J.

Adv Dental Research All Right Res

CASE REPORT

Prosthodontic management of complete edentulous patients with neuromuscular disorders - Case reports
Suresh S* VipulAsopa**
*M.D.S, Professor and Head, **Post Graduate Student, Department of Prosthodontics, Darshan Dental College, Udaipur, Rajasthan, India. Email: drsuresh72@gmail.com 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 components of 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 the Department 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 I relationship. 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 Listing: Print ISSN(2229-4112) Online-ISSN (2229-4120) Bibliographic Listing: Indian National Medical Library, Index Copernicus, EBSCO Publishing Database,Proquest., Open J-Gate.

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Fig3] 3] Thus the polished surface of denture base was contoured by functions of the tongue and action and tonus of affected and unaffected lips and cheeks.[ eeks.[ Fig 4] A plaster index was fabricated to duplicate the contour of polished surface in trial dentures. Teeth were arranged according to the neutral zone matrixand non anatomic posterior teeth were used to establish the centric occlusion. Dentures ntures were processed and inserted and

Figure 3 Recording Neutral zone.

Figure 1 Patient showing ptosis on right half and drooping corner of the mouth towards unaffected side on opening wide .

Figure 4 Mandibular record base with modeling plastic impression compound moulded to patients neutral zone.

Figure 2 Patient in effort of smiling.

Figure 5 Neutral zone complete dentures in situ while patient tried to contract his facial muscle to show his teeth

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Figure 6 Preoperative Photograph

Figure 9 Bracing mandible with little finger behind angle of the mandible and thumb above symphysis.

Figure 7 Supine head position and patient head cradled between ribcage and forarm.

Figure 10 Maxillary and Mandibular complete denture with metal mesh reinforced.

Figure 8 Four fingers of both hand over lower border of mandible.

Figure 11 Completed rehabilitation with maxillary and mandibular complete denture.

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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 Dyssynergia anterior posterior direction, small,jerky,clumsy movements,Dysmetria- inability to arrest 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 was positive 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 centric position (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 of dentures. 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 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 73111 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 3.

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Journal of Advanced Dental Research VolII : Issue I: January, 2011

www.ispcd.org