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Mathematical Validation of the Modified Sunnybrook Facial Grading System Using Four-dimensional Imaging.

Mahmoud A Alagha1, Xiangyang Ju2, Stephen Morley3

  • 1Scottish Craniofacial Research Group, Glasgow Dental Hospital & School, University of Glasgow, Glasgow, United Kingdom.

Journal of Plastic and Reconstructive Surgery
|May 19, 2025
PubMed
Summary
This summary is machine-generated.

A modified Sunnybrook facial grading system shows high reproducibility and mathematical validity for assessing dynamic asymmetry in unilateral facial palsy. This tool is effective for most facial expressions, aiding clinical evaluation.

Keywords:
4D imagingclinical indexdynamic asymmetryfacial palsystereophotogrammetry

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Area of Science:

  • Medical Imaging and Biomechanics
  • Facial Reanimation and Plastic Surgery

Background:

  • The Sunnybrook facial grading system is widely used for evaluating facial palsy, despite known limitations in its validity.
  • Dynamic facial asymmetry in unilateral facial palsy requires objective and reproducible assessment methods.

Purpose of the Study:

  • To modify and mathematically validate the Sunnybrook facial grading system for assessing dynamic asymmetry in unilateral facial palsy.
  • To compare objective, mathematically derived measurements of facial asymmetry with subjective clinical grades.

Main Methods:

  • A modified Sunnybrook facial grading system was developed with enhanced descriptive parameters.
  • Three-dimensional video analysis and advanced geometric morphometrics quantified facial asymmetry in 16 patients and controls across six expressions.
  • Seven assessors graded facial asymmetry using the modified index, with inter- and intra-observer reliability assessed.

Main Results:

  • The modified Sunnybrook index demonstrated high inter- and intra-observer reproducibility (r = -0.8).
  • Significant positive correlations were found between clinical grades and mathematical measurements for rest, maximum smile, lip purse, and eyebrow raising.
  • Correlations were poor for cheek puff and forceful eye closure expressions.

Conclusions:

  • The modified Sunnybrook grading index is a reproducible and mathematically valid tool for assessing unilateral facial paralysis in most expressions.
  • The system's utility is limited for grading cheek puff and forceful eye closure due to poor correlation with objective measures.