 986b). Subjects were studied through the use of video

analysis and photographs. At the tirne of recording the video, linear measurements were

collected, and a total of seven observers assessed each patient. The level of agreement, the

correlation between grading scales and the inter-observer variability were tested. Al1 scales

demonstrated satisfactory level of agreement and the coreIation between the scaies was

excellent at r=. 92 to .95. This would indicate that facial grading systems founded on

reasonable criteria would tend to correlate with each other. As weil, the superiority of the

LM was established, as it was able to accurateiy match the mean score of the judges. In

conclusion, Burres (1986) purports the LMI to be a clinically valid method of objectively

grading facial palsy (Burres, 1986a).

The simplicity of linear measurements has the potential to be a c l i n i d y useful approach in

documenting facial motion. The hand held caliper tooI is a practical measurernent tool that is

easily adaptable in the clinical setting. In more recent studies, Ross et al. (1991) used the raw

data fiom the linear measurements to determine the efficacy of biofeedback training. These

investigators evaiuated the in~a-rater reliability of the linear measurements and the midline

of the mouth to the commisure corner was chosen to represent smile. The interclass

correlation coefficient (ICC) of .98 demonstrated substantial ina-rater reliability with a

lower 95% confidence limit of .96.

In practice the proposed LM1 is hown for being complex and time consumuig to administer

and calculate the linear measurernent index score. M e r precise measurements are taken and

there is a conversion to an index score, valuable information is lost. Moreover, the

assessrnent does not take into account the correct vectors of movement in the examination of

srnile. The LM1 may be too arduous to be useful in clinical practice.

Faciorneter by Frey

Frey et al. (1 994) introduced the concept of three-dimensionai tracking. He recognized that

cornputers are usehl for research purposes but are not suitable in day to day practice

therefore, the hand held electronic faciometer (S&T Marketing Ltd.Q, Switzerland.) was

developed. The faciometer is an electronic caliper tool with sofl rounded tips, which aiiows

for direct skin contact. When measuring the distance between two points a foot switch is

used and the actual distance is digitally displayed in rnillirneters.

The first clinical trial with the faciometer was completed with twenty healthy subjects, and

ten subjects with a unilateral facial palsy. The landmarks chosen and the distances measured

have been previously described within the section "characteristics of the typical smile". in

this investigation the statistical analyses of the results are not clearly presented and it was

inferred that inha and inter rater reliability was good. The results were reported as a mean

score. The mean range of scores and the standard deviations for the resting positions = 0.67

t 0.66 mm and for maximal exercises = 0.86 t 0.80 mm denoting a low degree of variability.

For sub-maximal exercises the mean range of scores and the standard deviations =1.13 t 1 .O7

indicating a higher degree of variability. A recomrnendation was made that oniy intra-

individual comparison is made with the sub-maximal scores but the maximal exercises were

suitable for inter-individual comparison. These researchen ascertain this to be a valid and

reliable tool that was comparable to the VICON cornputer system although a direct

comparison was not made (Frey et al. 1994).

The overall assessrnent with respects to identification of landmarks and the distances

measured have been well developed. The faciometer has a few good qualities as a

rneasurement tool, for example soft tips and the ability to reach al1 data points on the face.

The reliability and validity of the tool is reported as being good and responsive to change

although no specific reliability testing was reported. Reliability represents the consistency of

the rneasure obtained. Typically this is best represented by a correlation coefficient score

that takes into account three sources of variance: patient, observer, and error (Streiner &

Norman, 1995, pages 106-109). Intuitively the faciometer appears to be highly reliable tool,

although the interclass correlation coefficient would have more accurately represented the

reliability of the i n m e n t .

There are a few difficuities with the faciometer in that the long lever amis make it difficult

for the observer to stabilize the device and achieve accurate measures. The digital reading is

displayed on a separate piece of equipment that typically sits on a table. The protocol also

suggests that two observes should complete the assessment, one to measure and the other to

read and document the digital read out. The faciorneter is not a tool that is widely utilized in

clinical practice and no M e r studies on its psychomeac properties have been published to

date. Moreover, this assessment does not evaluate the directionality of movement.

Computerized Quantitative Assesment of Dynam ic Facial Motion (QAFIY)

Neely et al. (1 992) developed a computerized quantitative assessment of dynamic facial

motion. This system is extremely complex and based on the reflection of light fkom a black

and white video image. The initial study involved subjects with and without facial palsy and

the QAFM was compared to the HBFGS.

Facial movements were recorded with a black and white video under specific light condition

and compared to a baseline resting position. Movements included: forehead wrinkle, eye

closing, nose wrinkiing and mouth smiling. The video was played into a rnicroprocessor for

analysis that involved digitization, subtraction and image enhancement. in brief, the

digitization process coded each pixel; the more intense the Light the higher the digital

number. In the subtraction step, the sequential fiames of the face in motion were paired and

subtracted fiorn the reference rest image. The areas of the face relocated by movement

changed the pixel values signincantly and this was reported as a positive number. Image

enhancement involved the following: any areas of the face that changed were rendered white,

and areas that remained the same were black (Neely et al. 1992).

The computer then generated x-y plots and a curve of motion was identified. The curve was

divided into the initial contraction slope (S-50), the falling relaxation slope (Fs), and the area

under the curve for the total pixel count. A ratio score was calculated to reduce the

variability of the absolute pixel values and to enhance the differential cornparison between

sides. No difference in the score would produce a ratio of 1 .O and 0.0 would approximate

extreme differences. Results indicated that the cornputer-generated data was highly

significant except for the falling slope of the eye motion, and there was a reasonable

comlation with the HBFGS (Neely et al. 1992).

Neely, Joanquin, Kohn, and Cheung (1996) continued to refhe this method for quantifying

facial motion. The grading system consists now of three components: the restrained human

observer index, the computer generated strength duration cuve in which five typical curves

are recognized and coded, and the computed c w e maximum amplitude. Weighted values

are assigned to each of the three components and a composite index score is calculated

ranging Born O to 102. The QAFM was again tested on twenty-seven subjects in various

stages of recovery h m facial palsy. When c6mpared to the HBFGS, this system was more

precise and better able to dserentiate within the grades. They concluded that this was a

discrete objective outcome measurement system. The degree of facial movernent was

defined by specinc regions and for the face as a whole. This system was able to document

individuai case progression and recovery.

This cornputer measurernent system is cornplex, expensive and not practical for day to day

clinical use. Neely, Cheung, et al. (1992) recognized that this system was not capable of

vector analysis and was ody able to identiS a change in the image. There are many

variables in the system creathg noise in the generated data and the weighting of the scale

was not criteria based and may change with M e r research. No validity or reliability

experiments have been conducted on this memurement system.

The Mmeimal Slatic Respome Assay (MSRA)

The MSRA was developed by a group of investigators in Pittsburgh. The evaluation allows

for simdtaneous measurernent of both global and regional specific zones. nie MSRA used

photographs or video analysis to record a rest position and maximal displacement of nine

landmarks during six movements: brow lie eye closure, smile, fiown with jaw open, whistle,

and fiown with jaw closed (see Appendix B, Figure 1 .). The displacements of facial

landmarks were measured and the data was analyzed as coordinates on a grid using a

digitizer board and hand-held puck (Johnson et al., 1.994).

The MSRA was aialed on seven normal subjects and three subjects with abnormal facial

movernents. To assess the intra- and inter-rater variations the photographie data was

rneasured independently by three observers and each photograph was analyzed three times by

each observer. The results of this analysis are not reported. The variability of dot

assignment was 0.07 cm for normal subjects (Johnson et al ., 1 994).

These researchers conclude that the MRSA has the ability to detect region specific facial

movements, region specific decreased movement, and the dinical absence of movement and

synkuiesis. As an adjunct to the ordinal scales, the MSRA was designed to give a

quantitative evduation of the retum of facial movement f i e r therapeutic intervention

(Johnson et ai., 1994).

In an attempt to assess the quality as well as the quantity of facial motion the MSRA was

modified to account for matornical motion versus non-anatomicd motion. Anatomical

motion is the primary movement of the regional facial muscies and non-anatomical motion is

the secondas, movement that occurs on the involved side of the face. Anatoinical and non-

anatomical index scores are calcuiated to summarize the data generated by the MSRA in a

clinically meaningful way. Through the digitization process each dot is assigned a x and y-

axis thereby indicating the direction of movement. The vecton of movement are

mathematically defined in degrees of movement from the horizontal line. A ratio score of the

affected side versus the unaffected side is calculated (Bajaj-Luthra, Mueller, & Johnson,

1997).

The revised MRSA was tested on thirty-four subjects with complete facial paralysis. To

evaiuate the indexes over time a sepamte cohort group of five subjects with Bell's pdsy,

fiom whom multiple assays were available, were studied and compared to twenty-six healthy

controls. The results indicated that the group of subjects with complete unilateral faciai palsy

demonstrated a signincant amount of non-anatomical motion that was not present in the

healthy group. When assessed over t h e the group of Bell's palsy subjects demonstrated

recovery of facial nerve function (Bajaj-Luthra et al. L 997).

The MSRA was used to study the movement outcornes of functional fiee-muscle transfers for

re-animation of smile. A retrospective study of six subjects who underwent smile re-

animation surgery was completed. They were cornpareci to a conkoi goup of twsnty-seven

heaithy subjects with normal facial hction. The results indicated that the change in the

direction and magnitude of the smile was statistically significant. Symmetry was improved

by decreasing the magnitude of pull from the other side (Johnson, Bajaj-Luthra, Llull, &

Johnson, 1997).

Johnson et al. (1994) identified that the misplacement of dots, misplacement of the grid,

change in head position, reading the results and entry errors are weaknesses to this

assessment. The major limitation to the MSRA is the two dimensional technique. A smile is

a three dimensional process and the MSRA is unable to assess the change in the

antenor/posterior direction, the z-axis. Therefore the results of the vector analysis are not

accurate (Johnson, Bajaj-Luth et ai. 1997). Furthemore, despite the evidence that the

MRSA is a reliable quantitative tool that will assess the severity of facial palsy and measure

motor recovery, it is very complicated and may not be reasonable for the busy practitioner

(Bajaj-Luthra et ai. 1997).

Three Dimenrional Tracking Sjstem (TDTS)

A group of investigators fiom Michigan explored the use of a TDTS to report facial mobility.

Subjects are video taped perfomiing six maximal facial expressions and each frame is

digitized for analysis. It was determined that a head cap with three stable markers is the best

method to account for head movement and a total eighteen skin based landmarks evaluated

facial movement. Face validity was documented and the analysis to assess displacement of

angles introduced (Trotman, Stohler, & Johnston, 1997).

To evaluate vector displacement a stable maxillary dentition was fabricated for each subject

and three markers attached. Thirty points on the faces of six subjects with different functiond

problems were identified (see Appendix B, Figure 2.). Vector displacement was based on

means and CO-variances and a percentile score computed. Two measures of functional

impairment were proposed: a total impairment score and a maximal impairment score. To

determine the sensitivity of these scores, resdts were compared to residents rating motor

impairment on a Msual analog scale. These investigaton concluded that the TDTS has the

ability to detect and characterize a range of clinically significant fiinctional deficits (Trotman,

Faraway, Silvester, Greenlee, & Johaston, 1998).

Further attempts were made to quant@ facial movement based on separation of landmarks.

A total of thirty landmarks were identified (see Appendix B, Figure 3.). The separations

between twenty landmark pairs during six maximal facial animations were evduated in five

normal subjects. This research determined that for each facial animation a pattern of

landmark separation was identifiable, quantifîable and representative (Trotman & Faraway,

2000). The correct direction of movement for smile was not accounted for in this study.

The TDTS is a very complex assessment and is not practical for the day to day use in the

clinical setting. In order to assess movement in the anterior/posterior plane each subject

needs to be fitted with a dental plate, and it is possible that this dental plate will interfere with

the natural motion of srnile. The TDTS computer assessment is in the early stages of

development but has the potential to provide three-dimensional analysis of vector movement.

These investigatoe recognized that for displacements less than 3 to 5 mm it may not be

possible to clinical resolve the direction of movement with this technique (Trotman, Stohler,

& Johnston, 1997). No reliability or tests of responsiveness have been conducted on this

measurement system.

Critical Analysis of Objective Memurement Systems

The mathematical analysis of facial movement has several advantages. It is objective,

quantifiable and has continuous variables (Ross et al. 1996). There are also many Limitations

to this nethod in that linear measures of facial movements are highiy variable fiorn day to

day, linear excursions do not address syokinetic movernent, methods can be time consuming,

and the calculation of a linear index score can be complex (Murty et al. 1994; Ross et al.

1996).

Several computer systems designed to measure facial movement have been discussed. These

systems do present with a few advantages, for example facial movement is recorded by

photography andor video therefore the facial image cari be retrieved at anytime for fûrther

investigations. With this technique several measurements can be performed at the same time

and this is important factor to consider for muscle fatigue can be an issue with this patient

population.

Overall these computer systems are complex, expensive, take t h e to complete and are

limited in everyday clinicai application. The assessments were primarily tested on an adult

population and it is questionable if young children wodd be able to comply with ihz

administration procedures. The majority of the computer assessments fail to provide an

analysis of vectors in the anterior/posterior plane of motion. In addition, the computerized

assessments are deficient in the development of reliability and validity studies as well as tests

for responsiveness.

SUMMARY OF LITERATURE REVIEW

This literature review highlights the fact that researchers of facial palsy are attempting to

describe facial hc t i on , to document change in facial function and to evaluate treatment

approaches. Indirect objective grading scales and objective measurernent systems produce

different results. The purpose of indirect objective grading scales are to grade the overall

functionai performance, they are not intended to give detailed information on facial

movernent. Three indirect grading scales were reviewed: the House-Brackmann Facial

Grading Scale (House & Brackmann, 1985), the Fisch Detailed Evaluation of Facial

Symmeûy (Fisch, 1981) and the Sunnybrook Facial Grading System (Ross et al. 1996).

Indirect grading systems present with several limiting factors. These assessments do not give

specific details about facial bc t ion , they rely on observer interpretation and are not

responsive to the s m d c l in id changes seen as a result of facial re-animation surgery. Whiie

the scientific value of these systems may be limited (Frey et al. 1994), the gross description

of facial palsy has been uaiversally accepted and can be helpful in the description of a

population.

In contrast to the indirect objective grading scales, objective measurement systems provide

very specific details on facial motion. Objective methods have the abiiity to give a lzss

biased and more sensitive assessment. Five objective measurement systems were reviewed:

the Lhear Measurement Index (Burres, 1 9 8 5), the Faciorneter (Frey et al. 1 994), the

Computerked Quantitative Assessrnent of Dynamic Facial Motion (Neely et al. 1992), the

Maximal Static Response Assay (Johnson et al. 1994) and the Three Dimensionai Tracking

System (Trotman, Stohler, & Johnston, 1997). To document facial ROM two investigatoa

used direct linear measurements. (Burres, 1985; Frey et al. 1994) The simplicity of this

approach has significant potential for day to day dinical use. As well, the caliper tool is a

practical measurement tool that is easily adaptable in the clinical setting. The three computer

assessments that were reviewed are expensive, complicated to administer, and do not

necessarily provide the analysis of vectors. To date computer assessments maybe useful for

research purposes but are not suitable for day to day clinical use with children.

In conclusion, a review of the literature has demonstrated that a suitable tool to measure the

ROM of srnile in children with facial palsy is not available. It is the intent of this research

study to develop an assessment tool that is suitable for day tu day clinical application with

children and considers the important parameters to measure in the ROM assessment of smile.

RATIONALE FOR THE CURRENT STUDY

With the advances made in the surgical treatment of facial palsy, ordinal grading systems are

not suniciently sensitive to document the detailed functional changes. Fuahermore, the

children typically folIowed at HSC do not present with the secondary deficits that the indirect

objective grading systems attempt to measure for there is often an absence of the facial nerve

and muscles. The few cornputer assessments in use may be of benefit in an aciuit researcii

setting however these systems are limited in the everyday application with children. In a

hospital based milieu children can be fearfbl of complex technical equipment and

consequently do not readily comply with testing procedures. Children c m present with a

limited attention span and they tend to require severd breaks fiom the testing procedures. To

date there is not a simple assessment battery that is suitable for the daily evaluation of

children in the dinical setting.

It is the opinion of this investigator that a direct objective measurement system that uses a

caliper method of measurement seems to have a number of advantages. The assessment can

be completed in a timely manner; it is easy to administer, portable, and inexpensive. The

hand held caliper tool that was originally designed for the measurements of various objects

requires a few adaptations in order to facilitate the assessment of linear measurements on the

face. These modification have been descnbed in the methods section of this thesis (pages 45

and 51). The MCT has superior clinical potential when compared to the electronic

faciorneter. The proposed MCT is easier to manipulate as it is held closer to the

meanirement point. The digital reading is directly on the caliper tool and at eye level of the

assessor allowing one therapist to complete the assessment. The digital reading is to a tenth

of a millimeter and this provides an accurate measurement that can be sensitive to small

changes. The caliper tool is inexpensive costing $52.75 Canadian where as the approximate

cost of the electronic faciorneter is $2000.00 American.

The modified hand held caliper tool will not be able to capture al1 the facial movements of

clinical interest therefore, a tlat transparent plastic goniorneter and straight ruier werç aiso

considered. niere have been no previous studies that have documented the application of

these two tools in the measurement of facial movement nevertheless these tools continue to

be used in clinical practice. In addition to evaluating the MCT it is of interest to this

investigator to also test the reliability of the goniorneter and the straight d e r in the ROM

assessment of srnile in children with facial palsy.

PURPOSE

The purpose of this shidy is to develop a valid and reliable assessment that will rneasure the

range of movement of smile in children with facial palsy. The identification of pertinent

facial landmarks, distance measurements (Iinear measurements), and the direction of

movement are addressed in the development of the ROM assesment. As well, the selection

of suitable instruments to masure the facial rnovement of smile are considered and the inter-

rater reliabiiity detennined.

OBJECTIVES

The specific objectives of this study are as follows:

a) to develop a range of motion assessment of srnile for children with facial palsy and

establish the content validity of the assessment, and

b) to determine the inter-rater rdiability of the clinicaiiy derived measures of smile

using three measurement tools: the MCT, the d e r and the goniorneter in the

assessment of srnile in children with facial palsy. It is not the intent of this study

to complete a comparative analysis of the three measurement tools. The most

clinically appropriate one of the three tools has been selected to complete each

measurement.

HYPOTBESES

Once the content validity for the ROM assessment of srnile has been established the

following hypotheses wili be tested:

1) In each designated measurement there is an almost perfect relationship (.8 1 - 1 .O)

between the ratings of two observes on the distance measurements in the assessment of

srnile when using the modined hand held caliper tool.

2) In each designated measurement there is a substantial relationship (-61 - 30) between the

ratings of two obsewers on the distance measurements in the assesment of smile when using

the de r .

3) ïhere is a substantial relationship (.61 - 30) between the ratings of two observers on the

direction measurements in the assessment of srnile when using the goniorneter.

4) There is a substantial relationship (.61 - .80) between the ratings of two observers on the

depth measurements in the assessment of srnile when usmg the modified hand heici caiiper

tool.

METHODOLOGY

E s investigation has been subdivided into three phases. Phase one delineates the

methodology for developing the ROM assessment of srnile. Phase two outlines the

procedures for the primary study that evaluates the inter-rater reliability of this assessment.

Based on the resdts of phase one and two, four of the measurements required refmement and

phase thtee outlines the methodology for the follow-up inter-rater reliability midy.

PHASE ONE: DEVELOPMENT OF THE ROM ASSESSMENT

Validity of a test refers to its ability to measure what it is design to measure (Law, 1987).

For an assessment to have appropriate content validity the evaluation must include ail the

necessary components relevant to the coostnict being measured. Content validity for the

facial ROM assessment wiIl be established and documented through a judgmental process.

No quantification with statistics is necessary as the overall opinion or consensus is sufncient

(Benson & Clarke, 1982).

Criterion validity is the correlation of the measurement tool with some other measure that has

been widely used and accepted in practice (Streiner & Noman, 1995, p. 147). To date there

is no such clinical tool for the direct measurement of a smile; therefore, criterion validity will

not evaluated in this shidy.

Constnict validity refers to the ability of a measurement to WIy describe the cnaracteristic

being meamred (Law, 1987). Establishing constmct validity is important when evaluating

abstract variables that are not readily observable; for example, sweaty paims, tachycardia and

difficulties concentrating are variables which dl can describe anxiety (Streiner & Norman,

1995, p. 150). In the ROM assessment, srnile is measured as a physical artnbute that is

readily observable and defined by the way it was measured, in millimeters.

DESIGN

The content validity of this srnile ROM assessment was established through an extensive

review of the Literature and with consultation with four expert clhicians. The facial ROM

assessment presented in the result section of this thesis was based on the scientific

investigations of Bunes, (1986a), Paletz et ai. (1 994) and Frey et ai. (1994). In addition Dr.

Manktelow and Dr. Zuker who are experts in the field of facial re-animation surgery

provided their recommendations on a routine basis. Dr. Farkas was also consulted in regards

to the parameters of the smile ROM assessment. He is a Plastic Surgeon who is world

renown for his scientinc research of the anthropological documentation of facial

measurements. Additionally, the facial ROM assessment was informally trialed by the

Occupational Therapist who routinely evaluates the children who present to therapy with

facial palsy.

PHASE TWO: PRIMARY RIELLABILITY STUDY

SUBJECT S E L E ~ O N

Children 5 - 18 years of age with a diagnosis of faciai palsy were recmited through the

Plastic Surgery Clinic at HSC. As well, the Division of Plastic Surgery facial palsy data base

was accessed and appropriate children and their parents were contact by mail requesting their

participation in the study (see Appendix D for recruitment letter, information sent to families,

and letter of response). niose children with cognitive irnpairments who were unable to

follow the assessrnent format were exciuded fiom the study. The minimum age of 5 yean

old was chosen to ensure the child would be able to comply with the testing procedures and

18 is the maximum age of children seen at HSC.

A convenience sample of thirteen subjects with facial palsy volunteered for the snidy. Both

sides of the face were measured and each side was considered an independent sample,

therefore, doubling the sample size to twenty-six. Subjects with facial palsy do present with

facial asymmetry and this will reduce the expectation bias of the rater. To consider each side

of the face as independent sarnples is a common practice in the facial measurement literature

(Frey et al. 1994; Neely et al. 1992).

There were ten girls and three boys who participated in the study. The chilcken's ages

mged nom 5.6 years - 15.3 years with a mean age of 1 1.8 years. The sample was

representative of a variety of diagnoses: three children presented with congenital facial palsy,

five children with prenatal acquired facial palsy and five children with an acquired a facial

@Y -

RATERS

Two Occupationai Therapists currently employed at HSC on the Plastic Surgery Program

served as the raters. Both therapists have considerable experience in the assessment of

children with facial palsy and are familiar with facial ROM assessments. One of the raters is

the primary investigator for this study. The raters received specific training in the protocol of

the measurement procedures, the identification of landmarks and each therapist practice

performing the measurements. This established a common baseline berneen the two raten to

decrease the inter-rater variability associated with the execution of the assessment technique.

TESTING PROCEDURES

Pnor to the completion of the facial ROM assessment inf'ormed consent was obtained.

Subjects older than 16 years of age provided informed consent. Parents for subjects less than

16 years of age signed a consent form and the children signed an assent fom. (see Appendix

E for consent forms)

Each subject was tested independently by the two raters in the Rehabilitation Department at

HSC. The testing room was quiet and fkee fiom distractions and only the rater, the child and

hidher parent(s) were present The subjects were seated on a chair during the measurement

session and the rater was seated directly in fiont of the subject at eye level. A picture was

placed on the wall facing the subject to serve as a place to focus while the rater identified the

facial landmarkS. Milky Gel RollersN (Pente1 Stationary 0, Richmond B.C.) were used to

draw a 1 mm dot at each facial landmark. The subjects were allowed to choose their own

color of millcy pen and the rater demonstrated on the child's hand how easily the marks were

removed.

Each rater completed a facial ROM assessment following a standard protocol for

administration (see Appendix F). The distance measurements and the direction of the

cornmisure corner of the mouth were assessed once ody. The depth of the nasolabial fold

measurement is a new measwernent therefore three triais were recorded. Each measurement

was taken in the resting position and while smiling with maximal teeth showing. Data were

collected and recorded on the Data Base: Range of Motion Assessrnent of Smile (see

Appendix F, Table 1). Rater one completed the facial ROM examination, which was

followed by a 15-minute break. During this break the landmarks were removed. Rater two

then completed the assessment for a second time. The total evduation was approximately

one hou. The younger children required more frequent breaks fiom the assessment

procedure.

THE MEASUREMENT TOOLS

The tips of the hand held caliper tool were lengthened so that al1 data points on the face could

be reached easily. To mesure the depth of the nasolabial fold a platform base was added

dong with a telescoping point. To improve the stabitity of the instrument in the coronal plane

for the depth measurement a s m d level was attached to the platfom base. This level was

able to pivot to facilitate measurernent on the nght and left sides of the face and to ensure

consistency in the placement of the level a mark was etched into the platform base. The

modifications of the tool were conducted through the Medical Engineering Department at

HSC. (see Appendix C, Figure 1 .) In consultation with Andrew Baziw, medical engineer at

HSC (personal communication, 1999), the modifications to the tool did not effect the digital

measurement scale and there was no loss in the accuracy of the tooi. The MCT has been

utilized Ui clinical practice at HSC on the facial paralysis program for several months with

positive findings.

The MCT will not be able to capture the directionality of movement at the cornmisure corner

of the mouth. A standard transparent flat plastic goniometer was used to document this

motion (see Appendix C, Figure 2.). The diameter of the goniometer was nine centimeters

and the resolution of this instrument was rnarked in individual degrees. As wefl, distance

rneasurements of small magnitudes such as lip droop and shifting of the philtrum were

measured with a standard 15 centimeter transparent straight d e r with a resolving power of 1

millimeter (see Figure 3, page 6 1).

DESIGN

Reiiability refers to the consistency of a measurement. It is dehed as the ability of the

assessrnent to measure the tme dineremes between subjects on the characteristics being

measured (Law, 1987). More specincdy, intramter reliability is the degree of agreement

between the obsewation made by the same rater on two different occasions and inter-rater

reliability refer to the consistency(.U of results between different raters. It has been proposed

that both intra and inter-rater reliability testing may not be necessary for the reason that al1

the sources of error that would contribute to inira-rater reliability will become apparent in the

testing of inter-rater reliability (Streiner & Norman, 1995, p. 114). To lessen the arnount of

testing the children were required to undergo this investigation was limited to the evaluation

of inter-rater reliability. Using a correlational design the inter-rater reliability between two

raters was investigated.

POWER AND SAMPLE SIZE

According to the estimates by Donner and Elisaziw (1987) fifieen subjects were required to

have 80% power to measure an inter-rater reliability of .80 or above. The lower 95%

confidence limit has been set at .81 (almost perfect relationship) as per the guidelines by

Donner and Eliasziw. An obtained ICC value of less than .8 1 would indicate a problem with

the inter-rater reliability of the measure.

ANALYSES

The interclass correlation coefficient (ICC) was used to deterrnine the inter-rater reliability of

the motor assessrnent of smile. The ICC is an index score that estimates the amount of

variation in a set of measurements. Due to the fact that there are successive measurements

the ICC is based on the variances obtained through the repeated measures analysis of

variance (ANOVA). ANOVA is a statistical method that is used to anaiyze the relationship

between variables and the total variance is broken down into three components: the rater

(independent variable), the subject (dependent variable) and enor (Portney & Watkins, 1993,

p. 509-5 10). To interpret inter-rater reliability scores general guidelines have been

established. Slight reliability is indicated by an ICC value betweenO - .20, fair .21 - .40,

moderate .41 - .60, substantial.61 - .80 and almost perfect .81 - 1 .O (Donner & Eliasziw,

1987).

The literature that considers what an appropriate cut point shouid be for a reliability

coefficient is divers. ui determining how reliable a test should be is reiateci to iiow the resr

will be used. For example if the test is to be used for making individual judgements it should

be more reliable (Streiner & Norman, 1995, p. 12 1). In keeping with the guidelines set by

Donner & Eliasziw (1 987) a cut point for an acceptable level of reliability for this assessrnent

was chosen to be .8 1, an almost perfect. Due to the fact that no previous studies in the facial

measurernent literature have used the d e r and goniorneter a lower ICC of -6 1 was chosen for

hypothesis testing. Although, this investigator recognizes that for theses measurements to be

considered for clinical use a reliability coefficient of .8 1 is required.

The inter-rater reliability for the eleven measurements of facial distance and the two

measurements for the direction of cornmisure movement were calculated using the ICC

random effects mode1 for absolute agreement. The random effects mode1 for absolute

agreement will take into account the variance produced by the raters. This mode1 is based on

a repeated measures analysis of variance with the rater as the independent variable (Portney

& Watkins, 1993).

ICC = BMS - EMS BMS + (k-1)EMS + klRMS - EMS)

n

The @&--rater reliability of the depth of the nasolabial fold was based on the three scores

taken by each rater. In this design, the ICC for absolute agreement was estimated by using

the likelihood method in the variance components procedures within the computer program,

Statistical Package for Social Science 9.0. With this method the enor variance is divided by

the number of trials, which would be three for this investigation.

- ICC =

I

os- os2 + o R 2 + b $

3

The 95% confidence interval was also calculated for each ICC (McGraw & Wong, 1996).

Reporting the lower limit of the confidence interval serves two purposes. Firstly to test the

underlying assumption that the value of the ICC is O and if this is true the confidence interval

will inciude the value of O. Secondly to determine the limit of uncertainty conceming the

degree of reliability present is one's data. The lower limit of the confidence interval may

suggest a much poorer reliability that the acnial ICC (Fleiss, 1986, p. 13). The lower 95%

confidence limit has been set at .8 1 (almost perfect relationship) as per the guidelines by

Donner and Eliasziw (1 987).

PHASE THREE: FOLLOWIUP RELIABILITY STUDY

Based on the poor results of the primary research study fou. of the facial measurements were

re-examined. Lip droop, the depth of the nasolabial fold and shifting of the philtnun required

modifications to the facial landmarks and measurement procedures. The procedures for the

direction of d e facial meamernent were aiso reviewed. These revisions have been

presented in the result section of this thesis.

At this point in the investigation it was difncult to recniit children with facial palsy, therefore

eight addts through the Rehabilitation Department at HSC volunteered for the study. No

subject presented with a facial impairment. Both sides of the face were measured, therefore,

doubling the sarnple size to sixteen. There were four fernale and four male subjects who

participated in this snuiy. The ages ranged from 27.0 y e m - 43.6 years with a mean age of

35.2 years.

RATERS

The same two raten completed the follow-up study. The raters reviewed the protocol for the

revised measurement procedures and the identification of landmarks. Each therapist

practiced performing the measurements. This established a comrnon baseline between the

two raten to decrease the inteprater variability associateci with the execution of the

assessrnent technique.

TESTMG PROCEDURES

Each subject was tested independently by the two raten in the Rehabilitation Department at

HSC. The testing room was quiet and fiee fiom distractions and only the rater and the

subject were present. The mbjects were seated on a chair during the measurement session

and the rater was seated directly in fiont of the subject at eye level. A pichue was placed on

the wd facing the subject to serve as a place to focus while the rater identifîed the facial

landmarks. Millcy Gel RoUersm (Pentel Stationary @, Richmond B.C.) were used to draw a

1 mm dot at each facial landmark.

Each rater completed a facial ROM assessment following a standard protocol for

administration as described in Phase Two. Data were collected and recorded on the Data

Base: Range of Motion Assessment of Smile (see Appendix H). The distance measurement to

document the shifting of the philtnim was assessed once. Three triais were recorded for the

measurements: depth of the nasolabid fold and the direction of the cornmisure corner of the

mouth. Each measurement was taken in the resting position and while smiling with maximal

teeth showing. Rater one completed the facial ROM examination, which was followed by a

IO-minute break. During this break the landmarks were removed. Next, rater two completed

the assessment for a second time. The total evaluation was approximately thirty minutes.

THE MEASUREMENT TOOLS

Further modifications to the hand held caliper tool were made in an attempt to improve the

inter-rater reliability of the depth measurement of the nasal-labial fold. With improved facial - land-rnarking the coronal level became redundant but a new level was attached to the

platform base to limit the movement of the device in the saggitd plane (see Appendix G).

The modification of the tool was conducted through the Medical Engineering Department at

HSC. In consdtation with Andrew Baziw, medicai engineer at HSC (personal

communication, 1 999), the modincations to the tool did not effect the digital meamrement

scale and there was no loss in the accuracy of the tool.

DESIGN

Validity

In an attempt to improve the inter-rater reliabifity of facial measurements: Lip droop, depth of

the nasolabid fold and shifüng of the philtrum the landmarks were revised. The new facial

measurements are presented within the result section of this thesis and are outlined in figures

5 and 6, pages 67 and 68 respectively.

The inter-rater reliability for shifting of the philtnim was calculated using the ICC random

eEecrs modei for absolute agreement. T'ne random effrçts mode1 for absolute agreement

takes into account the variance produced by the ratee. This mode1 is based on a repeated

measures analysis of variance with the rater as the independent variable (Portney & Watkins,

K C = BMS - EMS BMS + O<-1)EMS + k(RMS - EMS)

n

The inter-rater reliability of the depth of the nasolabid fold and the direction of srnile was

based on the three scores taken by each rater. Based on this design, the ICC for absolute

agreement was e h a t e d by using the likelihood method in the variance components

procedures within the computer program, Statisticd Package for Social Science 9.0. With

this method the error variance is divided by the number of trials, which would be three for

this investigation.

ICC = os2 oS2+az+bE

The 95% confidence interval was aIso cdculated for each ICC and the lower limit recorded

(McGraw & Wong, 1996).

RESULTS

PHASE ONE: DEVELOPMENT OF ASSESSMENT

The first objective of this investigation was to develop a ROM assessment of smile for

children with facial pdsy and establish the content vaiidity of the assessment. The concept

of direct measurements is not new in the facial palsy Iiterature and Burres (1986a) was one of

h e fust investigatoa to apply Lhis technique to racial rneasurements. He idenufieci faciai

landmarks and linear measurements (distance measurements) as the necessary parameters to

document facial movement. Frey et al. (1 994) highlighted the fact that facial landmarks need

to be reproducible and in locations that will not be dismpted as a result of surgicai

intervention. As weii this group recognized that the distance measurements need to be

representative of the actual movement that occurs during smile. nirough the investigation by

Paletz et al. (1994) the direction of movement was also identified as a factor that should be

considered during smile. In children who present with unilateral facial paralysis the direction

of the commisure rnovement is possibly more important that the extent of movement. As a

result of this review one can conclude that the important parameters for the ROM assessment

of smile are facial landrnarks, distance measurements and the direction of the commisure

movement.

The construction of the final assessment was achieved after a review of the literature;

consultation with experienced cliniciaos and informal use with a variety of children with

facial palsy. The presentation of this ROM assessment for smile has been subdivided into

îhree categories : facial landmmks, distance rnemwernents and the direction of movement.

FACIAL LANDMARKS

In the Iiterature static and fünctiondly representative dynamic points have been empirically

evaluated. Static reference points are necessary for three-dimensionai motion analysis,

although with the use of static landmarks the variability in direct measurements can be

partially controlled. The central chin point, the tragus and the central nose point have d l

been ,aidisil. Through tomputer andysis the centrai nose poin~ aad the tragus of the ear

were identifieci as the supenor static points. It has been determined that the movement of the

mandibular joint affects the center point of the tragus, therefore the upper border of the tragus

has been recommended (Frey et ai. 1994). Dr. Farkas @enonal communication, August 4,

1998) has suggested that the tragion be used as the most consistent static landmark, this is

located at the most supenor point of the tragus. It appears that these hvo points may in fact

be the sarne and for the purposes of this investigation this point will be referred to as the

tragion.

The cornplexity of the motion around the mouth necessitates that several dynamic points are

required to measure smile. Through computer analysis the cornmisure corner of the mouth

showed the greatest excursion. The midline of the philtrum best described the aesthetic of

the upper lip and symmetry of the mouth was best characterize by the mid-lateral points on

the upper and lower lips (Frey et al. 1994). With re-constructive surgery it is necessary to

concentrate on the cornminire rnovement but attention must also be paid to the

vertical/lateral movement of the upper Iip (Paletz et al. 1994). Dr. Manktelow (personal

communication, 1999) has recommended that a landmark at the superior attachment of the

helix of the ear (helix-scalp junction) and the landmark at mid-lateral upper lip would best

represent the verticaVlatera1 movement of the upper lip.

The nasolabial fold assists in defining the boundaries of a smile yet in the literature the

charactenstics of this fold have not been objectively measured. This investigation attempted

to measure the depth of the nasolabial fold and the distance of the fold fkom the commisure

comer of the mouth. For the depth rneasurement in the primary snidy reliability, a landmark

was identified halfway between the ala and the commisure comer of the mouth.

in summary, with an the extensive review of the literature and consultation with experts in

the field, three static and ihirteen dynamic facial landmarks have been identified for inclusion

in the facial ROM assessrnent (see Figure 2).

F i w e 2. Facial Landmarks. 1 : Central nose point. 2 and 3: Right and left tragion. 4 and 5: Right and left cornmisure corner of the mouth. 6 and 7: Right and Iefi rnid-laterd point of the upper lip. 8 and 9: Right and Ieft mid-lateral points of the lower lip. 10: Philmim. 1 1 and 12: Iderior boarder of the alar nm. 13 and 14: Mid-point between the inferior boarder of the d a rim and the cornmisure corner of the mouth dong the nasolabial fold. 15: Rîght ear helix - scalp junction.

In the evaiuation of smile, Paletz et ai (1 994) identified the elevation of the upper Lip, the

lateral movement of the commisure corner of the mouth and the direction of the conunisure

movement as essential movements in the anaiysis of smile. Another important component to

assess is symmetry of the mouth while in a resting position and during srnile (Frey et ai.

1994; Paletz, et al). For distance meanirements to be representative of smile rnovements

they need to be representative of the actual movement that occurs during smile (Frey et al.).

The commisure comer of the mouth moves in an upward and lateral direction at

approximately a 40' angle (Paletz et ai. 1994). To represent this movement Frey et al. (1 994)

measured nom the tragus (tragion) of the ear to the commisure corner of the mouth. Burres

(1986) chose to measure fiorn the comrnisure comer of the mouth to the lateral canthus

(outside corner of the eye), fkom the commisure comer to the nasal spine, and fkom the

commisure comer to the midine of the lips. None of the distance rneasurements

recommended by Burres represent the actual movement during smile, which should be at an

approximate 40' angle fiom the commisure corner of the mouth. The best distance

measurement was determined to be fkom the tragion to the commisure comer of the mouth

(see Figure 3 #1, page 60).

The mid-lateral portion of the upper lip moves in a more veriical/lateral direction at

approximately a 43' angle (Paletz et al. 1994). Frey et al. (1994) recommended a

measurement nom the Md-laterd upper lip to the central nose point. This direction of

movement is not entirely correct for it does not take into account the movement in the lateral

direction. The movernent of the mid-Iateral portion of the upper lip is best measured b e ~ e e n

the helix point and the midpoint of the upper lip (Dr. R. Manktelow, personal

co~lllflUILication, 1999) (see Figure 3, #2).

The symmetry of the lower lip is best detennined through the distance measurement fiom the

midpoint of the lower iip to the central nose point. This has been recommend by Frey et al.

(1994) and is reasonable for the actual direction of movement (Dr. R Manktelow, personal

communication, 1999) (see Figure 3, #3).

Direct objective measurements for lip droop have not been described in the literature.

Clinically, Lip droop demonstrates asyrnrnehy in the mouth at rest and during smile. Dr.

Manktelow (personal communication, 1999) has recommended that the negative

displacement of the commisure corner of the mouth be directly measured with a ruler, fiom

the horizontal line at the base of the teeth to the commisure comer of the mouth (see Figure

3. M, page 61).

The aesthetics of the upper lip are best described by the symmetry of the philtrum (Frey et al.

1994). Dr. Manktelow (personal communication, 1999) suggested that the shifüng of the

philtrum be directly rneasured with a ruler, from the mid-point of the two front incisors to the

philtmm (see Figure 3, #5, page 61).

The distance the nasolabial foId fiom the commisure corner of the mouth is a valuable

measurement to document during smile (see Figure 3, #6). This distance measurernent is

particularly important to assess in the outcornes following fiee muscle transfers, as the

muscle is inserted dong the commisure comer of the mouth @r. R. Zuker and Dr. R.

Manktelow, personal communication, 1999). The depth of the nasolabial fold is a new

measurement and the procedures have been outlined (see Figure 3, #7, page 62).

This literature has determined that the most consistent movement is smiling with the

maximal showing of teeth @mes, 1985; Frey et al. 1994; Neely et al. 1996; Johnson et al.,

1994; Trotman et ai. 1997). Each distance measurement with the exception of the distance

fiom the commisure corner of the mouth to the nasolabial fold is measured with the mouth in

a resting position and at maximal smile with teeth showing. The distance tiom the

commisure corner of the mouth to the nasolabid fold is measured at maximal srnile oniy. A

total of eleven distance measurements are documented in this range of motion assessrnent of

smile. In addition to the distance measurements, depth measurements are evaluated in an

attempt to characterize the contour of the nasolabid fold.

F i w e 3. Range of Motion Assessrnent of Smile

1) Tragion to Commisure Comer of the Mouth Goal: To assess lateral excursion and symrnetry of smile. Method: Modified hand held caliper tool Landmarks: Tragion to the Commisure Comer of the Mouth, rneasured in rest and

with maximal smile.

2) Helix Point to Mid-lateral Upper Lip Goal: To wess verticaYlatera1 excursion and symrnetry of smile. Method: Modified hand held caliper rool

Landmarks: The superior attachent of the helix of the ear; (helix- scalp junction). The micilateral point of the upper Iip is the distance between the philtrum and the commisure corner of the mouth i 2 . Identify landmark at the vermilion border of the upper iip. Measure in rest and with maximal srnile.

3) Centrai Nose Point to Mid-lateral Lower Lip Goal: To assess the symmetry of the lower lip. Method: Modified hand held caliper tool Landmarks: Central nose point is at the midline of the domun of the nose level

with the lowest point of the columella of the eye. The mid-lateral point of the lower lip is the distance between the center point of the lower lip and the cornmisure corner of the mouth R. Identify landmark at the vermilion boarder of the lower iip. Measure in rest and with maximal srnile.

4. Lip Droop 5. S h i h g of the Philtnim

4) Lip Droop Goal: To assess the negative displacement of the cornmisure corner of

the rnouth. Method: Transparent Plastic Ruler Landmarks: From the horizontal line (base of the upper teeth) measure the negative

displacement of the cornmisure corner of the mouth in rest and with maximal srnile.

5) Shifüng of the Phi1hu-n Goal: To assess symmetry of the mouth; deviation of the philtrum. Method: Transparent Plastic Ruler Landmarks: Have the child relax and open their mouth slightly. Measure the

horizontal distance fiom the midine of the incisor surface to the center point of the philtnim in rest and with maximal smile.

6) Distance from the Cornmisure Corner of the Mouth to the Nasolabid Fold at a 45" angle. Goal: To assess the insertion placement of the gracilis muscle; symmetry of

smile. Method: Modified hand held caliper tool Landmarks: Cornmisure corner of the mouth the nasolabid fold, measure the

srnailest distance with maximal smile.

coronal plane tevel - r-l

- -

7. Depth of the Nasolabial Fold

7) Depth of the Nasolabial Fold Goal : To assess the contour of the nasolabid fold. Method: Modified hand held caliper tool-telescoping device (appendix C, figure

3) Landmarks: Landmark the midpoint between the cornmisure corner of the mouth

and the da of the nose. Place transparent plastic platform base of the caliper tool on the surface of the cheek at the apex of the zygomatic arch with the telescoping point on the landmark identified above. Set coronal plane level to maintain the correct angle. In rest and with maximal smile, record depth of the nasolabid fold in mm using the telescoping point

DIRECTION OF COMMISURE MOVEMENT

Paletz et al. (1 994) reported that the direction of the cornmisure movement is a valuable

objective measurement to document in the analysis of srnile. A direct objective measurement

for the direction of commisure movement has not been described in the literature. This

investigator has proposed a method that uses a transparent plastic goniorneter. The clinical

procedure on how to execute this measurement is outlined in Figure 4.

Figure 4. Direction of the Comrnisure Movement

Direction of S d e Goal: To assess the direction of the cornmisure mouth movement. Method: Transparent, flat goniorneter Landmarks: Midline of the incisor Surface to the Cornmisure Corner of the Mouth.

Place the axis of the goniometer over the base of the midline of the incisor surface. Place the movement arm dong the lower edge of the upper lip so that it will intersect with the commisure corner of the mouth. Measure in rest and with maximal smile.

PHASE TWO: PRIRlARY RELIABILITY STUDY

INTER-RATER RELIAB ILITY

The second objective was to determine the inter-rater reliability of the clinically derived

measures of srnile using k e measurement took: the MCT, the d e r and the goniorneter in

the assessment of srnile in children with facial palsy. The most clinically appropriate one of

the three tools was selected to complete each of* the measurements. Refer to AppendUt I for

the raw data related to the prllnary reliability study.

The between rater random effects interclass conelation coefficient for each of the

measurements are presented in Table 3, page 65. The distance measurements documented

with the MCT (tragion to commisure corner of the mouth, helix point to mid-laterai upper

lip, central nose point to nid-lateral lower lip and distance of the nasolabial fold fiom the

commisure comer of the mouth) have reliability values which range fiom 0.92 - 0.97. With

the exception of the resting measurements (tragion to commisure comer of the mouth and

helk point to mid-lateral upper Iip) the lower limit of the 95% confidence intervals are above

the recommended reliability coefficient of 0.8 1.

Lip droop and shifting of the philtnim were distance measurements documented with the

der . The measurement of fip droop has reliability values that range fiom .88 - .89 with a

lower limit of the 95% confidence interval below the recommended standard. Measurement

of the shifting of the philûum redted in poorer reliability scores that are below the

recommended standard. As well, the direction of srnile measurements documented with the

goniorneter have reliability values which are below the recornmended standards.

Table 3. Inter-rater Reliability of Facial Range of Motion Measurements: Interclass Correlation Cd~cients* h=26)

The ICC for absolute agreement (based on three ûials) for the depth measurement of the

C

Movment (mm)/Measzirement Tool

Tragion - Commisure Corner Mouth/ Caliper T d Heik Point - Mid-lataal Upper Lip/ C d i p Tu02 Central Nose Point - Mid-lateral hwer LiplCaliper Toul Lip DrooplRuler

Symmetry ofPhiltrum/Ruler

Nasolabid Fold f?om Cornmisure Corner MouthlC'iper Tool Direction of &le (degreesy Gonimeter

nasolabid fold is presented in Table 4. The depth measurements documented with the

telescoping adaptation on the caliper tool have reliability values which range fkom .73 - 34.

*Shrout, Fleiss 1979

Resting Maximal Smile

Resting Maximai Srnile Resting Maximai Smile ReSting Maximal Smile Resting MPùmal Smile

Maximal Smile Resting

,Maximal Smile

In light of the 95% confidence intervals lower limit, these values are far below the

recommended standards.

Reliabilit

0.9 1 0.97 0.93 0.92 0.9 0.96 0.89 0.88 OS8 0.69

0.9 1 0.65 0.77

h w e r 95% Confidence T.imit

0.67 0.93

I

0.75 0.84 0.89 0.92 0.77 0.75 0.26 0.4 1

0.78 0.36 0.43

Table 4. Inter-rater Reliability of Facial Range of Motion Measnrements: Interclas Correlation Coefficients* (n=26)

f

Lower 95% Confidence Lirnit

0.17 O

Reliability

0.73 0.84

Movement (mm)lMeanaement Tool Depth of Nasdabial FoW C d i m Tool

Resting Maximal S d e

PHASE THREE: FOLLOW-UIP RELIABILITY STUDY

In view of the poor reliability results in phase two, four of the facial measurements required

refinement. These included: lip droop, s h i h g of the philtmm, depth of the nasolabid fold

and direction of smile. Phase three of this investigation outhes the methodology for the

follow-up inter-rater reliability study.

CONTENT VALIDITY

Facial Landmarks and Distance Measurements

In the evaluation of lip droop this investigator considered revising the facial landmarks to

reflect a distance measurement from the central nose point to the cornmisure corner of the

mouth. As a resuit the MCT could be used to measure this distance. With this anaiysis, the

reliability may improve yet the assessrnent of the negative displacement of the lip droop kom

the horizontal line is not documented. Consequentiy the clinical relevance of this

measurement would be lost. No alternative measurement was tested in this study.

To assess the symmetry of the philtnim the landmarks were revised to retlect the previous

work of Frey et ai. (1994). This group of investigaton determined that the symmetry of the

philtrum was bea evaiuated by measuring the distance from the tragus (tragion) to the

philtnim. As a result of this modification the MCT could then be used to document this

distance (see Figure 5, page 67).

In codta t ion with Dr. Manktelow and Dr. Zuker (personal communication, 2000) the

laadmark for the nasolabid fold needed to be closer to the commisure corner of the mouth in

order to capture the greatest depth of the nasolabid fold. The distance between the da and

the cornmisure corner of the mouth was then divided into thirds and the lower one third was

used as the landmark in this follow-up reliability shidy. In an attempt to reduce the

variability in the measurement the MCT was aiso modified to include a level in the saggital

plane of motion (see Figure 6 , page 68).

Fime 5. Shifting of the Philtrum - Revised

1) Shifting of the Phiitnun Goal: To assess symmetry of the mouth; deviation of the philûum. Method: Modified hand held caliper tool Landmarks Tragion to the philtrum, measured in rest and with maximal smile.

Fiwe 6. Depth of the Nasolabial Fold - Revised

2) Depth of the Nasolabial Fold Goal: To assess the contour of the nasolabial fold. Method: Modified hand held caliper tool (telescoping device) Landrnarks: Landmark the point dong the nasolabiai fold at the lower l/3 between

the cornmisure corner of the mouth and the d a of the nose. Place transparent plastic platform base of the caliper tool on the surface of the cheek at the apex of the zygomatic arch with the telescoping point on the landmark identified above. The line etched into the platform base should line up with the mid-point of the lower lip. The saggital Ievel will maintain the device in a neutrai position with the ground and the position of the head will be referenced to the saggital level. With maximal srnile only, record depth of the nasolabiai fold in mm.

The inter-rater reliability scores for the shifang of the philtnim, the depth of the nasolabial

fold and the direction of smile were re-evaluated. The reliability results for the philtnim

were based on a single score and three scores were taken for the nasolabid fold measurement

and the direction of smile. Refer to Appendix J for the niw data related to the foliow-up

reliability study.

The between rater random effects interclass correlation coefficient for the distance

measurements fiom the tragion to the philtrum measured by the modified hand held caliper

toul are presentzd in Table 5. Thzse measurements have icliability ~alucs ivhich =ge h m

0.93 - 0.97 and the lower Iimit of the 95% confidence intervals are above the recornmended

standard of 0.8 1 .

Table 5. Inter-rater Reliability of Faciai Range of Motion Measurements: Interclass Correlation Coefficients* (1146)

The ICC for absolute agreement for the direction of srnile and the depth measurement of the

nasolabid fold is presented in Table 6. The reliability values ranges kom 0.26 - 0.72 and the

lower Iimit of the 95% confidence intervals are far below the recommended standard.

Movement (mm)lMeasurernent Tool Symmetry of Philtrum (tragion - philtnim)/CuZiper Tool

Table 6. Inter-rater Reliabüity of Facial Range of Motion Measuremeats: Interclass Correlation Coefficients* (n=16)

L

*Shrout, Fleiss 1979

Resting Maximal Smile

1 1 (Reliability ILower 95% 1

Reliability

0.97 0.93

Lower 95% Confidence Limit

0.94 0.9

Movement (mm)/Meawement Tool Direction of smile (degreefs)/

l~aliper Tool 1 ~aximal Smile 1 0.26 1 01 "SPSS 7990

Goniorneter Depth of Nasolabid Foldf

Resting Maximal SrniIe

0.72 Confidence Lirnit

I

O 0.64 O

DISCUSSION

The primary purpose of this study was to develop a valid and reliable assessment that would

mesure the range of movement for smile in children with facial palsy. An extensive

literature review and consultation with experts within the field has delineated the clinically

appropriate parameters for the ROM assessment of srnile and has established the content

validity of these measurements. The incer-racer reliabiiiry oirhe faciai ROM assessment was

dso investigated. For the purposes of this discussion al1 three phases of this investigation

will be considered concurrently.

DEVELOPMENT OF THE ASSESSMENT

Validity is an important aspect to consider when choosing and developing a measure. This

psychometric property refers to the suitability of a measure and of the inferences that cm be

made from the scores (Cole, Finch, Gowland, & Mayo, 1994). in fact, Silva (1993, p. 63)

believes that the reliability of a measure is dependent on it's vaiidity, the score that is the

moa reliable is one that accurately reflects the attribute of interest. Unfominately, validity

cm never be proven; it is only esùmated and not measured directly (Law, 1987). This

process is continuou and evidence increases the more the instrument is used and studied

(Duan, 1989).

This investigation addressed the content validity of the ROM assessment of smile. The

parameters of the evaiuation and the selection of instruments were detennined through an

extensive iiterahue review and consultation with expert clinicai opinions. It was concluded

h t in the ROM assessment of smile one must consider the identification of pertinent facal

l ~ d m a r h (Paletz et al. 1994; Frey et ai. 1994), the distance m e w e m e n t s , @unes, l986a;

Paietz et al. 1994; Frey et al. 1994) and the direction of movement (Paletz et al. 1994).

Several of the investigators of facial measurement agree bat the most consistent movement

is smiling with the maximal showing of teeth (Burres, 1985; Frey et ai. 1994; Neely et al.

1996; Johnson et al. 1994; Trotman et al. 1997).

Dr. Manktelow, Dr. Zuker and an Occupational Therapist who used the ROM assessment

clinically perfonned an informa1 qualitative review of the facial ROM assessment. The

parameters of this assessment have been thoroughiy examined and are presented in the

results section of this thesis. As well, the methods of measurement and protocol for

measurement were determined to be appropriate to answer the objectives of this assessment.

INTER-RATER RELIABILITY

The inter-rater reliability was evaluated by using the ICC. The advantages to using the ICC

is that it can assess the reliability among two or more rating, the analysis does not require the

same number of raters for each subject and most importantly the ICC supports the

generalizability model. The generalizability model recognizes that differences between

observed scores are due to a variety of factors not just tme variance and random error

(Portney & Wakins, 1993, p. 509-5 10). For example, in this investigation the ICC accounts

for the variances between the raters, the subjects, and error.

nie disadvantages in using the ICC are two fold. The fint consideration is that the reliability

coefficient is based on an average correlation across raters. Consequently, if the ICC is low

and the variance between the raters is high, the individual variance of the raters c m o t be

determined. A follow-up inna-rater reliability study would be necessary to discem the

variability of the individuai raters.

The second concem in utilizing the ICC relates to the actual study sample. When evaiuating

a reliability study it is important to consider the characteristics of the study sample. The pre-

requisite for a good reiiabiiity study is a sample with a wide range of scores, for as the total

mie variance increases the error component will account for a smaller proportion and

reliability will improve (Portney & Watkins, 1993, p. 508). In this investigation the sample

in the primary reliability study was comprised of children who presented with facial paisy

and the raw data collected represented a wide range of possible scores. The follow-up

sample was drawn fkom the nomal addt population. The range of raw scores in the addt

sample were less variable and this may have been a factor in the poor reliability resuits.

This investigation delineated four research hypotheses each relating to the reliability of the

proposed facial ROM assessment. At this point each hypothesis will be reviewed and the

interpretation for the current results discussed.

Hypothesis One

In ench location, there is an alrnost per-ct relationship (81 - 1.0) b e ~ e e n the ratings of two

observers on the distance measurements in the assessment of smile when using the modijed

hand held caliper too l.

The MCT is a reliable assessment tooi for the measurement of facial distances. Of the nine

distances measurements assessed in this investigation there were three exceptions to this

statement. It is not clea. as to the discrepancy in two resting measurements that indicated a

low reliability: the tragion to the commisure corner of the mouth (lower limit .67) and the

helix point to the mid-lateral upper lip (lower limit .75). The same two measurements

indicate a high reliability in the maximal smile position denoting adequate assessment

technique. Variability in the subject resting positions is not a typical h d i n g and this is more

likely to occur with movement. It is possible that one of the raters measured to the incorrect

landmark on a few of the subjects, for example fiom the tragion to the mid-lateral upper lip

and this could account for the less than desirabIe results.

A low reliability was also docurnented in the distance measurement of the commisure corner

of the mouth to the nasolabial fold (lower limit .78). The majority of variance was fiom

between the subjects and secondly from error. In children who present with an abnormal

nasolabial fold it cm be difficuït to determine at what point the fold begins moreover there

cm acnially be an absence of the fold. This factor may increase the error component in the

variance. Another element to consider is the statistical power used in this investigation.

With the statistical power set at 80% it is expected that 20% of the scores will not f d with in

the desked range of .8 1 or above. Consequently, these findings maybe more of a result

regarding statistical power than with an achial deficiency in the measurement system.

The remainder of the distance measurements do present with reasonable ICC's. With a lower

limit of the 95% confidence intelvals of .84 or greater one cm conclude that the differences

between measurements on diffèrent subjects primarily represent subject to subject

differences. The landmarks chosen for these measurements were well defïned and there was

a wide range of scores within the raw data. The caliper tool is able to measure to a tenth of a

millimeter dlowing for a more accurate measurement of distance. Through the ANOVA the

majority of variance was fiom between the subjects and secondly from error. Although

smiling with maximal teeth showing has been detemiined to be the most consistent

movement this may account for a degree of the variability between subjects.

Of al1 the direct measurement systems reviewed in this thesis none have reported on the

reliability of the measure. As previously discussed Ross et al. (1 99 1) reported on the inna-

rater reliability of linear measurements assessed with a caliper tool. An ICC of -98

demonstrated substantial infra-rater reliability with a lower 95% confidence limit of .96.

Inter-rater reliability was not evaluated in the investigation therefore a direct cornparison to

the cunent study cannot be made.

With the exception of two resting meanirements and the distance fkom the cornmisure corner

of the mouth to the nasolabid fold, there is evidence to conclude that there is an dmost

perfect relationship between the ratings of two observers on the distance measurernents in the

assessment of srnile when using the MCT.

Hypothesis Two

In each location there is a substantial relationship (. 61 - .80) between the ratings of two

observers on the distance measuremenrs in the assessment of'smile when using the d e r .

Two distance measurements were evaluated with the d e r : lip droop and shifüng of the

philtnun. The measurements for lip droop presented with reasonable ICC's and lower limit

confidence intervals for this hypothesis, although the reliability is below the recommended

standard of. 8 1 . Again, these maybe as a result of the statisticai power rather than limitations

in the measurernent tool. The reliability of measurements for shifting of the philtnim were

poor, and below the recommend standard of .8 1. Based on the ANOVA, the majority of

variance was fiom between the subjects and secondly h m error. Linear meanirements are

inherently variable and continue to be a limiting factor. The landmarks chosen for these

measurements were well defined but there was a small range of scores in the raw daîa

therefore the error component accounted for a larger proportion and reliability decreased.

These two movements were technicdy more difficult to measure for example, the distances

were mal1 and the horizontal line for lip droop required visualization on the part of the rater.

As well the d e r is not as fine a meamernent tool and may be less accunite than the caliper

tool. Al1 of these factors wiIl increase the error component in the variance.

Frey et al. (1994) recommended that the distance measurement from the tragus (tragion) to

the philtnim be used the document symmetry of the philtrum. In the follow-up study

excellent results were obtained ushg the MCT and a lower 95% confidence i h i t of -90 was

achieved. The rationde for these resdts have been discussed within the hrst hypothesis.

In the measurement of lip droop there is evidence to conclude there is a substantial

relationship between the ratings of two observers on the distance measurements in the

assessment of smile when using the d e r . Although, the reliability obtained is below the

recommended standard of .8 1. in the measurement of the shifting of the philtnim there is

evidence to conclude that there is a less than a substantid relationship between the ratings of

two observers on the distance measurements in the assessment of srnile when using the d e r .

Hpothesis Three

For each memurernent there is a substantial relutionship (. 61 - .80) between the ratings of

two observers on the direction measurements in the assessment of smile when using the

goniorneter.

The ICC's for the direction of the cornmisure movement were substantial in both studies but

the lower limit 95% confidence level was very low indicating poor reliability with this

measurement. Based on the ANOVA, the major@ of variance was fiom between the

subjects and secondly fiom the error. The landmarks chosen for this measurement were well

defined but there was a s m d range of scores in the raw data. Therefore, the error component

accounted for a larger proportion of the variance and reliability decreased. As well, this

facial measurement is inherentiy variable and the goniometer is not as fine a measurement

tool. Ail of these factors will increase the error component of the variance.

The direction of commisure movement does have clinical importance in the assessrnent of

smile therefore an attempt was made to improve its reliability. When rneasurements are

unstable it may be necessary to take a mean of several scores and use the mean of repeated

independent measures to obtain a satisfactory reliability. This has the effect of increasing the

reliability due to the fact that mean scores are considered better estimates of tnie scores,

thereby reducing the error variance (Portney & Watkins, 1 993, p. 5 1 1). In the follow-up

study the direction of the cornmisure movement was evduated again and an average of three

scores was taken. The ICC's obtained were comparable with the primary study yet the lower

level confidence limit was very poor. The low reliability scores may in part be due to the

fact that the subjects in the second study were fiom a homogenous sample with limited

variability (Pormey & Watkins, 1993, p. 508).

The evaluation of the direction of the commisure movement presented with several negative

factors. As a result there is no evidence to conclude that there is a substantial relationship

between the ratings of two observers on the direction rneasurements in the assessment of

smile when using the goniometer.

Hypothesis Four

For each rnemrement there is a substantial relatiomhip 661 - -80) beiween the ratings of

two observers on the depth rneanaemenis in the assessment of smile when using the modified

hand held caliper tool.

The ICC's for the depth of the nasolabid fold measurements were initially substantid in both

studies yet the lower Iimit 95% confidence level was consistently low indicating poor

reliability with this measurement. Based on the ANOVA, the majority of variance was fiom

between the raters and secondly from between the subjects. EEorts to improve the reliability

of this measurernent were made; for example, landmark identification, modification to the

measurement tool and calculation of the ICC's using the mean of repeated independent

measures. In the follow-up study a saggital level was added to the device in order to

maintain the position of the instrument parallel to the ground. As well, the head was held in

a stable position in relation the caliper tool. The caliper tool was still able to rock on the

surface of the cheek thereby decreasing or increasing the distance between the tool and the

landmark on the nasolabid fold. As a result this increase in the variance between raters.

Despite these corrections this measurement remained technicaily difficult to record. Other

factors such as the small range of movement and the homogenous sarnple in the second study

will negatively impact on the reliability of this measurement.

In spite of the attempts to improve the testing procedures, the testing hsmiment and the

statistical analysis there continued to be several negative factors intluencing the reliability of

this measurernent, As a result there is no evidence to conclude that there is a substantial

relationship between the ratings of two observers on the depth meannements in the

assessrnent of s d e when using the MCT.

In summary, this investigation has identified the important parameters to measure in the

ROM assessment of smile and has established the content validity of the assessment. The

inter-rater reliability of the facial ROM assessment was evaluated and the MCT appears to be

reasonably constant in the documentation of distance measurements in the assessment of

smile.

CONTRIBUTIONS OF THIS THESIS

Based on previous investigations and expert opinion this current research study proposed

four new facial landmarks and fifteen new distance measurements in the evaluation of facial

ROM. The methodology for seven of the rneasurements presented were exclusive to this

study and are as follows: lip droop, the depth of the nasolabid fold, the direction of srnile

(resting and maximal smile) and the distance of the nasal-labial fold fiom the commisure

corner of the mouth (maximal smile).

Rigorous reliability testing of direct measurement techniques have not been presented in the

facial movement literature and in order for an instrument to be useful in the clinical

environment proven inter-rater reliability is a necessary component. This research study

assessed the inter-rater reliability of the proposed facial ROM assessment using three

measurernent tools. The resdts of this investigation clearly indicate that the MCT presents

with the highest reliability. As well, one of the new landmarks: helix point; and four of the

distance measurements: tragion to cornmisure corner of the mouth (maximal smile), helk

point to mid-lateml upper lip (maximal smüe), and tragion to philtmm (resting and maximal

smile) are the measurement parameters that support a reliability above the recommend

standards of. 8 1.

Facial motion is complex and difficult to measure in a way that is reproducible. The

assessment of lip droop, the direction of commisure movement and the distance of the

nasolabial fold fiom commisure corner of the mouth were not reliable yet continue to be

important characteristics to measure in the assessment of srnile. These measurements

continue to require refinement in order to improve their reliability. An attempt was made to

objectively measure the depth of the nasolabid fold, but this was also proven to be

unreliable. Reliability of these measurements may be improved through more ngorous land

marking and testing procedure, intensive rater training, and perhaps a superior measurement

tool.

A unique and important feature of this investigation was that the initial study sample

consisted entirely of children with facial palsy. Furthemore, the children were able to

comply with the testing procedures and did not appear to find the instruments intimidating.

The raten reported the MCT was easy to use and the assessment was quick to admuiiner.

LIMITATIONS

Throughout this research snidy every effort was made to ensure a sound scientific approach.

Despite the established research protocol some methodological limitations did occur which

may have effected the intemal and extemal validity of this study.

The intemal validity of the reiiability study may have improved if the raters were evaluated

on the assessment techniques following the training period. An evaluation by an independent

assessor wouid ensure the consistency between the raters. As wel1, facial movement is

innately variable and despite the efforts to implement a standardized protocol this variability

may have negatively irnpacted on the reliability results. Another threat to the intemal

validity of this study was the decision to limit the amount of testing to which the children

were exposed and to calculate the reliability of several measurements based on a single score.

From a statistical perspective this may have had a negative impact on the reliability of the

measmement for mean scores are consiciered better esGmotzs of tniz scorzs (I>ortney $

Watkins, 1993, p. 5 1 1).

The follow-up reliability study used a convenience sample of normal adult subjects. Due to

the fact that the subjects presented with no facial asymmetry, expectation bias may have

influenced the rater's scores. The results obtained from the follow-up reliability study may

not be generalizable to the target population of children with facial palsy.

FUTURE DIrnCTION

The empincal investigations regarding objective measwement of facial ROM are in their

infancy stages of development. To capture the smaller facial movements such as Iip droop,

direction of smile and facial contours the community of researchers need to continue to

perfect the computer analysis of facial movement. Computer analysis needs to become cost

effective and less complex so that it can be used in the clinical setting and be acceptable to

c hildren.

The MCT does have cIinical value as an assessrnent tool for facial ROM and further

reliability midies are warranted. Streiner and Norman (1 995, p. 1 14) recommend that if the

inter-rater reliability is low it maybe necessary to continue with an inûa-rater reliability shidy

in order to determine the source of unreliability; for example, between the raters, within the

raters or both. As well, it is also necessary to test the sensitivity of this rneasurement tool to

record clinically important changes. A reliability study to assess the responsiveness of this

facial ROM assessment is a fundamental step in the development of this assessrnent.

Despite the adequate reiiabiliv of this motor assessment of smile for ciinical activities, in

order to assist in the surgical decision rnaking for children with facial palsy a highly reliable

instrument is required. An ICC with a point estimate of .99 with the lower 95% confidence

lirnit set at .96 indicates minimal variability in the rneasurement and would be preferred.

This high reliability may be achieved with the MCT by using the same rater, or an alternate

assessrnent tool may prove to be the method of choice; for example, cornputer analysis.

The limitations in facial ROM is only one aspect that may effect the overall function in

children who present with facial palsy. The research literature to date focuses on the clinical

outcornes of adults with face nerve palsy and very little has been devoted to children.

Clearly it is important to research and publish on the fûnctional implication impairment in

smile has on children who present with facial palsy. More specifically to assess the impact

of a facial impairment on ones self-perception and ability to participate in the tasks of daily

living.

CONCLUSIONS

The predominant request fiom children who present with facial palsy is to be able to srnile

and with new surgical techniques this wish has become a reality. Ordinal grading systems

are not sensitive enough to document the detailed functional changes that occur as a result of

these interventions and the few compter systems in use may be of benefit in an adult

research setting.

The results of this investigation have produced an adequate ROM assessment that will

reliably measure most of the important motor components of m i l e in the clinical setting:

commisure rnovement, upper lip movement, symmetry of the upper and lower lips and

symmetry of the philtrum. To document the changes in the nasolabial fold a descriptive

classification has been proposed. Although there is a significant amount of research to be

done in this area this study has provided therapists with a basic facial ROM assessment that

is inexpensive, acceptable to children and can be used in the clhical setthg (Table 7, page

84).

The assessment of lip droop, the direction of commisure movement and the distance of the

nasolabial fold fiom commisure corner of the rnouth were not reliable yet continue to be

important characteristics to measure in the assessrnent of srnile and will benefit fiom M e r

investigations.

Table 7. Pro~osed Facial Assessrnent Data Base

l Previous Surgeries:

Date: Therapist:

Affected Side: Right Left IRIGHT [mm] IEXCURSION (LEFT [mm] IEXCURSION 1 I

Resting Position 1 r

Name: Date of Birth:

1 Maximal Smile 1 1 1 1

HSW Unilateral Bilateral

l ~ e l i x Point - Midlateral U ~ p e r Lin 1

1 Maximal Srnile 1 1 1 1 1 - - - - --

(central Nose Point -

1 Maximal Smile 1 1 1 1 1

Resting Position Maximal Smile

IL~D D r o o ~ (from horizontal line to CCM) 1 . . Resting Position Maximal Simle

kMance of NIL from CCM 1 - - l

Maximal SmiIe 1

Direction of Smile Resting Positon (3 Trials)

1 ~aximal Smile (3 Trials) fil

Bilateral 1 A = Absent both sides

Description of the Nasal Labial Ford:

1 = Present c (N) side 2 = Present = to (N) side 3 = Present > (N) side

Unilateral O = Absent

B = ~resent and = both sides C = Absent (L), Present (R) O = Absent (R), Present (L) E = Present Both > on (R) F = Present Both > on (L)

REFERENCE LIST

Bajaj-Luthra, A., Mueller, T., & Johnson, P.C. (1997). Quantitative analysis of facial

motion components: Anatomic and nonanatomic motion in normal persons and in

patients with complete facial paralysis. Plastic and Reconstnictive Surgerv. 99(7),

1 894-1 902.

Benson, J., & Clarke, F. (1982). A guide for instrument development and validation.

Amencan Journal of Occupational Therapy, 36(12), 789-800.

Brackrnm, D.E., & Bam, D.M. (1984). Assessing recovery of facial b c t i o n following

acoustic neuroma surgery. Otolarniaoloq Head and Neck Sur~erv, 92(88), 88-93.

Burns, N., & Grove, S. (1 997). The ~ractice of nuninc! research: conduct critique &

utilization. (3rd ed.). Philadelphia, Pennsylvania: W.B . Saunders Company.

Burres, S. (1985). Facial biornechanics: The standards of normal. Larvngosco~e. 95,

708-7 14.

Burres, S. (1 986a). Objective grading of facial paralysis. Annals of Otolom, Rhinolow,

and Lamieolow. 95(3 Pt 1 ), 23 8-24 1.

Burres, S., & Fisch, U. (1986b). The cornparison of facial grading systems. Arch

Otolamgolow Head and Neck Surpem 112(7), 755-758.

Cole, B., Finch, E., Gowland, C. & Mayo, N. (1994). Physical rehabilitation outcomes

measures. @p. 21 -33). Toronto: CPA, Health and Welfare Canada, and Canada

Communications Group.

decatanzaro, D.A. (1 999). Motivaton and Emotion - evolutionarv. ohvsiolopical.

dea7clo~mentd. md social ~ e s ~ e c t i r e s . Yew Jersey: Prenticc-Hal1 hc.

Donner, A., & Eliasziw, M. (1987). Sarnple size requirements for reliability studies.

Statistics in medicine. 6,44 1-448.

Dunn, W. W. (1 989). Validity. [Speciai issue: Developing nom-referenced standardized

tests]. In Miller, L.J. (Ed.) Physical and Occu~ational Theraw in Pediatrics. 9(1),

149-1 68.

Evans, R.A., Harries, M.L., Baguley, D.M., & Moffat, D.A. (1989). Reliability of the

Houe and Brachann grading system for facial palsy. Journal of Laqneolow and

Otologv. 1 O3 (1 1 ), 1 045- 1046.

Fisch, U. (1 98 1). Surgery for Bell's paisy. Archives Otolaryn~olopv, 1 07(0 1 ), 1 - 1 1.

Fleiss, J.L. (1986). The design and analysis of clinical experiments. In Reliabilitv of

measurement. @p. 1-32). New York: Wiley.

Frey, M., Jemy, A., Giovanoli, P., & Stüssi, E. (1994). Development of a new

documentation system for facial movements as a b a i s for the international registry

for neurornuscular reconstmction in the face. Plastic and Reconstructive Surgew, - -

93(7), 133491349. -

Goldberg, C., & Zuker, R. (in press). Facid reanimatiition in children uith Mocbius

syndrome using gracilis muscle transplants. Plastic and Reconstnictive Su~erv.

Hennekens, C.H., & Buring, LE. (1987). Epidemiolom in medicine. Toronto: Littie

Brown Company.

Hepner, W.R. (1 95 1). Some observations of facial paralysis in the newbom infant:

Ideology and incidence. Pediatrics. 8,494-497.

House, 1. W. (1 983). Facial nerve grading systems. Laryngoscope. 93(8), 1056-1 067.

House, J.W., & Brackmann, D.E. (1985). Facial nerve grading system. Otolanmeolo~ -

Head and Neck Suraerv. 93(2), 146- 147.

Johnson, P.C., Brown, H., Kuzon, W.M., Bailiet, R., Gaxrison, J.L., & Campbell, J.

(1994). Simultaneous quantitation of facial movements: The maximal static response

assay of facial nerve function. Annals of Plastic Surgerv. 32(2), 17 1 - 179.

Johnson, P.J., Bajaj-Luthra, A., Llull, R., & Johnson, P.C. (1997). Quantitative facial

motion analysis for hinctiond fiee muscle reanimation procedures. Plastic and

Reconstructive Sur~erv. 100(7), 1 7 10-1 7 19.

Kumar, V. (1995). Cross-face reanimation of the pardysed face, with a single stage

Law, M. (1987). Measurement in Occupational Therapy: Scientific criteria for evaluation.

Canadian Journal of Occu~ational Therapy. 54(3), 133-1 3 8.

McGraw, K.O., & Wong, S.P. (1 996). Psvchological-Methods. 1(1), 30-46.

McHugh, H.E., Sowden, KA., & Levitt, M.N. (1969). Facial paraiysis and muscle

agenesis in the newbom. Archives Otolaqmgologv. 89, 157-169.

M~rty , G.E., Diver, J.P., Kelly, P.J., OtDonoghue, G.M., & Bradley, P.J. (1 994). The

Nottingham System: Objective assessrnent of facial nerve function in the chic .

Otolamiirolo~ Head and Neck Sur~ery. 1 1 O@), 156- 16 1.

Neely, J.G., Cheung, J.Y ., Wood, M., Byers, J., & Rogerson, A. (1 992). Computenzed

quantitative dynamic andysis of facial motion in the paralyzed and synkinetis face.

The American Journal of Otologv. 1 3 (2), 97- 1 0%

Neely, J.G., Joaquin, A.H., Kohn, L.A., & Cheung, J.Y. (1996). Quantitative assessments

of the variation within grades of facial paralysis. Larvngosco~e. 1 O6(4), 438-442.

O'Brien, B.M., Pederson, W.C., Khazanchi, R.K., Momson, W.A., MacLeod, A.M., &

Kumar, V. (1 990). Results of management of facial paisy with rnicrovascuiar fiee-

inuscle tnnsfcr. Pladc and Rcconstnictive S u r ~ e n . 56(1), 12-22.

Orobello, P. (1991). Congenital and acquired facial nerve paralysis in children.

Otolarvnirolo~icai Clinics of North Amerka 24(3), 647-652.

Padwa, B.L., Evans, C.A., & Pil1emer.F.C. (1991). Psychosocial adjustment in children

with hemifacial microsornia and other craniofaciai deforrnities. Cleft Palate -

Craniofacial. 28(4), 354-359.

Paletz, J.L., Manktelow, R.T., & Chaban, R. (1994). The shape of a normal srnile:

Implications for facial paralysis reconstruction. Plastic and Reconstnictive Sur~erv,

93(4), 784-789. -

Pearson, B. W. (1 985). Editorial. Otolanm~o~ogv Head and Neck Sureery. 93 (2), 145-

145.

Pertschuk, M.J., & Whitaker, L.A. (1 985). Psychosocid adjustment and craniofacial

malformations in childhood. Plastic and Reconstnictive Surnery. 75(2), 177-1 84.

Pope, A.E., & Wood, J. (1 997). Self-perceived facial appearance and psychosocial

adjustment in preadolescents with craniofacial anomalies. Cleft Palate - Craniofacial,

3 5(5), 396-40 1. -

Portney, L.G., & Watkins, M.P. (1993). Statistical rneasure of reliability. In Foundations

of Chical Research: A~~licat ion to ~raciice. @p. 505-528). Nom&, Connecticut:

Appleton & Lange.

Rickenmann, J., Jaquenod, C., Cerenko, D., & Fisch, U. (1997). Comparative value of

facial nerve grading systems. Otolarvneoloev Head and Neck Sur~ew. 1 17(4), 322-

Ross, B.G., Fradet, G., & Nedzelski, J.M. (1 996). Development of a sensitive clinical

facial grading system. Otolaryncrolop Head and Neck Surgew. 1 14(3), 3 80-386.

Ross, B.G., Nedzelski, LM., & McLean, A. (1991). Efficacy of feedback training in long-

standing facial nerve paresis. Larvne;osco~e. 10 1 (7), 744-750.

Rubin, L.R. (1974). The anatomy of a srnile: Its importance in the treatment of facial

paralysis. Plastic and Reconstnictive Surgery. 53,384

Sassoon, E.M., Poole, M.D., & Rushworth, G. (1991). Reanimation for facial palsy using

gracilis muscle grafts. British Journal of Plastic Sur~erv. 44, 195-200.

Silva, F. (1993). Psvchometnc Foundations and Behavioural Assessment. Newbury Par:

SAGE Publications.

Smith, LM., Murray, J.A.M., Cdl, RE., & Slattery, J. (1 992). A cornparison of facial

grading systems. Chical Otolaryngolow. 17(4), 303-307.

Streiner, D.L., & Norman, G.R. (1995). Health measurernent scaies: A ~racticai mide to

their develooment and use. (second ed.). New York: Oxford University Press Inc.

Trotman, C., & Faraway, J.J. (2000). Sensitivity of a method for the analysis of facial

mobility: Interlandmark separation. C M Palate - Craniofacial. 3 5(2), 142- 153.

Trotman, C., Faraway, J.J., Silvester, KT., Greenlee, G.M., & Johnston, L.E. (1 998).

Sensitivity of a method for the analysis of facial mobility: vector of displacement.

Clefi Paiate - Craniofacial. 3 S(2), 1 32- 14 1.

Trotman, C., Stohler, C.S., & Johnston, L.E. (1 997). Measurement of facial soft tissue

rnobility in man. Clefi Palate - Craniofacial, 35(1), 16-25.

Zuker, R., & Manktelow, R.T. (1993). Functiond and aesthetic muscle transplants.

Advances in Plastic and Reconstnictive Surgew, 9? 37-66.

INDIRECT OBJECTIVE FACIAL GRADING SYSTEMS

Table Al. The House Brackmann Facial Nerve Grading Scale

. . non Charactemcs 1 Normal Normal facial fiinction in al1 areas II Mild Dysfunction Gross: slight weakness noticeable on close inspection;

may have very slight synkmesisa Rest: normal symmeîxy and tone Motion: forehead-moderate to good function; eye-complete

closure with minimum effort; mouth-slight asvmmetrv

III Moderate Gross: obvious but disfiguring differences between 2 sides; noticeable but not severe synkmesis, contracture andor hernifacial spasm

Rest: normal symmetry at rest Motion: forehead-slight to moderate movement; eye-complete

closure with effort; mouth-slightly weak with maximal effort

N Moderately Severe Gross: obvious weakness andior disfiguring asymmetry Rest: normal symrnetry and tone Motion: forehead-none; eye-incomplete closure; mouth-

asvmmetric with maximal effort V Severe Dysfunction Gross: only barely perceptible motion

Rest: asymmetry Motion: forehead-none; eye-incomplete closure; mouth-

s k h t movement VI Total Paralysis No niovement

Note. From Facial nerve grading system by J.W. House and D.E. Brackmann, 1985 Otolarnnoloev Head and Neck Surgerv, 93(2), 146.

a synkinesis is a secondary deficit described as involuntary muscle contraction which is associated with vo1untary facial movernent.

Table A2. The Fisch Detailed EvaIuation of Facial S v r n m e t ~

etry of the face Points At rest O O

30 6 70 14

Wrinkling Forehead O O 30 3 70 7

Eye closure

Note. From Comparative value of facial nerve grading systems by Rickenrnann, J.; Jaquenod,C.; Cerenko, D.; Fisch, U. 1997 Otolmnolow Head and Neck Suroerv, 1 17(4), 323.

Fimre Al. The Sunnybrook Facial gradin^ Svstem

-- -- I"&.( 2 J 4 6 Q I * 1 t i [ 7

Note. From Development of a sensitive dinicd facial grading system by Ross, B.G., Fradet, G., & Nedzelski, J.M. 1996 Otoiarneolow Head and Neck Surgerv, - 114(3), 382.

Figure B1. The Maximal Static Response Assav

Facial Landmarks. 1 and 2: Right and left supraorbitais. 3: The radir. 4 and 5: Right and left infraorbaitais. 6: The philtram. 7 and 8: Right and Iefi oral commissures. 9: The mentum.

Note. From Sirnuitaneou quantifkation of facial movements: The maximal static response assay of facial nerve function. Johnson, P.C., Brown, H., Kuzon, W.M., Balliet, R., Ganison, J.L., & Campbell, J. 1994 Annals of Plastic Sumerv, 32(2), 172.

Figure B2. The Three Dimensional Trackine System

Note. From Sensitivity of a method for the d y s i s of facial mobility: vector of - displacement Trotman, C., Faraway J.J., Silvester, K.T., Greenlee, G.M., & Johnston, L.E. 1 998 Cleft Palate -CraniofaciaI Journal, 35(2), 1 3 3.

Fieure B3. The Three Dimensional Trackine System

FIGURE 1 l&ria~~dmnrk scparation4e distance bctween selm

Note. From Sensitivity of a method for the analysis of facial rnobility: Landmark sepration. Trotman, C., Faraway J.J. 2000 Clef? Pdate -Craniofacial Journal, 35(2) 143.

APPENDIX C

MEASUREMENT TOOLS

m r e Cl. The Modified Hand Held CaIiper Tool

1. Modified Outside Measuring Points 2. Digital Dis play 3. Coronal Plane Level 4. Telescoping Point 5. Platform Base 6. Battery Cornpartment Cover 7. Power On/Zero Switch 8. Power off Switch

Note. Original caliper tool "Digimatic Plastic Caliper #7OO 1 O3B fiom MihitoyoMTI Corporation, Mississagua, Ontario.

Figure C2. The Transparent Goniometer

Note. The Finger Goniometer by Smith and Nephew Rolyan Incorporated, 1999 Rehabilitation Producr Catalome, 13 8.

INFORMATION SENT TO FAMILES

Recmitment Letter Date

Insert Address

Dear Mr. and Mrs. and child's name,

Facial palsy in children is a fairly uncommon condition that affects how the muscles of the face work. Many children with facial paisy have surgery a d o r therapy to help them use their facial muscles. The changes seen as a result of these interventions are hard to measure and the tool that is used m u t be accurate. In an effort to improve how to mesure facial movement we are currentiy doing a study at the Hospital for Sick Children to determine the most accurate way to mesure facial movement in the clinicai setting. From this study we hope to improve our ability to measure facial motion and to gain a better understanding of the long-term results of therapeutic interventions for children with facial paisy.

In order to complete this study we require that children with facial palsy undergo two separate clinical assessments of facial motion. This c m ail be done at the time of a clhic visit to Plastic Surgery in order to make this as convenient as possible. In the event you do not have a scheduled appointment, a mutuaily convenient assessrnent time can be arranged. For more information about the study please refer to the attached information form. Once the study results are complete, results will be made available to interested participants.

If you would like to participate in this study please contact S h n a Wade at 8 136755 and press 7-2 to leave a message on voice mail indicaihg your name and what number(s) you may be contacted at. Or, you may fill out the response letter included and return it in the self-addressed stamped envelope.

Again, thank you for considering this request.

Sincerel y,

Dr. R Zuker, MD, FRCSC, FACS, FAAP Shawna Wade BMR OT [Cl Head, Division of Plastic Surgery Department of Rehabilitation Services Hospital for Sick Children Hospital for Sick Children Tel: (416) 813-6447 Tel: (416) 8 13-6755 Voice Mail 7-2

Information for Families

Title of Research Project: The Validity and Reliability of a Range of Motion Assessment of Smile for Children with Facial Palsy

Primary Investigator: Shawna Wade, MSc[candidate], BMR O.T. [Cl

Co-lnvestigatoa: Dr. R.T. Manktelow, Dr. R. Zuker, Dr. L. Mainwaring and Dr. C. Graveline

Purnose of the studv Facial palsy is a condition that affects how the muscles of the face work. Many children who have facial palsy have therapy to help them use their facial muscles. The changes seen as a result of therapy are hard to measure and the tool that is used m u t be accurate. The purpose of this study is to test a measurement tool and how well we use it.

What will hamen? If you agree to participate in this study, you will undergo two separate clinical assessments that will be CO-ordinated with your scheduled r e m visit to the Plastic Surgery Clinic a d o r Occupational Therapy. In the event you do not have a scheduled appointment, a mutuaily convenient assessment time will be ananged at the Hospital for Sick Children. The 30-minute assessments will be cornpleted one d e r the other, with a 15-minute break in between. The assessment will include, marking specific measurernent points on your face with a special pencil [the marks will wash o q , and measuring what your face is like when your are not smiling, and when you are smiling. M e r a break another therapist will complete the same assessrnent over again. This is done to make sure our resdts are accurate.

Benefits You and your child will help to improve our ability to measure facial motion in a more accurate way. You will make a significant contribution to the curent literature for very little has been devoted to children on this topic. This will assist the health care professionals to better understand the long-term resdts of therapeutic interventions for children with facial palsy.

mks - There are no hown hanns associated with participation in this study. By taking part in this study, you will undergo an assessment that will take approximately 1 hour to complete. You may become tired during the study and a rest period can be requested at any tirne. You can decide not to participate in the study at any the. This will not affect your treatment at the Hospital for Sick Children.

Letter of Response

Please place a checkmark in the appropriate response:

O 1 would older)

O 1 would

be interested in participating in this study (16 years or

like my child to participate in this study

O 1 am not interested in participating in this study

Telephone Number(s) where you may be contacted:

Home:

Business:

Comments:

Signature:

Date:

CONSENT FORMS

Consent Form For Participants 16 Years and Older

1 Name:

Date of Birth:

HSC #:

Title of Research Proiect: The Vaiidity and Reliability of a Range of Motion Assessment of Srnile for Children with Facial Palsy.

Investi~ator(s): Primary Investigator: Shawna Wade, MSc[candidate], BMR O .T. [Cl

Department of Rehabilitation Services: Division of Occupational Therapy Hospital for Sick Children [416] 813-6755

Co-Investigatoa: Dr. R.T. Manktelow Department of Plastic Surgery The Toronto General Hospital [416] 340-4800 ext. 6720

Dr. RI Zuker Division of Plastic Surgery The Hospital for Sick Children [41q 813-6447

Dr. L. Mainwaring Assistant Professor, Faculty of Physical Education and Health University of Toronto [416] 946-5134

Dr. C. Graveline Director, the Department of Rehabilitation SeMce The Hospital for Sick Children [416] 813-6755

XII

Purpose of the Research: Facial palsy is a condition that affects how the muscles of the face work. Many children who have facial palsy have therapy to help them use their facial muscles. The changes seen as a result of therapy are hard to rneasure and the tool that is used must be accurate. The purpose of this study is to test a measurement tool and how well we use it.

Description of the Research: If you agree to participate in this study, you will undergo two separate clinicai assessments that will be CO-ordinated with your scheduled retum visit to the Plastic Surgery C h i c andor Occupational Therapy. In the event you do not have a scheduled appointment, a mutually convenient assessment time will be arranged at the Hospital for Sick Chddren. The assessments will be completed one after the other, with a 15-minute break in between. The assessment will include, marking specific measurement points on your face with a special pencil [the marks will wash off], and rneasuring what your face is like when your are not smiling, and when you are smiling. After a break another therapist will complete the same assessment over again. This is done to make sure our results are accurate.

Potential Harms, Iniuries, Discornforts or Inconvenience: There are no known hamis associated with participation in this study. By taking part in this study, you will undergo an assessment that will take approximately 1 hour to complete. You may become tired during the study and a rest penod can be requested at any tirne. You cm decide not to participate in the study at any tirne. This will not affect your treaûnent at the Hospital for Sick Children.

Potential Benefits: You will not benefit directly fiom participating in this study.

You will help to irnprove our ability to measure facial motion in a more accurate way. You will make a significant contribution to the cunent literature for very little has been devoted to chilchen on this topic. This will assist the health care professiods to better understand the long- temi results of therapeutic interventions for children with facial palsy.

Confiden tialitv: Confidentiality will be respected and no information that discloses your identity will be released or published &thout consent unless required by law. For your information, the research consent fom wili be inserted into your health record.

Partici~ation: Participation in research is voluntary. If you choose not to participate, you and your family will continie to have access to quality care at HSC. If you choose to participate in this study you can withdraw fiom the study at any time. Again, you and your farnily will continue to have access to quality care at HSC.

Sponsorshi~: If you would like to know the source of funding, please discuss this with the investigator.

Consent : '1 acknowledge that the research procedures described above have been exphined to me and that any questions that I have asked have been a w e r e d to my satisfaction. I have been infirmed of the alternatives to participation in this study, including the right not to pmticipate and the right to withdraw without compromising the quality of medical care ut The Hospital for Sick Children for me and for other members of my family. As well. the potential harms and discornforts have been expkained to me and I also understand the benefts (if any) of participating in the research study. 1 know that I rnay ask now, or in the future, any questions I have about the study or the resemch procedures. I have been assured that records relating [O me and my care wilZ be kept confidential and that no information will be reZeased or printed thnt would disclmi? p2rsoizal &dzlr;is. witltour i i ~ ~ pémission urile~~s required by l m . "

I hereby consent to participate.

Name ofPatient and Age The Person who rnay be contacted about the research is:

Shawna Wade

who rnay be reached at telephone #: Signature (if1 6 yrs. or over)

Signature Name ofperson who obtained cornent

Date

Consent Form For Partichants less than 16 Years of Age

Name:

Date of Birth:

HSC #:

Title of Research Proiect: The Validity and Reliability of a Range of Motion Assessrnent of Smile for Children with Facial

Investi~ator(s): Primary Investigator: Shawna Wade, MSc [candidate], BMR O .T. [Cl

Depariment of Rehabilitation SeMces Division of Occupational Therapy Hospital for Sick Children [416] 813-6755

Co-Investigators: Dr. R.T. Mankteiow Department of Plastic Surgery The Toronto General Hospital [416] 340-4800 ext. 6720

Dr. R Zuker Division of Plastic Surgery The Hospital for Sick Children [416] 8 13-6447

Dr. L. Mainwaring Assistant Professor, Faculty of Physical Education and Health University of Toronto [416] 946-5 134

Dr. CI Graveline Director, the Department of Rehabilitation Service The Hospital for Sick Children [41q 813-6755

Purpose of the Research: Facial palsy is a condition that affects how the muscles of the face work. Many children who have facial palsy have therapy to help them use their facial muscles. n i e changes seen as a result of therapy are hard to measure and the tool that is used must be accurate. The purpose of this study is to test a measurement tool and how well we use it.

Descri~tion of the Research: If your child agrees to participate in this study, he/she will undergo two separate clinicai assessments that will be co-urdinated with a schedded r e m visit to the Plastic Surgery Clinic andor Occupational Therapy. In the event your child does not have a scheduled appointment, a m u W y convenient assessment time will be arranged at the Hospital for Sick Children. The assessments will be completed one d e r the other, with a 15-minute break in between. The assessment will include, marking specific measurement points on your child's face with a special pencil [the marks will wash off], and measuring what your child's face is like when he/she is not smiling, and when he/she is smiling. M e r a break another therapist will complete the same assessrnent over again. This is done to make sure our results are accurate.

Potential Harms, Iniuries, Discornforts or Inconvenience: There are no known harms associated with participation in this study. By taking part in this study, your child will undergo an assessment that will take approximately 1 hour to complete. Some children can become tired and your child may request rest penods at any tirne during the shidy. Your child can decide not to participate in the study at any t h e . This will not affect hisher treatment at the Hospital for Sick Children.

Potential Benefits: Your child will not benefit directly fiom participating in this study.

Your child will help to improve our ability to measure facial motion in a more accurate way. This information will make a significant contribution to the current iiterature for very linle has been devoted to children on this topic. This wili assis the health care professionals to better understand the long-term results of therapeutic interventions for children with facial palsy.

Con fiden tialitv: Confidentiality will be respected and no information that discioses the identity of your child will be released or published without consent unless required by law. For your information, the research consent form will be inserted into your child's health record.

Partici~ation: Participation in research is volmtary. If you or your child choose not to participate, you and your family wili continue to have access to quality care at HSC. If you choose on behaifof your child to participate in this study you c m withdraw your child fkom the study at any tirne. Again, you and your family will continue to have access to quality care at HSC.

Sponsorshi~: If you would like to know the source of fûnding, please discuss this with the investigator.

Consent: I acknowledge that the research procedures described above have been explained to me and thut any questions that I have asked have been answered to my satisfaction 1 have been Nifomed of the alternatives to participation NI this study, including the right not tu participate and the right to withdraw without compromising the quality of medical care at The Hospital for Sick Children for my child and for other mernbers of my family. As well, the potential harms and discornforts have been explained to me and 1 ulso understand the benefts (ïf any) of participating in the research study. I know that I may ask now, or in t h e f h r e , riny questions I have about the study or the research procedures. I have been assured that recordr relating to my child and rny child's care will be kept confidential and that no information will be released or printed ihat would discIose persund irlrntity without my permission unless required by law.

I hereby consent for my child to part icipate.

The Person whu may be contacted Name oflarent about the research is:

Shawna Wade

who may be reached at teiephone #: Signature

14167 813-6755

Nome ofperson who obtained consent.

Signature

Assent Form

Name:

Date of Birth:

HSC #:

Title of Research Proiect: The Validity and Reliability of a Range of Motion Assessrnent of Srnile for Children with Facia Palsy .

Investigator(s): Primary Investigator: Shawna Wade, MSc[candidate], BMR O .T. [Cl

Department of Rehabilitation Services Division of Occupational Therapy Hospital for Sick Children [416] 8 13-6755

Co-Investigaton: Dr. R.T. Manktelow Department of Plastic Surgery The Toronto General Hospital [416] 340-4800 ext. 6720

Dr. R. Zuker Division of Plastic Surgery The Hospital for Sick Children [416] 813-6447

Dr. L. Mainwaring Assistant Professor, Faculty of Physical Education and Health University of Toronto [4 161 946-5 134

Dr. C. Graveline Director, the Department of Rehabilitation Service The Hospital for Sick Children [416] 813-6755

Whv are we doing this studv? Children with facial palsy can not move the muscles in their face very well and many children have therapy to help them get better. It is very hard to measure how rnuch the children get better. The purpose of this project is to test a measuring tool and see how well we use it.

What wil1 happen during the study? If' you participate in this study, you will be seen by two Occupational Therapists at separate times. The assessment will include, marking specific points on your face with a special pencil [the marks will wash off], and measuring what your face is like when your are not smiling, and when you are smiling. Mer a break another therapist will complete the same assessment over again. This is done to make sure the therapists test the same.

Are there good things and bad things about the studv? We know of no bad things that will happen to you if you do this study. If you become tired you may ask for a rest penod at any tirne.

Who will know about what 1 did in the study? Only the people doing the study will know how you did. Your name or address will not be given to anyone.

Can 1 decide if I want to be in the study? Yes you can. If you do not want to be part of this study, that's okay, no one will be upset with you. You will still have your regular appointment with the doctor if you are here for an appointment at the Plastic Surgery Clinic. You can ask the therapist any questions that you have. He/she will try to answer your questions and help you to understand. If you Say yes now but change your mind later, that is okay. If you Say no, it d l not change the way you are treated at the Hospital for Sick Children.

Assent: "1 was present when read this form and gave hisher verbal assent."

Name of person who obtained

Signature

Date

ASSESSMENT PROCEDURES

Standard Protocol for the Administration of the Assessrnent

Procedure: Children will be tested one at a time by the two raters. The participants will be seated on a chair during the measurement. The room for measurement should be quiet and fiee from distractions. Only the rater, the child and hisher parent[s] should be in the roorn.

The rater will be seated directly in fiont of the child at the same eye level as the child. A picture poster will be placed on the wail facing the child to serve as a place for the child to focus while the rater identifies the landmarks [Part II]. The rater m u t record the results of each separate measurement immediately upon completing the measure on the data sheet [Part a* Script for testhg: I wanf to rneawe how much you can mi le with this new meamring tool. I am going to measure f i o m dzjjierent points onyour face and I will memure before you smile and then I will askyou to give me the biggest smile you cun and I will measure again. I am going to do this for both sides of your face. This will not hurt you.

Before I meanrre I would iike to phce a few srnail dots on your face like you see in this picture. We will wash these dots off when we are finished This helps me to mak sure thnt I measure the right spots. Pieme look struighr ahead at the poster on the wull. Now we are ready to measure.

Example of script for assessment: Lookstraight a k d ut me without smiling. I will memure fiom the corner of you mouth to your ear /@eTfm m e m e m e n t and record]. N w 0 to mi le as much as you c m and hold YOM srnile @er$brm the meawement and record]. ïE~hat good! Now lets do the same memrements on the other side ofyour face.

Table FI. Data Base: Range of Motion Assessment of Smile

Data Base: Reiiabiüty Study for the Range of Motion Assessment of Smile

Resting Position Maximal Srnile

Affected Side: Right Left L

Tragioo-Cornmisure Corner Mouth

Helü Point - Midlateral Upper Lip 1 d

HSC#: Unilateral Bilateral

"

Date: Rater:

RIGHT [mmJ (LEFT [mm J I

1 Resting Position 1 1 1

Diagnosis:

Previots Surgeries: I

Subject ID#: Date of Birth:

[ Maximal Smile -

I I l kentral Nose Point - Mid-lateral Lower Lip 1 -

Resting Position Maximal Srnile

l~istance of N/L from CCM 1

-- -

Restùrg Position Maximal Smile

Depth: Midpoint Nasal Labial Fold Resting Position (3 bids) / / 1 1 1 I

Deviation (R) = mm, (L) = mm Deviation (R) = mm, (L) = mm

1 MW Srnile (3 triais) I I I I I I

m

Ï%ction of Srnile Restiug Position Msucmial SmiIe

The Modified Hand HeId Cab per Tool with the Saegîtal Plane Level

1. Modified Outside Measuring Points 2. Digital Display 3. Platform Base 4. Telescoping Point 5. Saggîtal Plane Level 6. Battery Cornpartment Cover 7. Power OnIZero Switch S. Power off Switch

Data Base: Range of Motion Assessment of Smile - Follow-up Studv

bats Base: Reliabilitv Studv for the Rauee of Motion Assessrnent of Srnite 1

Restinpr Position Maximal Smile

Date: Rater:

epth: Midpoint Nasal La biai Fold 1 1

Subject ID#: Date of Birth:

[ Resting Position (3 trials) 1 1 1 / 1 , I

Direction of Smile Resting Position (3 trials) Maximal Smile (3 trials)

1 / 1 1 1 1 / / J

Primarv Reliabilitv Studv: Raw Data

Patient ID# #1

#2

#3 1

#

. #5

#6

#7

#8

#9

#10

# I l

#12

#-l3

TM T-CCM R 109.4 111.8 104.6 109.6 1 10.7 1 14.6 107.5 99.3

101.4 96.8

103.5 103.4 89.7 94.5 82.5 86.5 98.1 96.1

101.5 96.1

103.2 104.8 87.4 92.6

106.5 IO1 -5

Side R L R L R L R L R L R L R L R L R L R L R L R L R L

SW T-CCM R 112.8 113.5 112.8 107.9 110.3 1 13.9 105.7 104.6 105.2 102.8 105.9 104.2 96.6 95.4 85.5 88.3 100

101.2 102.7 96.2

108.6 1 07

87.1 94.2

105.2 100.9

(TM T-CCM M 107.5 94.2 86.4

109.1 110.9 96.9

100.6 79.3 90.3 80.9 94.6 91.9 80.9 82.9 74.3 76.6 81.4 83.2 85.1 79.7 99.5 86.3 80.4 75.5 94.4 89.6

SW T-CCM M 106.9 96.6 95.3

1 10.2 113.1 95.9 101

83.6 90.6 84.7 95.1 93.3 78.6 82.7 73.4 74.9 83.2 87.8 82.6 77.8 101

87.5 79.8 78.9 95.7 88.4

Patient ID# #1

1 #2

1

#3

#4

#5

#6

#7

#8

#9 -

#IO

SW HP-MUL 122.4 116.8 108.4 11 3.6 133.1 11 8.7 123.5 106.3 11 5.1 98.8

122.3 1 15.2 106.8 109.1 88.1 88.8

108.6 11 0.5 101.8 103.8 113.8 107.4 103.4 106.9 114.4 106.9

Side R L R L R L R L R L R L R

M-TM HP-Mm R 126.9 129.1 1 15.2 114.8 136.2 132.2 124.1 1 17.7 1 19.8

SW HP-MUL Fi 127.3 127.3 11 9.4 1 13.3 134.2 129.8 124.9 121.6 122.5 1 14.4 127.1 125.1 1 12.4

TM HP-MUL M 123.5 119.8 103.9 1 17.8

132 121.1 125.9 105.2 114.2

1 10.7 124

122.2 106.5 112.1 119.9 1 13.9

L #11 )R

IL

L R L R L

IR

#12

#13

111.8 123.4 125.2 107.6 112.1 99.7 99.7

114.2 1 14.4 1 16.6 1 12.6

118 121.1 103.3 107.9

115 107.7

112.9 98.8 102

,. 1 14.6 1 19.9 114.9

R L R L

102.7 1 19.6 108.6 103.3 1 10.2 95.7 94.5

109.2 112.3 101.5 108.1 110.6 106.8 3 03.9 100.7 111.1

99

,

SW CNP-ML1 M 78

74.7 94.2 97.3 77.4

TM CNP-MLL R 81.6 77.8 95.7

104.6 75.3

TM CNP-MLL M 77.4 71 .7

103.4 102.7 75.4

SW CNP-ML1 R 81.1 78.3 98.6

101.7

Patient ID# #1

#2

83.1 83.8 82.3 71.2 69.3

74 83.6 80.5 68.1 70.6

Side R L R L

#4

#5

82.1 82.9 81.3 66.3 73.4

#3 R 1 81.3

##6

#7

#8

#9

# l O

#11

#12

#13

L 1 80.7 R 1 87 L 1 87 R L

72.3 68.9 63.6 64.8 54.3

68.9 69.2

R L R L R L R L R L R L R L R L

72.3 72

61.3 61.8

53

73.6 73.4 60.3 60.1 56.9 60.8 74.1 73.1

70 66.1

72 72

74.7 72.8

61 62.8

68 67.5 65.4 60.6 58.2

60.1 65.7

66 70.9 68.1 73.2 79.3 79.1 79.6

65

58.1 73.5 69.8 68.4 68.3

70 68.8 74.9

73 63.8

62.1 65.8 63.6 72.4 67.3 73.5 76.8 77.1 78.8 65.9

- 66 1 62.6 67.2

LIP DROOP (FROM HORIZONTAL LME - COMMISURE CORNER OF THE MOUTH (REsTING AND MAXIMAL SMILE M MM.)

Patient Iû# #1

#2

#3

#4

#5

##6

#7

#a

#9

#10

#11

#12

Side R L R L R 1 R L R L R L Fi L R L R L R L R L , R L

SW Lip Droop R -3 -3

10.5 -1 7 -5 -2 O O

-2 O -2 -3 -3 4 O O -2 O 1 O 2 2 -3 -2 -4 -3

SW Lip Droop M -3 10 5

-1 0 -5 10 3 10 5 15 3 4 9 4 8 7 8 9 8 6 2

14 2 4 7

10

TM Lip Droop R 4 O 10 -1 3 -9 2 O O

-3 O -4 O -2

- -2 -2 O

-2 -2 O O 2 O

-3 -3 -7 -2

#13

TM Lip Droop M -2 13 2

-12 -6 10 4 10 9 13

O 8 9 4 9 8 19 11 10 8 4

12 O 7 5

10 R

1 L

WLME OF INCISORS - PHILTRUM (REsTING AND ~ ~ A X M A L SMILE IN MM.)

Patient ID# Side SW Philtntm R SW Philtrurn M TM Philtnim R TM Philtnim M #1 R O O O O

L 1 O 2 2.2 3.3 #2 R 1 O 8 O 8

L 1 2 1 O 3 O #3 Fi 3 O O O

L O O 2 II #4 R 5 5 3 4.2

L O O O O

DIRECTION OF S ~ E (RESTMG AND MAXMAL SMLE iN DEGREES)

Patient ID# SidelSW Nlf Dpth R SW Nlf Dpth M ITM Nlf Dpth R !TM Nlf Dpth M # l R 7.5 10.21 5.7 1 10.3

L 8.3 14 6.6 11.5 #2 R 5.5 12.4 12.5 18

L O O O O #3 fi 1.9 1.9 2.2 2.5

L 1 9.81 16.2 4.4

DISTANCE OF NASOLABIAL FOLD FROM THE COMMIUSRE CORNER OF THE MOUTH (RESTING AND MAXIMAL SMILE M MM.)

Patient ID# Side SW CCM-NLF TM CCM-NL

5.7

Foilow-Up Reliabilitv Study: Raw Data

TRAGION - PHILTRUM (REsTING AND MAXIMAL S ~ E M MM.)

TM T-Phil M 129.5 128.9 128.4 127.3 138 1 34

140.2 138.8 139.2 137.4 11 9.7 123.2 121

120.7 121.5 121.9

TM T-Phil R 131.4 132.9 136.8 135.6 141.6

- Staff ID# #l

#2

#3

#4

#5

#/6

#7

SW T-Phil M 127.7 129.3 130.7 129.5 137

Side R L R L R

SW T-Phil R 133.1 132.2 137.9 137.7 142.7

L R 1 R L R L R L

141.1 140.1 138.2 144.8 144.7 126.4 127.8 124.2 125.3

134.6 1 140.6 138.21 143.4

129 126.3

135.7' 145

144.7 125.7 123.9 120.4 121.9 125.3 122.7.

#8

142.2 143.7 142.5 122

123.6 122.8 122.5 124.9 122.3=

R L

J

DIRECTION OF S ~ E (RESTING AND MAXIMAL SMLE DEGWS)

DEPTH OF THE NASOLABIAL FOLD (MAXIMAL SMILE IN MM.)

Staff ID # # l

#2

Side R L R L

1 311 411 4 1 2/10111 31515 4/5/6 1 511 611 4 1 311 511 7 18ll7ll6 17/18/17 i

TM Dir M 1 U10111 14/15/16 911 O11 O 81918

.

#3

#4

TM Dir R . -51-51-6 4-51-3 41-51-51 -41-51-4

SW Dir R -3/-3/-4 -8/-6/06 -21-2l-2 4-41-3

R L R

OlO/O ZIZI2 0/0/2 Z3/2 -41-41-3

SW Dir M 27119123 1 912012 1 1211 311 3 1 1 1 1 17/18/17 1 811 611 7 8191 1 4 91911 4 1 511 5122 #5

#6

O/-11-1 01-1 /O -51-61-4 4 / 4 5 -51-41-5

L R L R

-41-51-6 O/-110

i 1 L 1

-2l-U4 5/46 51415 1 23/20/18 1 O/O/O 1

' 16/17/20 17115/18