CD in Cerebral Palsy

8/12/2019 CD in Cerebral Palsy

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This article describes the prosthodontic treat-

ment for a patient with cerebral palsy, in which

complete dentures were successfully stabilized

using treatment dentures.

A 69-year-old edentulous male with no medical

complications or mental retardation presented to

our clinic. Opening movement of the jaw was pos-sible, but a conspicuous mandibular shift towards

the right was observed. He had never received any

prosthodontic treatment.

Initially, treatment dentures with flat tables were

fabricated to rectify his erratic mandibular move-

ments. During the first 3 weeks, the treatment

dentures functioned poorly. Eventually, the

patient could make tapping movement to some

degree and have a meal with less effort.

Indentation marks from the cusps of the opposing

maxillary denture could be clearly seen on the flat

tables. After six weeks, as he did not complain ofany pain, definitive dentures were fabricated.

When flat table treatment dentures are used, it is

considered that the mucosa provides information

regarding the vertical stop and bite force. In addi-

tion, it is speculated that there is an increase in the

response from masseter muscle. In the present

case, flat tables were effective for rehabilitation of

the mandibular movement.

Key words: disabled patient, cerebral palsy, treat-

ment dentures, flat tables, habituation

Introduction

Cerebral palsy is a physical disorder leading to failure

of balance and unpredictable motion1. The frequent

erratic movement of the limbs and trunk often interfere

with daily life2. Individuals with cerebral palsy often

have difficulties in mastication, speech, and deglutition

because of the involuntary muscle spasms caused by

their condition3.

Few reports2-5

have discussed the difficulty of dental

treatment in patients with cerebral palsy. Ogata6

reported that severe functional disability was the pri-mary reason for failure of prosthodontic treatment in

these patients.

It is often observed that mandibular movements of

edentulous patients are unstable. Most edentulous

patients often have irregular mandibular movements

due to long-term use of ill-fitting dentures7. Hence, it is

difficult to make complete dentures for edentulous

patients with cerebral palsy.

It has been suggested that the mandibular move-

ments of these patients should be analyzed and

adjusted when necessary5,6

. Use of intermediate

treatment dentures with flat occlusal tables is one of thetechniques applied in severe cases. This method

Case Report

Complete denture treatments for a cerebral palsy patient by using a treatment

denture. A Case Report

Minoru Inada1, Tsuneyoshi Yamazaki

1,2, Osamu Shinozuka

2, Goro Sekiguchi

2,

Yasuka Tamamori2

and Takashi Ohyama1

1) Clinic for Persons with Disabilities, University Hospital, Faculty of Dentistry, Tokyo Medical and Dental

University2) Section of Dentistry for Persons with Disabilities, Graduate School, Tokyo Medical and Dental University

J Med Dent Sci 2002; 49: 171177

Corresponding Author: Minoru Inada, D.D.S, Ph.D.

Clinic for Persons with Disabilities, University Hospital, Faculty of

Dentistry, Tokyo Medical and Dental University

1-5-45 Yushima, Bunkyo-ku, Tokyo 113-8549, Japan

Tel: +81-3-5803-5727; Fax: +81-3-5803-0255

E-mail: [email protected] August 27; Accepted September 27, 2002


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enables the patients condition to be analyzed prior to

delivery of the definitive dentures8. Here, we report a

case in which we were able to make complete dentures

for a patient with cerebral palsy by initially fitting treat-

ment dentures. The patients condition was very

severe, with very irregular or erratic mandibular

movements.

Case Report

A 69-year-old edentulous male with athetoid type

cerebral palsy, diagnosed at the age of three years,

presented to our clinic (Figure 1). He had no medical

complications or mental retardation. His lower limbs

were paralyzed. He was able to move his arms volun-

tarily to a certain extent. However, the movement dis-

order was evident when performing actions such as

crushing a paper cup in his hand.

Opening and closing movements of the jaw were

possible, but a conspicuous mandibular shift towards

the right was observed (Figure 2). He could not perform

limiting or tapping movement of his mandible when

instructed. Previously, he had received simple dental

treatment such as extraction and restoration of teeth.

However, he had never undergone prosthodontic

treatment. Residual root stumps in maxilla and

mandible were extracted three years earlier and he had

remained edentulous thereafter. The patient provided

informed consent to participate in this study.

Treatment

Impressions were taken for study models. Custom

trays were then prepared on these for taking precise

impressions with silicone rubber impression material

(Hydrophilic Exaflex

, GC Ltd., Japan). Bite plates

were made on the working models. We determined his

bite plane using the conventional method based on

Campers plane9. However, it was difficult to determine

his occlusal vertical dimension because he could not

M. INADA et al. J Med Dent Sci172

Fig. 1. Oral cavity of the patientUpper: maxilla Lower: mandible.

Fig. 2. Mandibular shift towards the right side on opening


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maintain the position while biting on the bite plates.

Therefore, we held his mandible in position to obtain

the occlusal vertical dimension.

With the occlusal bite registered, we proceeded to

make the treatment dentures. Artificial teeth

(Duradent

, GC Ltd., Japan) were arranged in lingual-

ized occlusion10

on an average value articulator (Gisi

simple articulator

, ONUKI Dent. Ltd., Japan).

Dentures were fabricated by the conventional

method. After occlusal adjustment on the articulator,

posterior artificial teeth were removed from the

mandibular denture to make the occlusal tables. Self-

curing resin (Unifast Trad

, GC Ltd., Japan) was

applied to these surfaces. Maxillary and mandibular

dentures were occluded on the articulator to mark the

position of the palatal cusps of the maxillary teeth,

before the resin was completely cured. Self-curing resin

was reduced until all palatal cusps were in even con-tact. The occlusal tables were flattened as much as

possible8

(Figures 3, 4).

To ensure the form and retention of the dentures,

functional impressions were taken with the treatment

dentures and tissue conditioner (Coe-Comfort

, GC

Ltd., Japan). After the treatment dentures were deliv-

ered, we followed the patient on a weekly basis. Weperformed occlusal adjustment and tissue conditioning

at all recall appointments. In this method, because the

cusps of maxillary denture should indent the

mandibular flat tables during occlusion, we did not grind

the maxillary artificial teeth. Adjustment of the

mandibular flat tables by grinding was also limited to

removal of the premature contacts that seemed to tip

the dentures. As the patient was unable to perform tap-

ping movement, we positioned the mandible so that the

flat tables contacted the artificial teeth of maxillary den-

ture.

After this preliminary treatment, we observed his tap-ping movement and determined the frequency 4-6

173COMPLETE DENTURES FOR A CEREBRAL PALSY PATIENT

Fig. 3. Adjustment of the occlusal table of the treatment denture


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times at every visit (Table 1). While observing the tap-

ping, we did not regulate the frequency, intensity, or jaw

opening distance, thus permitting voluntary move-

ment by the patient.

During the first 3 weeks, the dentures were not stable

and he could only perform tapping continuously for 1 to

13 times. The patient suffered from frequent ulcers in

the oral cavity and had difficulty in eating. However,

after 4 weeks, the dentures became more stable and

his tapping frequency improved to a maximum of 26

times.

On the flat tables, we detected the indentation

marks from cusps of the opposing maxillary denture

(Figure 5). No more ulcers were observed in the oral

cavity and the patient found it much easier to eat.

After 6 weeks, the patient did not complain of any


Table 1. The number of Tapping movement

Fig. 5. Indentation marks on the flat table of the mandibular denture

Upper: after 4 weeks

Lower: after 6 weeks

Fig. 4. Treatment dentures

Upper: Maxillary and Mandibular dentures mounted in the articulator

Lower: Flat tables of mandibular denture


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pain. He was able to tap a maximum of 31 times as

instructed. In addition, the indentation marks could be

seen more clearly and he could maintain his mandible

in a position where each cusp of the maxillary denture

contacted the indentation marks on the flat tables.

The bite was registered again with silicone material

(EXABITE , GC Ltd., Japan). These treatment den-

tures were remounted on an average value articulator

to arrange posterior artificial teeth in the mandibular

denture with lingualized occlusion and to rebase themaxillary and mandibular dentures. The definitive

dentures were thus fabricated8

(Figure 6). Using sili-

cone material (Fit checker

, GC Ltd., Japan) and

occlusal papers, we checked and adjusted the fitting

and occlusal relationship of the definitive dentures.

After the definitive dentures were delivered, the

patient was recalled regularly, and he remains satisfied

with his dentures.

Discussion

The detailed mechanisms of involuntary move-

ments associated with cerebral palsy have not been

clarified. However, failure of muscular control is

regarded as the main reason1. Ogata

6recorded

mandibular movements of four patients with athetoid

type cerebral palsy using Mandibular Kinesiography

(MKG) and reported extreme deviations to the right or

left during opening movement. In addition, he reported

that complex movements such as limiting the move-

ment of mandible could not be made in severe cases.

In the present case, a similar condition was observed.In addition, our patient had been edentulous for about

3 years.

For mandibular movement, the most important

information originates from the receptors of periodontal

ligament11

, temporomandibular joint12

and muscle

spindles of masseter13

. Edentulous patients are not

able to receive information from the periodontal liga-

ment. Furthermore, input signals from the muscle

spindles of the edentulous patient are decreased14

.

Thus, most edentulous patients cannot perform

smooth and precise mandibular movements. For the

above-mentioned reasons, our patient appeared to bein an unfavorable condition as he was unable to per-


Fig. 6. Post-treatment photographs

Right: Definitive dentures

Left: The patient wearing definitive dentures


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form functional mandibular movements.

During the fabrication of complete dentures,

occlusal vertical dimension is usually determined with

bite plates based on the patients facial appearance,

rest position of the mandible and other factors. The hor-

izontal relation is determined by the Gothic arch

method9. To employ the Gothic arch method, patients

have to keep the Gothic arch tracer in the oral cavity

and move the mandible as instructed. However, for our

patient it was impossible to follow these instructions.

Thus, we did not apply this method but used the flat

tables instead and analyzed the occlusion.

We followed a modified version of Sakurais

method8

for the treatment of this patient. While making

definitive dentures from treatment dentures, Sakurai

used silicon and plaster cores to register details of the

occlusal relation and the polished surface of dentures.

This method requires insertion of the materials into the

buccal vestibule and molding by the buccal muscula-

ture. As our patient could not perform this procedure,

we adopted a simple method in which the patient had

to bite the material.

Ideal flat tables must have moderate elasticity and

softness so that the cusps of the maxillary denture form

indentations on them15

. In the present case, we used

only self-curing resin, as it is simple and easy.However, it took a long time to register the indentations.

Previous studies have mentioned the addition of baby

powder or sealing resin to self-curing resin is helpful

when making flat tables15

. However, application of

these materials must be studied further.

By using treatment dentures with flat tables, the

occlusal condition can be analyzed by observing the

indentations on them8,15,16

. If the indentations are

spread out or Gothic arch-shaped, the centric occlusion

of the patient is not stable. In such cases, cuspless

teeth are recommended in the definitive dentures8. On

the contrary, if mandibular movement is stable and thecentric spot becomes fixed, it is recommended that all

the maxillary cusps should be in contact with the cor-

responding points on mandibular flat tables. The

indentations formed as a result of maxillary cusps con-

tacting the flat tables would be narrow and spot-

shaped, rather than wide and imprecise or Gothic

arch-shaped. In the present case, the indentations were

spot-shaped. Moreover, after 6 weeks the patient

could perform tapping in the exact point where the

cusps of the maxillary denture contacted the indenta-

tions on the flat tables. Thus, we concluded that our

patients mandibular movement was stable.Irregular mandibular movements might recur in

cerebral palsy. Hence, it might have been appropriate

to manage his irregular mandibular movements by

applying cuspless teeth. However, we thought that the

possibility of recurrence would be higher if we applied

cuspless teeth. Therefore, we set normal artificial

teeth in a lingualized occlusion10

in order to regulate his

mandibular movement to some degree. It is considered

that the lingualized occlusion rarely causes distortion or

lateral movement of dentures17

and is superior in

terms of mastication rhythm and efficiency18,19

.

Iwatate et al.5

reported that lingualized occlusion was

suitable for patients with cerebral palsy who grind

teeth involuntarily.

When flat table treatment dentures are used, it is

considered that the mucosa provides information

regarding vertical stop and bite force16

. In addition, it is

speculated that there is an increase in the response

from the masseter muscle14

. Due to these reasons, we

believe that our patient was able to perform mandibular

movements smoothly.

The following requirements should be satisfied

before insertion of the definitive dentures15

.1) The

patient does not complain of pain. 2) Indentation

marks can be clearly seen on the flat tables. 3)

Treatment dentures are stable in the oral cavity. 4) The

mandibular movement is smooth.After 4 weeks, the patient found it much easier to eat.

The indentations on the flat tables could be clearly

seen. Abe15

reported that formation of indentation

marks resulted from the stability of dentures and

patients became capable of performing smooth and

precise mandibular movements with the help of

indentations. Therefore, it was considered that irregu-

larities in the mandibular movement were rectified in

our case. No more ulcers were observed in the oral

cavity and the frequency of tapping improved to a max-

imum of 26 times after 4 weeks. After 6 weeks, the

patient did not complain of pain and the indentationmarks were more conspicuous. Moreover, he could

maintain his mandible in an exact position, where

cusps of the maxillary denture contacted the indenta-

tions on the flat tables. His tapping movement had sig-

nificantly improved and reached a maximum of 31

times. Hence, we decided to make the definitive den-

tures after 6 weeks.

It is known that the tapping movement is influenced

by the jaw opening distance, frequency, attitude, and

vertex presentation20

. In cases of cerebral palsy, con-

trolling tapping movements is difficult. It is considered

that restraint by head dipping may disturb replication ofa tapping exercise. Feeling tense might also negative-



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ly affect tapping21

. We, therefore, did not advocate any

restraints and permitted voluntary exercise by the

patient.

As the patient could perform tapping movement to

some degree, it was possible for him to bite on the

treatment dentures and to have a meal more easily

than before. This implies that flat tables were effective

for rehabilitation of mandibular movement. However, to

the best of our knowledge, this is the first case to suc-

cessfully apply this technique for a patient with cerebral

palsy, and the details of the mechanisms are unclear.

Further studies are necessary to elucidate the under-

lying mechanisms.

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CD in Cerebral Palsy

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