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J. Adv Dental Research CASE REPORT

All Right Res

Journal of Advanced Dental Research VolII : Issue I: January, 2011 www.ispcd.org

Prosthodontic management of complete

edentulous patients with neuromuscular

disorders - Case reportsSuresh S* VipulAsopa**

*M.D.S, Professor and Head, **Post Graduate Student, Department of Prosthodontics, Darshan Dental

College, Udaipur, Rajasthan, India. Email: [email protected]

Abstract:

Management of complete edentulous patients suffering

neuromuscular disorders like cerebral ataxia, unilateral

facial paralysis etc is challenging task and requires

modification of traditional techniques of complete

denture construction. This clinical report addresses the

difficulties encountered and its prosthodontic

management with modification in clinical procedures.

Keywords:cerebral ataxia, neuro muscular disorder,

prosthodontic managment

Introduction:Patient who seek complete denture treatment commonly

belongs to the old age with compromised medical health.

The impairment in stomatognathic functions like

mastication, deglutition, speech and esthetics are further

compounded by compromise in systemic health status of

the patient. The recognition and diagnosis of systemic

related conditions, lesions and anomalies are componentsof history-examination process, essential in planning

complete dentures treatment and estimate of prognosis. The

clinical technique of complete denture construction is

challenging task and requires modifications if patients

suffer from various neuro-muscular disorders such as

facial paralysis, cerebral ataxia, bells palsy, acoustic

neurinoma, myaesthenia gravis1,2

etc.

The purpose of this article is to describe symptoms and

management of complete edentulous patients suffering

from neurological disorders like unilateral facial paralysis

and cerebral ataxia.

CASE 1

Complete edentulous patient suffering from unilateral

facial paralysis.

A 62 year old completely edentulous male patient reported

with facial paralysis of right half of the face to theDepartment of Prosthodontics, Darshan Dental College,

Udaipur with complaint of inability to chew food since two

years.

Extra-oral clinical examination revealed facial

asymmetry with reproducible left side mandibular deviation

during mouth opening. Patient was unable to close his right

eye completely ,unable to blow air from mouth, unable to

lift his right eyebrows indicative of unilateral facial

paralysis of right half of the face. [Fig1and Fig 2] There

was no impairment of speech and lips were competent at

rest. Intra-oral examination revealed well-formed maxillary

and mandibular completely edentulous ridges in class Irelationship.

Neuro-muscular function and coordination are foundation

for successful and stable dentures. Failure to diagnose

importance of flange contour and teeth position in facial

paralysis patients often leads to unstable dentures. The

force exerted on external surface of the teeth and polished

surface are horizontal in direction. The stability of the

denture is affected by fit of the impression surface and

direction, magnitude of forces transmitted through polished

surface. Hence in unilateral facial paralysis patient, it is

essential to record neutral zone because of imbalanced

forces generated by unaffected and affected side causing

instability in dentures.3,4

Conventional technique for making primary and

final impressions was followed. A stable denture base was

constructed on master cast and compound rim were

attached. After initial adjustment of occusal plane

according to aesthetics and phonetics, compound rim was

softened and patient was encouraged to do functional

movements such as swallowing, sucking, pursing lips.[

Serial List ing: Print ISSN(2229-4112)

Online-ISSN (2229-4120)

Bibliographic Listing: Indian National Medical

Library, Index Copernicus, EBSCO Publ ishing

Database,Proquest., Open J-Gate.

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Journal of Advanced Dental Rese

Fig3] Thus the polished surface of

contoured by functions of the tongue a

of affected and unaffected lips and che

A plaster index was fabricate

contour of polished surface in trial d

arranged according to the neutral z

anatomic posterior teeth were used to

occlusion. Dentures were processed an

Figure 1 Patient showing ptosis on rig

corner of the mouth towards unaffec

wide .

Figure 2 Patient in effort of smiling.

rch VolII : Issue I: January, 2011

denture base was

d action and tonus

ks.[ Fig 4]

d to duplicate the

entures. Teeth were

one matrixand non

establish the centric

inserted and

t half and drooping

ed side on opening

Figure 3 Recording Neutral zo

Figure 4 Mandibular record

impression compound moulded

Figure 5 Neutral zone comp

patient tried to contract his faci

68

www.ispcd.org

ne.

base with modeling plastic

to patients neutral zone.

lete dentures in situ while

al muscle to show his teeth

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Journal of Advanced Dental Rese

Figure 6 Preoperative Photograph

Figure 7 Supine head position and

between ribcage and forarm.

Figure 8 Four fingers of both hand o

mandible.

rch VolII : Issue I: January, 2011

atient head cradled

ver lower border of

Figure 9 Bracing mandible w

of the mandible and thumb abo

Figure 10 Maxillary and Mandmetal mesh reinforced.

Figure 11 Completed rehabil

mandibular complete denture.

69

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th little finger behind angle

ve symphysis.

bular complete denture with

itation with maxillary and

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patient was educated about oral and denture hygiene

maintenance.[ Fig 5]

Modification of removable prosthesis to prevent epulis has

been suggested by various authors. Steven J. Larsen et al5

recommended additional thickness of denture borders to

provide support for affected side to improve speech and

esthetics for patients suffering from unilateral facial

paralysis.

CASE 2

Complete denture patient suffering from cerebral

ataxia

Ataxia means without order or Loss of coordination.

Ataxia is a condition in which there is gait impairment,

unclear speech ,visual blurring, hand in coordination,

tremors with movement resulting from involvement of

cerebellum & its afferent & efferent pathway including

spino cerebellar pathway &fronto ponto cerebellar

pathway.

Signs and symptoms may include: Poor coordination

patient may show unsteady walk and tendency to stumble,

difficulty with fine-motor tasks such as eating, writing or

buttoning a shirt, change in speech, abnormal eye

movements, difficulty swallowing. Intentional Tremor

is most prominent during voluntary movement toward

target and it is less at rest. Finger nose test is positive is

typical feature of hereditary ataxia, Cerebellar ataxic gait

is broad based gait in which the speed and length of strides

varies irregularly from step to step, as in alcoholic (posture

is erect but feet are separated), Nystagmus-involuntary

movements of the eyes, Titubation - nodding of head

anterior posterior direction, Dyssynergia -

small,jerky,clumsy movements,Dysmetria- inability toarrest the movements at desire point, Dysarthria - slow ,

slurry , irregular, scanning type speech. 6,7,8,9

A 62 years old women was referred to Department

of prosthdontics, Darshan dental college, Udaipur with a

complain of missing teeth and desires to get them replaced.

Patient gave medical history that she was suffering from

cerebral ataxia since 8 years and patient was

psychologically depressed as she was unable to eat with

previous dentures.(Fig. 6)

Examination reveals patient walk was affected, patient had

reeling gait with severe tremors and titubation, patient had

slow slurred scanning type of speech, nose finger test waspositive which reveals intentional tremors -Dyssynegia sign

was present.

Past denture history revealed patient was treated

with complete dentures, but she complained unable to wear

dentures and difficulty in mastication. Inability to wear and

remove dentures, difficulty in mastication, broken

maxillary denture showed patients lack of coordinated

motor skills Dysmetria and Dyssynergia, in managing

dentures.

Extra oral examination revels symmetrical facial

profile with competent lip and loss of cheek support, with

tremors of head at movement and also at rest. Intra oral

examination revealed completely edentulous upper and

lower arch. Maxillary and Mandibular ridges were smooth

& well-formed covered with firm mucosa , palatal vault

was shallow U shaped with House Class 1 hard and soft

palate relation. Tremors were evident on tongue and

mandible.

The patients chief complaint was impaired

mastication due to inadequate retention and stability of her

existing dentures. Approach for complete denture

treatment started with proper education and training for

removal and insertion of dentures, non anatomic teeth as

occlusal scheme, high strength heat cure resin as denture

base material with metal mesh reinforcement.

Because of intentional tremors, while making

impression patient was seated in upright position and head

was properly supported and care was taken to steady the

mouth in head supported position. Standard protocol for

primary and secondary impressions were followed, but

ensured upright position with head support while making

impressions. Medium body polyether material was selected

for final impression because of viscosity and good control.

Denture base and occlusal rims are prepared, maxillary and

mandibular occlusal plane were adjusted according to

aesthetics and phonetics.

Due to unstable mandible, there were difficulties in

recording resting position and centric relation of mandible.

It was challenging task to record accurate jaw relations.Patient was repeatedly asked to swallow and relax and most

consistent measurements were considered for vertical

relations.

Dawsons bimanual manipulation10

was used to

record centric jaw relation. Centric jaw relation was

recorded at supine position, at this position patient was

more relaxed, tendency for protrusion is prevented and it is

easy for operator to stabilize and guide the

mandible.Patients head was cradled between ribcage and

forearm and was stabilized with firm grip to manipulate

mandible.(fig 7) Thumbs were encircled symphysis region

to form C and mandible was manipulated in centricposition (Fig 8 and Fig 9). Midline was marked with help

of assistant. On repeated guidance, centric closure was

confirmed and centric relation was recorded using nick and

notch technique using elastomeric bite registration paste.

Anterior teeth arrangement was done according to

patient aesthetic needs and non-anatomic teeth were

selected to develop occlusal scheme. After final evaluation

of wax denture, processing is done using high strength

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acrylic resin, maxillary denture was reinforced with metal

mesh and mandibular with incorporating stainless steel

wire (Fig 10).

At denture insertion appointment patient was

encouraged and trained to hold dentures, insertion and

removal of dentures and denture hygiene manoeuvres(Fig

11). Patients progress was monitored at regular recall

appointments.

Discussion:

Neuromuscular disorders are common among aged

population and it is important to recognise clinical

manifestations of these disorders and derive treatment

planning, which otherwise might lead to failure of

treatment. Aim of this article was to describe

manifestations of Neurological disorders and its influence

on various stages of complete denture construction.

Complete denture prosthesis in patients who suffer from

neurological disorders is complicated by several problems.

Advanced age; Most patients are elderly, loss

of oral sensitivity, degenerative changes in

supporting structures are contributory to poor

prognosis.

Impaired neuromuscular balance affecting

denture stability.

Tremors, lack of coordination and unstable

jaw position require different skill while

recording impressions and jaw relations.

Uncontrolled tremors of mandible and tongue

may lead to prosthesis instability.

Dysmetria may lead to accidental falling of

dentures while insertion and removal ofdentures.

Conclusion:

Complete denture patients may present with various

neuromuscular disorders. Planning complete denture

treatment is challenging task, which requires modification

of clinical procedures. If precautions are taken at every step

during denture fabrication, a functionally acceptable

denture can be delivered. This paper has emphasized care

and modifications of various clinical procedures for

patients with neuromuscular disorders.

References:

1. Prosthodontic management of a patient with

neurological disorders after resection of an

acoustic neurinoma: A clinical report :Hercules C.

Karkazis, J Prosthet Dent 2002;87:419-22.

2. Management of patients with myasthenia gravis

who requires maxillary dentures :William K.

Bottomley et al; J Prosthet Dent 1977;38:609-14

3. The neutral zone in complete dentures :Victor E.

Beresin, DDS, and Frank J. Schiesser, DDS J

Prosthet Dent 1976;36:357-67

4. Using the neutral zone to obtain

maxillomandibular relationship records for

complete denture patients :Stephen G. Alfano,

DDS, LCDR, USNR, and Richard J. Leupold,

DDS, CAPT, USN J Prosthet Dent 2001;85:621-3

5. Prosthetic support for unilateral facial paralysis :

Steven J Larsen,John F carter, Hratch A.

Abrahamian ; J Prosthet Dent 1976;35:192-201

6. William R. Laney .Oral manifestation of systemic

disease. William R. Laney and Joseph Gibilisco,

In. Diagnosis and treatment in prosthodontics,

Philidelphia, Lea and Febiger,1983 : page no 73-

111

7. Roger N. Rosenberg. Ataxic Disorders. In, T.R

Harrison volume 2. Principles of internal

Medicine, 15th International Edition. New Delhi,

McGraw Hill company, 2003; page no 2406.

8. Richard k. Olney, Michael J. Weakness, Myelgia,

Disorders of Movment, and Imbalance. In, T.R

Harrison volume 1. Principles of internal

Medicine, 15th International Edition. New Delhi,

McGraw Hill company, 2003; page no 119.

9. Arupkumarkundu. Short cases cerebellar disorders

In, Arupkumarkundu Bad side clinics in Medicine

part 1,5th Edition, Kolkata, Academic publisher,

2006; page no 284-288.

10. Determining centric relation. In, Peter E.

Dawson,functional occlusion ; from TMJ to smile

design. Missouri, 2007 ;page no 75-84.

Source of Support: Nil

Conflict of Interest: Not Declared

Received: October 2010

Accepted: December 2010

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