J.

Adv Dental Research CASE REPORT

All Right Res

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 CASE 1

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, bell’s 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.
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.
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.[

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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 4 Mandibular record base with modeling plastic

Figure 1 Patient showing ptosis on right half and drooping impression compound moulded to patient’s neutral zone.
corner of the mouth towards unaffected side on opening
wide .

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 9 Bracing mandible with little finger behind angle

Figure 6 Preoperative Photograph 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
anterior posterior direction, Dyssynergia - recording resting position and centric relation of mandible.
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
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70
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 patient’s 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
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.
Dawson’s 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.Patient’s 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). Patient’s 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
Journal of Advanced Dental Research VolII : Issue I: January, 2011
71
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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