Presentation:

Scenario: 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??

By : Sara Sajjad Final Year B.D.S

Department of Prosthodontics SBDC Gandhara University

What is BELL'S PALSY??

Named after CHARLES BELL (Well known for his studies on the nervous system and the brain) In the 19th century he discovered that lesions of the 7th cranial nerve i.e the facial nerve cause facial paralysis.

Types:
A). Temporary y
y y y Most common Lasts for weeks to months only Recovers but can reoccur Causes includes:

viral infections, ear infections, high B.P. Diabetes, headaches, trauma etc.

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

Clinical features
y y y y y y y Facial asymmetry Eyebrow droop Inability to close eye Uncontrolled tearing Drooping of corner of mouth Loss of forehead &nasolabial folds Lips not held tightly together: Difficulty keeping food in mouth Difficulty in keeping food on occlusal table

Other signs and symptoms

y y y y y y y y y 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

The facial muscles which are affected include:

y y y y y y y y Occipitofrontalis Procerus Nasalis muscle Depressor septinasi Orbicularis oculi Corrugator supercilii Depressor supercilii Auricular muscles (anterior, superior, posterior)

Facial muscles that affect denture stability

y y y y y Buccinator Orbicularis oris Levatorangulioris Depressor angulioris Mentalis

BUCCINATOR MUSCLE:
Importance in recording
Maxilla: y y Buccalfrenum Buccal vestibule

Mandible: y y y y Buccalfrenum Buccal vestibule Retromylohyoid fossa Retromolar pad

ORBICULAROUS ORIS:
Importance in recording
Maxilla: y y Labial vestibule Buccalfrenum

Mandible: y Labial frenum

LEVATOR ANGULI ORIS:

Importance in recording
Maxilla: y Buccalfrenum

Mandible: y No any

DEPRESSOR ANGULI ORIS:

Importance in recording
Maxilla: y No any

Mandible: y Buccalfrenum

MENTALIS:
Importance in recording
Maxilla: y No any

Mandible: y Labial frenum

Central VS Peripheral Facial Nerve Palsy

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

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.)

An upper motor neuron lesion:

Affects only the lower half of the contra-lateral side of the face

Important Note
y y y 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 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

What is neutral zone??

y y y y 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

Initial & Final Impression Recording

y Conventional technique for making primary and final impressions is followed except that excessive material is incorporated on the right side that is the affected side

Temporary Denture Base

y A stable denture base is constructed on master cast

Recording Neutral Zone

y 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 Thus the polished surface of denture base was contoured by functions of the tongue and action and tonus of affected and unaffected lips and cheek

Recording Neutral zone

Ma n d ibu la r re c o rd ba se with mo d e lin g pla stic impre ssio n c o mpo u n d mo u ld e d to pa tie n ts n e u tra l z o n e

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

Occlusal wax Rims

Midline placed in the middle of the oral cavity rather than the facial midline

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

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. keep the cant of the occlusal plane on the right side a little low for incisal show

Buccal sulcus support

y y Placing buccal support on the right side to reduce the facial droop This will also help reduce the accumulation of food in the affected buccal vestibule

Finally
y y Dentures are processed and inserted Pateint's satisfaction

Instructions
Patient is educated about oral and denture hygiene maintenance

References
y y y y y Designing Full Dentures by Watt and MacGregor Prosthodontic treatment of edentulous patients by Zarb-Bolender Jaypee text book of Prosthodontics by Nallaswamy Prosthodontic management of complete edentulous patients with neuromuscular disorders Case reports (Suresh S VipulAsopa) Pictures from e-net and books