facial palsy prosthesis

MAXILLOFACIAL PROSTHETICS TEMPOROMANDIBULAR JOINT DENTAL IMPLANTS

I. KENNETH ADISMAN, Section editor

Prosthetic support for unilateral facial paralysis

Steven J. Larsen, D.D.S.,* John F. Carter, Ph.D.,** and

Hratch A. Abrahamian, D.D.S.***

Veterans Administration Center, Martinsburg, W. Vu.

S 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 Bell’s 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 im- precise 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 Pathology Service, Veterans Administration Center, Mar- tinsburg, W. Va.; Clinical Associate Professor, West Virginia University, School of Dentistry, Morgantown, W. Va.; Lecturer, West Virginia University, Extension Credit Program.

***Consultant to Dental Service, Veterans Administration Center; Associate Professor, De- partment of Prosthodontics, Georgetown University, School of Dentistry, Washington, D. C.

192

Support for unilateral facial paralysis 193

Fig. 1. Patient C. B. at rest without a prosthesis.

Fig. 2. Patient N. B. at rest without a prosthesis.

Figs. 3 and 4. Manual elevation of paralyzed musculature provided improvement il sounds.

through manual elevation of the paralyzed facial tissues (Figs. 3 and 4) . The Service was asked to determine if an oral prosthesis could be constructed whicl provide this elevation.

Neither patient desired further surgery. However, both were told that plan

cedures were available that had been successful in improving effects of facial SlI,.

n speech

I Dental !r would

itic pro-

paraly-

194 Larsen, Carter, and Abrahamian J. Prosthet. Dent. February, 1976

Fig. 5. The cast framework contains a buccal attachment to support modeling compound in

acrylic resin.

Fig. 6. Heat-cured acrylic resin dentures. The maxillary denture will be used to provide support for the paralyzed tissues.

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 speech was determined.

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Fig. 9. Intraoral modification with modeling compound provided support for the cheek.

Fig. 10. Use of intraoral modification with modeling compound resulted in no tension on the vestibular fornix. Only the thickness of the denture was modified.

i__ i

Figs. 11 and 12. Intraoral modifications with modeling compound resulting in distosuperior sup-

port.

Figs. 13 and 14. Intraoral modifications with modeling compound resulting in mediosuperior

support.

1% Larsen, Carter, and Abrahamian J. Prosthet. Dent. February, 1976

Fig. 15. The intraoral-extraoral appliance is in place. Note that the support provided by the loop has elevated the commissure and straightened the lip line.

Fig. 16. The intraoral-extraoral prosthesis (altered complete denture) 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 prosthesis was developed. All tests were administered by one of the authors, a speech pathologist (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 speech clinicians for their evaluation.

Modifications of the supporting prostheses

Intraoral-extraoral approach.13* I* Stainless steel (0.020) wire loops were attached to the prostheses with modeling compound. The loops were adjusted until they ex- tended slightly outside the lip at the commissure to support the affected side (Figs. 7 and 8).

Intraoral approach with no vestibular tension. Modeling compound was added to the prostheses and border molded so minimal 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 process of 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 patient’s

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Figs. 17 and 18. The intraoral prostheses with no tension on the vestibular fornix were not

satisfactory for either patient.

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 commissure and 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-


Fig. 21. Patient Cl. B. at rest with the finished prosthesis in position.

Fig. 22. Patient N. B. at rest with the finished prosthesis in position.

ing ability, and (5) it caused further 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 speech with 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 commissure and 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 speech pathologist 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) . Postinser- tion examination revealed some irritation in the vestibular for-nix of C. B. so the mediosuperior border of the acrylic resin was reduced. The oral mucosa of N. B. re- mained asymptomatic (Figs. 21 and 22).

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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 as-

tsociated 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-


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 in- sufficient 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 that esthetics and speech could be improved for patients with permanent unilateral facial paralysis. Esthetics had to be compromised somewhat to obtain the maximum benefit for intelligible speech. This

procedure can be beneficial in helping patients who are high surgical risks or for whom surgery, for various reasons, is unacceptable.

The authors express their appreciation to the Medical Illustration Service, Veterans Ad- ministration Center, Martinsburg, W. Va.

References

1. Ojemann, R. G., Montgomery, W. W., and Weiss, A. D.: Evaluation and Surgical Treat-

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 Paraly- sis, 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 Bell’s Palsy, J. PROSTHET. DENT.

5: 579-581, 1955. 13. Sather, A. H. : Dental Appliances of Value in Bell’s 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 Paraly-

sis, Milit. Surgeon 196: 122-124, 1950.

17. Bierman, W.: Treatment of Bell’s 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.

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21. Sharry, J. J.: Complete Denture Prosthodontics, ed. 1, New York, 1962, McGraw-Hill

Book Company, Inc., pp. 169-257.

:22. Fairbanks, G.: Voice and Articulation Drillbook, ed. 2, New York, 1960, Harper & Row, Publishers, pp. 13-15 (preface).

DR. LARSEN

P.O. Box 1626

IDAHO FALLS, IDAHO 83401

DR. 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 TO APPEAR IN FUTURE ISSUES

Edentulous gnathologic recordings utilizing vacustatics Gary C. Hunt, D.M.D., and James N. Yoxsimer, D.D.S.

Posterior accessory foramina of the human mandible Carl W. Haveman, D.D.S., and Hey1 G. Tebo, MA., D.D.S.

The relationship of bevels to the adaptation of intracoronal inlays Richard J. Hoard, D.D.S., and Jay Watson, D.D.S.

Abrasive wear, tensile strength, and hardness of dental composite resins- Is there a relationship? Alan Harrison, B.D.S., F.D.S., R.C.S., and Robert A. Draughn, D.Sc.

Physical properties of dental-amalgam containing metal pins Aquira Ishikiriama, C.D., M.S.D., Dioracy Fonterrada Vieira, C.D., M.S.D., Ph.D., and Jose Mondelli, C.D., M.S.D., Ph.D.

A practical technique for the fabrication of a direct pattern for a post-core restoration William E. Jacoby, Jr., D.D.S.

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facial palsy prosthesis

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