MAXILLOFACIAL PROSTHETICS TEMPOROMANDIBULAR JOINT DENTAL IMPLANTS

I. KENNETH ADISMAN, Section editor

Prosthetic
Steven Hratch

support

for

unilateral

facial
Ph.D.,** and

paralysis

J. Larsen, D.D.S.,* A. Abrahamian,

John F. Carter, D.D.S.***

Veterans

Administration

Center,

Martinsburg,

W. Vu.

urgical approaches to improving effects of permanent facial paralysis have been extensively described.l-lo Prostheses have been proposed to support facial musculature during the recovery phase of Bells palsy .l*-17 A combined approach utilizing surgery and mechanical support has also been reported. Is, I8 However, little has been written concerning palliative treatment of patients with permanent facial paralyses for whom surgery is contraindicated or has been unsuccessful. The purpose of this article is to describe and evaluate a method of palliative treatment and its effect on facial appearance and speech. Two patients were treated -a dentulous patient (C. B.) and an edentulous patient (N. B.) . Methods of treatment and results were so similar that they are combined, and only minor differences will be noted.
DESCRIPTION OF PATIENTS

Two middle-aged men with unilateral facial paralysis were referred to the Dental Service by the Audiology and Speech Pathology Service (Figs. 1 and 2). The speech pathologist had noted in both patients a moderate dysarthria characterized by imprecise consonant sounds, harsh voice, change in vocal pitch, and disturbance in the rate and flow of speech. Fricative, affricate, some plosive, and combinations of consonant sounds were primarily involved. Both patients were experiencing significant difficulty with the bilabial plosive sounds (p, b) and the labiodental fricative sounds (f, v) because of the buccolabial insufficiency causing restricted lip activity. However, definite improvement in intelligibility of sounds could be obtained
*Idaho Falls, Idaho. **Chief, Audiology and Speech tinsburg, W. Va.; Clinical Associate

Pathology Professor,
Veterans

Service, Veterans Administration West Virginia University, School

Center, Marof Dentistry,

Morgantown,

W. Va.; Lecturer,

West Virginia

University,

Extension Credit Program.

Center; of Dentistry, Associate Professor, DeWashington, D. C.

***Consultant to Dental Service, partment of Prosthodontics, Georgetown 192

Administration University, School

Support

for unilateral

facial

paralysis

193

Fig. Fig.

1. Patient 2. Patient

C. B. at rest without N. B. at rest without 4. Manual elevation

a prosthesis. a prosthesis. of paralyzed musculature provided improvement il n speech

Figs. 3 and sounds.

through manual elevation of the paralyzed facial tissues (Figs. 3 and 4) . The I Dental Service was asked to determine if an oral prosthesis could be constructed whicl !r would provide this elevation. Neither patient desired further surgery. However, both were told that plan itic procedures were available that had been successful in improving effects of facial paralySlI,.

194

Larsen, Carter, and Abrahamian

J. Prosthet. February,

Dent. 1976

Fig.
acrylic

5. The cast resin.

framework

contains

a buccal The

attachment maxillary

to support denture will

modeling be used

compound to provide

in sup-

Fig.
port

6. Heat-cured acrylic resin for the paralyzed tissues.

dentures.

Fig. 7 and 8.

Intraoral-extraoral

modifications

with

stainless

steel

wire

loops.

METHODS Construction

of the supporting

prostheses

A traditional approach was used to fabricate a cast cobalt-chrome alloy removable frarneworkzo with a labial plastic attachment for C. B. and heat-curing acrylic resin complete denture?l for N. B. (Figs. 5 and 6). By the addition of red stick modeling compound, these prostheses were easily modified so that the patients could use them, and the effects of the modifications were evaluated weekly. In this manner, the most functional and esthetically acceptable restoration to support the facial musculature and improve speechwas determined.

Volume Number

35 2

Support

for unilateral

facial

paralysis

195

Fig.

9. Intraoral

modification

with

modeling

compound

provided

support resulted

for the cheek. in no tension on the

Fig. 10. Use of intraoral modification vestibular fornix. Only the thickness

with modeling compound of the denture was modified.

i__

Figs. port.

11 and

12. Intraoral

modifications

with

modeling

compound

resulting

in distosuperior

sup-

Figs. 13 and support.

14. Intraoral

modifications

with

modeling

compound

resulting

in mediosuperior

1%

Larsen,

Carter,

and Abrahamian

J. Prosthet. February,

Dent. 1976

Fig. 15. The intraoral-extraoral loop has elevated the commissure Fig. 16. The intraoral-extraoral

appliance is in place. Note that and straightened the lip line. prosthesis (altered complete denture)

the support

provided

by

the

is in place.

Evaluation

of speech

Both patients were tested formally for articulatiorP* within a week following the placement of the dental restoration. In addition, an informal test of articulation was administered as each modification of the prosthesiswas developed. All tests were administered by one of the authors, a speechpathologist (J. F. C.) . No formal tests of intelligibility of speech were administered. However, each formal test session was recorded and then presented to a panel of three staff speechclinicians for their evaluation.
Modifications of the supporting prostheses

Intraoral-extraoral approach.13* I* Stainlesssteel (0.020) wire loops were attached to the prostheseswith modeling compound. The loops were adjusted until they extended slightly outside the lip at the commissureto support the affected side (Figs. 7 and 8). Intraoral approach with no vestibular tension. Modeling compound was added to the prostheses and border molded sominimal tension was exerted on the vestibular fornix. Only the added thickness of the modeling compound supported the cheek (Figs. 9 and 10). Intraoral approach with distosuperior tension. I8 Tension was placed on the vestibular fornix with modeling compound in a distosuperior direction toward the posterior border of the zygomatic processof the maxilla. The thickness of the modeling compound was varied to provide additional support to the cheek (Figs. 11 and 12). Intraoral approach with mediosuperior tension. Mediosuperior pressure exerted by the modeling compound on the vestibular fornix was directed toward the patients

Volume INumber

35 2

Support

for

unilateral

facial

paralysis

197

Figs. 17 and 18. The intraoral satisfactory for either patient.

prostheses

with

no tension

on the vestibular

fornix

were

not

Figs.

19 and

20. The

finished

prostheses

with

distosuperior

modification.

midline and nasal ala. Again, the thickness of the modeling compound was varied (Figs. 13 and 14). RESULTS
Intraoral-extraoral approach. The loop lifted the commissureand straightened the lip line. However, this procedure was unacceptable to both patients because ( 1) it could be seen, (2) it did little to improve the facial sag, (3) it allowed drooling, (4) it resulted in buccolabial insufficiency of lip activity which interferred with suck-

198

Larsen,

Carter,

and Abrahamian

J. Prosthet. February,

Dent. 1976

Fig.

21. Patient

Cl. B. at rest with N. B. at rest with

the finished the finished

prosthesis prosthesis

in position. in position.

Fig. 22. Patient

ing ability, and (5) it causedfurther distortion of the bilabial (p, b) and labiodental (f, v) sounds (Figs. 15 and 16). Intraoral approach with no vestibular tension. Esthetically, this modification was of little value since the musculature was not raised but only plumped out. C. B. detected some improvement in intelligibility of speechwith this design which could not be demonstrated clinically. N. B. could detect no appreciable difference in speech compared to that with the unmodified conventional denture. No improvement could be measured by the speech pathologist. Neither patient was pleased with the result since the sag of the facial tissues was largely unaltered (Figs. 17 and 18). Intraoral approach with distosuperior tension. By placing distosuperior pressure on the vestibular fornix and by adding thickness that supported the cheek, this change did raise the commissureand straighten the lip line. At first, the commissural seal was broken and more effort was required by both patients to speak and drink. However, by removing some of the modeling compound, the tension was reduced allowing the commissure to sag and causing a reduction in the buccolabial insufficiency of lip activity. The speechpathologist reported significant improvement in the articulation of the bilabial plosive and labiodental fricative sounds.In addition, there was noticeable improvement in the patients speaking rate and the length of time they could talk without experiencing fatigue. This modification proved to be the most beneficial in terms of esthetics and speech. Therefore, cold-curing acrylic was substituted for the modeling compound, and the respective prostheses were adjusted and inserted (Figs. 19 and 20) . Postinsertion examination revealed some irritation in the vestibular for-nix of C. B. so the mediosuperior border of the acrylic resin was reduced. The oral mucosaof N. B. remained asymptomatic (Figs. 21 and 22).

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35 2

Support

for unilateral

facial

paralysis

199

Figs.

23 and

24.

Intraoral

prostheses

placing

mediosuperior

tension

on the vestibular

fornix.

Intraoral approach with mediosuperior tension. The direction of lift was altered to place tension on the vestibular fornix in a medial and superior direction. Although less bulk of modeling compound was needed, the esthetic result was questionable. The modeling compound appeared as a noticeable bulge adjacent to the ala of the nose, and the commissure still had to droop before any improvement in speech could rbe noted. Also, because of more movement near the midline resulting from pull of ,the unaffected muscles, some redness was evident in the fornix and pressure in this region had to be relieved (Figs. 23 and 24). DISCUSSION Our findings indicated that facial symmetry could be improved with the use of ,removable prostheses for patients with unilateral facial paralysis. Esthetics has to be (compromised, however, because labial commissural sag is necessary if a functional :seal is to be maintained between the lips. Without this seal, drinking and speaking appear to be much more difficult. Both patients demonstrated some improvement in speech with either medial or distal modifications, but the distal design was more pleasing esthetically. According to the speech pathologist, the patients abilities to produce the bilabial plosive sounds (p, b) and labiodental fricative sounds (f, v) .improved significantly. In addition, both patients reported reduction in fatigue astsociated with sustained conversation. Apparently, by supporting the paralyzed side ,with the prosthesis, less resistance was encountered by the muscles on the unaffected aside during the formation of words. Vocal characteristics were not altered by the yprosthesis. Some tension can be placed in the vestibular fornix to lift sagging muscles, raise the commissure, and straighten the lip line without resulting in ulcerative epulis for-

200

Larsen,

Carter,

and Abrahamian

J. Prosthet. February,

Dent. 1976

mation. This is due to slight movement being imparted to the affected side by the pull of the nonparalyzed muscles. This movement is enough to allow circulation but insufficient to cause irritation and ulceration except when too near the midline. Patient acceptance of the prostheses has been very good. The patients are still being evaluated regularly by the Dental and Speech Pathology Services. SUMMARY Removable prostheses were used to determine improved for patients with permanent unilateral compromised somewhat to obtain the maximum procedure can be beneficial in helping patients whom surgery, for various reasons, is unacceptable.
The authors express their ministration Center, Martinsburg, appreciation W. Va. to the

that esthetics and speech could be facial paralysis. Esthetics had to be benefit for intelligible speech. This who are high surgical risks or for
Illustration Service,

Medical

Veterans Ad-

References
and Surgical TreatOjemann, R. G., Montgomery, W. W., and Weiss, A. D.: Evaluation ment of Acoustic Neuroma, N. Engl. J. Med. 287: 895-899, 1972. 2. Guerros-Santos, J., Ramirez, M., and Espaillat, L.: Treatment of Facial Paralysis by Static Suspension With Dermal Flaps, Plast. Reconstr. Surg. 48: 325-328, 1971. 3. McCabe, B. F.: Facial Nerve Grafting, Plast. Reconstr. Surg. 45: 70-75, 1970. 4. Conley, J. : Treatment of Facial Paralysis, Surg. Clin. North Am. 51: 403-416, 1971. 5. Sundell, B.: Dynamic Correction of Permanent Facial Paralysis, Ann. Chir. Gynaecol. Fenn. 58: 312-317, 1969. 6. Jobe, R.: Another Support in the Correction of Facial Paralysis, Plast. Reconstr. Surg. 45: 441-445, 1970. 7. Jongkees, L. B.: On the Therapy of Facial Paralysis, Bibl. Psychiatr. 139: 319-327, 1969. 8. Brown, J. B., Fryer, M. P., and Zografakis, G.: Reanimation in Ptosis and in Facial Paralysis, Plast. Reconstr. Surg. 41: 343-351, 1968. 9. Brown, J. B., McDowell, F., and Fryer, M. P.: Facial Paralysis Supported With Autogenous Fascia Lata, Ann. Surg. 127: 858-862, 1948. 10. Collier, J., Spillane, J. D., and Bauwens, P.: Symposium: Treatment of Facial Paralysis, Proc. R. Sot. Med. 43: 746-758, 1950. 11. Folkins, J. A., and MacLeod, W. D.: Intraoral Appliance for Facial Paresis, Can. Med. Assoc. J. 69: 632-633, 1953. 12. Lazzari, J. B.: Intraoral Splint for Support of the Lip in Bells Palsy, J. PROSTHET. DENT. 5: 579-581, 1955. 13. Sather, A. H. : Dental Appliances of Value in Bells Palsy, Arch. Otolaryngol. 78: 210-212, 1963. 14. Dahlberg, A. A.: Treatment of the Lip and Cheek in Cases of Facial Paralysis (Plastic Lip Cradle), J. A. M. A. 124: 503-504, 1944. 15. Crouch, Z. B.: Lip Taping for Buccal-Labial Insufficiency, J. Speech Hear. Disord. 36: 543-546, 1971. 16. Shields, C. D., and Smith, E. M.: Physical Medicine Management of Facial Nerve Paralysis, Milit. Surgeon 196: 122-124, 1950. 17. Bierman, W.: Treatment of Bells and Other Palsies, Bull. N. Y. Acad. Med. 25: 307-322, 1949. 18. Elfenbaum, A.: Facial Paralysis and Denture Construction, Dent. Dig. 73: 78-79, 1967. 19. Kittel, E.: Use of Plastics in Treatment of Irreversible Facial Paralysis, Psychiatr. Neural. Med. Psychol. (Leipz.) 21: 339-343, 1969. 20. McCracken, W. L.: Partial Denture Construction, ed. 2, St. Louis, 1964, The C. V. Mosby Company, p. 530. 1.

Volume

Number 2 21. :22.

35

Support

for unilateral
ed. 1, New

facial paralysis
York, 1962, 1960, McGraw-Hill Harper

201

Sharry, J. J.: Complete Denture Prosthodontics, Book Company, Inc., pp. 169-257. Fairbanks, G.: Voice and Articulation Drillbook, Publishers, pp. 13-15 (preface).
DR. LARSEN

ed. 2, New

York,

& Row,

P.O. Box 1626 IDAHO FALLS, IDAHO

DR.

83401

CARTER VETERANS ADMINISTRATION CENTER MARTINSBURG, W. VA. 25401

DR. ABRAHAMIAN

GEORGETOWN UNNERSITY SCHOOL OF DENTISTRY 4000 RESERVOIR RD., N. W. WASHINGTON, D. C. 20007

I ARTICLES
Edentulous
Gary C. Hunt, D.M.D.,

TO APPEAR
recordings
and James

IN FUTURE
utilizing vacustatics
D.D.S.

ISSUES

gnathologic

N. Yoxsimer,

Posterior
Carl

accessory

foramina

of the human
G. Tebo, MA.,

mandible
D.D.S.

W. Haveman,

D.D.S.,

and Hey1

The relationship
Richard J. Hoard,

of bevels
D.D.S.,

to the adaptation
D.D.S.

of intracoronal

inlays

and Jay Watson,

Abrasive wear, tensile Is there a relationship?

Alan Harrison, B.D.S.,

strength,
R.C.S.,

and hardness
and Robert

of dental
D.Sc.

composite

resins-

F.D.S.,

A. Draughn,

Physical

properties

of dental-amalgam
C.D., M.S.D., M.S.D., Ph.D. Dioracy

containing
Fonterrada

metal
Vieira, C.D.,

pins
M.S.D., Ph.D., and

Aquira Ishikiriama, Jose Mondelli, C.D.,

A practical restoration
William

technique

for the fabrication

of a direct

pattern

for a post-core

E. Jacoby,

Jr., D.D.S.

l-