prosthodontic management of CD patients with unilateral facial paralysis case report

1. P R E S E N T E D B Y
B R A V I
Prosthodontic management of a
completely edentulous patient with
unilateral facial paralysis
- case report
The Journal of Indian Prosthodontic Society |
October 2007 | Vol 7 | Issue 4
Saumya Pandey, Kusum Datta Department of
Prosthodontics, Punjab Government Dental
College, Amritsar, India

2. CONTENTS
 INTRODUCTION
 BELL’S PALSY
 FACIAL MUSCLES THAT AFFECT DENTURE STABILITY
 PROSTHETIC MANAGEMENT
 DISCUSSION
 CONCLUSION
 REFERENCES

3. INTRODUCTION
 Paralysis is defined as a temporary suspension or a
permanent loss of function. Facial paralysis has a
multitude of etiologies such as immune or viral diseases
(herpes zosteroticus), trauma (iatrogenic, accidental),
ischemia of nerve (neoplasms) or idiopathic (Bell’s
palsy).

4.  In the prosthodontic management of facial paralysis,
the general principles of complete denture design are
essentially the same; the disorder does affect the
design of particular surfaces or parts of denture.

5. What is BELL'S PALSY??
a condition in which the muscles on one side of your
face become weak or paralyzed. It affects only one
side of the face at a time, causing it to droop or
become stiff on that side. It's caused by some kind of
trauma to the seventh cranial nerve

6.  Facial paralysis is due to a lesion of the facial motor
nucleus or of the nerve

7.  A lower motor neuron lesion:
 All the muscles of the same side of the face are
affected.(There may also be inadequate lacrimal or
salivary secretion, or a localized taste deficit,
depending on the exact location of the lesion.)

8. An upper motor neuron lesion:
 Affects only the lower half of the contra-lateral side
of the face

9. Types
A). Temporary
 Most common
 Lasts for weeks to months only
 Recovers but can reoccur
 Causes includes:
 viral infections, ear infections, high B.P. Diabetes,
headaches, traumatic.

10. B). Permanent
 Less common
 Considered when lasts for more than 9 months
 Causes includes
 birth trauma, major damage to the nerve due to trauma,
laceration etc

11. Clinical features
 Facial asymmetry
 Inability to close eye
 Uncontrolled tearing
 Drooping of corner of
mouth
 Loss of forehead & naso
labial folds
 Lips not held tightly
together : Difficulty
keeping food in mouth
 Difficulty in keeping food
on occlusal table

12. Other signs and symptoms
• Pain or discomfort in
jaw
 Headache
 Dizziness
 Dryness of eyes
 Loss of taste
 Dryness of mouth and
Impaired speech
 Difficulty in eating
and drinking
 Ringing in the ear
 Hypersensitivity to
sound

13. Examination of facial Nerve
 Show the teeth
 Open mouth— compare nasolabial folds
 Close his eyes
 Wrinkle forehead
 Raise eyebrows
 Bare his teeth and open his mouth
 Blowing out cheeks
 Pursuing the lips

14. Investigations
 Enhancement of the facial nerve on gadolinium
enhanced MRI
 Increased lymphocytes ,mononuclear cells in CSF.
 Other tests
 Tensilon test
 Shirmer test
 ESR
 Blood glucose levels

15. PROSTHETIC MANAGEMENT
The facial muscles which are affected include:
 Occipitofrontalis
 Procerus
 Nasalis muscle
 Depressor septinasi
 Orbicularis oculi
 Corrugator supercilii
 platysm

16. Facial muscles that affect denture stability
 Buccinator
 Orbicularis oris
 Levatorangulioris
 Depressor angulioris
 Mentalis

17. BUCCINATOR MUSCLE:
Importance in recording
 Maxilla:
 Mandible:

18. ORBICULARIS ORIS:
Importance in recording
 Maxilla:
 Mandible:

19. LEVATOR ANGULI ORIS:
Importance in recording
 Maxilla:

20. DEPRESSOR ANGULI ORIS:
Importance in recording
 Mandible:

21. MENTALIS:
Importance in recording
 Mandible:

22. CASE REPORT
 A patient has been suffering from bell's palsy on the
right side for the last one year visits your clinic as he
wants a denture. How this condition would affect your
treatment protocol??

23.  Initial & Final Impression Recording
 Conventional technique for making primary and
final impressions is followed except that excessive
material is incorporated on the left side that is the
affected side

24.  Recording Neutral Zone
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

25.  Thus the polished surface of denture base was
contoured by functions of the tongue action,tonus of
affected and unaffected lips and cheek

26. Also known as “zone of minimal conflict” or “Dead
Space”
 The zone where the cheeks, lips and tongue are in
maximal harmony with the dentures
 That is the teeth in the denture must occupy the
same position as there natural predecessors
 The inward forces by the lips and cheeks should be
balanced by the outward forces by the tongue

27.  A plaster index was fabricated to duplicate the
contour of polished surface in trial denture

28. Occlusal wax Rims
 Midline placed in the middle of the oral cavity rather
than the facial midline

29. Teeth Set-up
 Teeth are arranged according to the neutral zone
matrix
 Non anatomic posterior teeth are used to establish
the centric occlusion

30. Some improvement of the appearance can be achieved
by:
 1. Placing the mesio-incisal point in the middle of the
mouth rather than the middle of the face
 2. keeping the cant of the occlusal plane on the left
side a little low for incisal show

31.  Buccal sulcus support
 Placing buccal support on the left side to reduce the
facial droop
 This will also help reduce the accumulation of food
in the affected buccal vestibule

32.  Finally
 Dentures are processed and inserted
 Pateint's satisfaction

33. DISCUSSION
 Facial palsy is indicative of neurological
involvement. Patients with this disease can be
treated but it is essential that they understand their
problems. Denture retention, maxillomandibular
relation records and supporting the musculature are
some of the added denture problems.

34.  The finished prosthesis had a shifted midline and
canting of occlusal plane to enhance esthetics.
Flaccid facial muscles needed support and this was
done by adding wax and then acrylizing it, The
additional material could be easily added since
muscular force exerted against it by the paralyzed
muscle and tissues were no longer a deterrent factor.

35.  It was important that the remaining oral structures
be maintained in a state of good health so that the
prosthesis lasts longer. Use of nonanatomic posterior
teeth minimizes the damage to the denture
supporting tissues

36.  Since the food accumulates on the paralyzed side,
the patient was instructed to maintain the hygiene of
the prosthesis and oral cavity. Regular gum massage
was advised to maintain the supporting tissues in a
state of good health.

37. CONCLUSION
 The denture prosthesis should fulfill its basic
objectives of restoration of function, restoration of
facial appearance and maintenance of health of
remaining oral tissues.

38.  Various steps of denture fabrication were
methodically executed and modified with respect to
the abnormal conditions in an attempt to enhance
esthetics, function and self image of the patient and
to improve the prognosis of treatment.

39.  References
 Designing Full Dentures by Watt and Mac Gregor
 Prosthodontic treatment of edentulous patients by
Zarb-Bolender
 Jay pee text book of Prosthodontics by Nallaswamy
 Prosthodontic management of complete edentulous
patients with neuromuscular disorders -Case reports
(Suresh S Vipul Asopa)
 Pictures from e-net and books