ental implants rma: A clinical Yair Langer, DMD,a and Haim Tal, DMD,
Harold PhDC
The Maurice Aviv. Israel
Goldschleger
and
Gabriela
in the treatment report
S. Cardash, School
BDS,
of Dental
cleroderma is a disease leading to fibrosis of connective tissue and blood vessels, characterized by hardening and contracture of the skin.l Microstomia is a common complication of scleroderma.ls 2 The limited accessto the oral cavity hinders dental treatment and may prevent the insertion of removable dentures or impression trays. Residual alveolar ridges and border extension regions are subject to constricting distortion. The insertion and removal of prostheses may be complicated by the patient’s loss of tactile sensation and his or her finger deformity.3 The disease is progressive, but not life-threatening. Treatment should be completed while accessto the oral cavity is still available. Treatment planning should include provision for future worsening of the condition. Various methods of treatment for patients with microstomia are recorded in the literature. Naylor2 and Naylor and Manor4 suggest exercises to maintain the patency of the oral aperture. Devices that apply pressure bilaterally to the oral commissures to reduce the severity of microsto-
aInstructor, Department of Oral Rehabilitation. bSenior Clinical Lecturer, Department of Oral CAssociate Professor and Chairman, Department
Rehabilitation. of Peridontology.
10/l/41680
Fig. 1. Patient demonstrating maximum opening.
THE
JOURNAL
OF PROSTHETIC
DENTISTRY
LDS, Medicine,
of patients
wit
RCS,b Tel
Aviv
University,
Tel
mia have been described.5, 6 A sectional denture7 has been advocated for severe cases of microstomia. The prosthodontic treatment described for a patient with scleroderma, edentulous, with microstomia, includes the use of two dental implants to retain and support a maxillary complete overdenture with an embedded colbatchrome mesh reinforcement and a clip attachement.s Any future alterations in the form of dimensions of the maxillary complete overdenture caused by the progressive course of scleroderma and microstomia would not appreciably affect the retention of the maxillary overdenture.g, lo
CLINICAL
FINDINGS
This report describes the treatment of a 54-year-old woman who had had scleroderma for approximately 10 years. The patient complained of difficulty in eating and of retaining a maxillary removable partial denture. The only teeth remaining in the maxilla were the second permanent molars, which although mobile, retained a removable partial denture. Some mobile tissue was present at the crest of the anterior maxillary ridge. The mandibular incisors were missing and had been replaced by an acrylic resin fixed partial denture supported by the canine teeth. The mandibular right first permanent molar was also absent. Maximum vertical opening measured 28 mm (Fig. 1). Moderate to advanced adult generalized chronic periodontitis was
Fig.
2. Panoramic radiograph shows implants in place. 873
LANGER,
Fig. 3. Maxillary impression incorporating connector and dowel pins. Shallow distorted in region of right tuberosity.
Fig.
intramobile sulcus is seen
4. Bar attachment.
associated with the mandibular teeth. Bone loss around these teeth ranged from 20 % to 60 % , and probing depth was 2 to 7 mm. The radiographs showed some widening of the periodontal ligament.
CLINICAL
TREATMENT
The maxillary second molars were extracted and a maxillary immediate complete denture was inserted. Healing of the extraction sockets was very slow, and the retention of the complete denture was poor despite relining with tissue conditioner (Softliner, G. C. Dental Industrial Co-op, Tokyo, Japan) and subsequently with visible light-cured acrylic resin (Triad, L. D. Caulk Division, Dentsply Internation Co., Milford, Del.). This was mainly a result of the almost nonexistent turberosities and buccal spaces. Radiographs indicated a sufficient quantity of bone in the canine region of the maxilla. A 3.3 mm diameter, 10 mm
874
Fig.
CARDASH,
5. Bar in place with intramobile
Fig. 6. Reinforced ment.
maxillary
overdenture
AND
TAL
elements.
and clip attach-
long, plasma-sprayed titanium I.M.Z. implant (Interpore International, Irvine, Calif.) was surgically placed in each maxillary canine area (Fig. 2). Healing was uneventful, during which the mandibular posterior teeth were restored and periodontal treatment was provided. An acrylic resin veneer fixed partial denture was inserted, extending from the mandibular right canine to the left first premolar (Fig. 2). The mandibular posterior teeth were equilibrated to obtain an acceptable occlusal plane. After 6 months, the implants were exposed and a border molded impression was made with impression posts in the implants. Dowel pins with laboratory intramobile connectors were screwed into the impression posts (Fig. 3) and the impression was boxed and poured. A bar attachment was constructed (Fig. 4) and was screwed into the implants together with shock-absorbing intramobile elements (Fig. 5). The casts were mounted on a semiadjustable articulator in
DECEMBER
1992
VOLUME
66
NUMBER
6
DENTAL
IMPLANTS
AND
MICROSTOMIA
Fig. 7. Completed prosthesis in mouth.
Fig. 8. Instrument that enables patient to remove denture.
centric relation at the established vertical dimension and the maxillary artificial teeth were set in bilateral balanced occlusion. In accordance with the manufacturer’s instructions, a 0.75 mm space was created between the bar and the clip. A maxillary complete overdenture reinforced by a cast chrome cobalt mesh was processed and inserted (Figs. 6 and 7). The mesh reinforcement was considered necessary to prevent fracture, because the maxillary denture was opposed by mandibular natural teeth and was supported by both the rigid implants and the resilient mucosa.4 The patient was supplied with an instrument to enable her to remove the denture despite her finger deformity (Fig. 8).
have dislodged the denture if auxiliary retention had not been provided by the clip-bar attachment.
DISCUSSION The history of the patient indicated that progressive microstomia as a result of scleroderma was present. In anticipation of future changes in the denture border region of the mouth necessitating alterations in the denture with a possible reduction of denture retention and stability, it was decided to place a maxillary overdenture retained by osseointegrated implants. Other reasons were (1) retention of the complete immediate denture was poor; (2) the possibility of reducing the denture flanges at some future date to insert the denture would lead to a further loss of retention; (3) the need to prevent a possible increase in flabby tissue that might occur as a result of a maxillary complete denture opposed by mandibular natural teeth5, $ and (4) the pressure of the scarred lip on maxillary anterior denture teeth placed according to esthetic requirements would
THE
JOURNAL
OF PROSTHETIC
DENTISTRY
REFERENCES 1. Burket LW. Burket’s oral medicine, diagnosis and treatment. 8th ed. Philadelphia: JB Lippincott, 1984:798. 2. Naylor WP. Oral management of the scleroderma patient. J Am Dent Assoc 1982;105:814-7. 3. Pare1 SM. Scleroderma: a prosthetic problem. J PROSTWET DENT 1972; 25~560-4. of a flexible prosthesis for the 4. Naylor WP, Manor RC. Fabrication edentulous scleroderma patient with microstomia. J PROSTHET DENT 1983;50:536-8. J PROS5. Koumjian JH, Firtell DN. A prosthesis to control microstomia. THET DENT 1990;64:502-3. P. The Vancouver microsto6. Canine TA, Carlow DL, Stevenson-Moore mia orthosis. J PROSTHET DENT 1989;61:476-83. I. McCord JF, Tyson KW, Blair IS. A sectional complete denture for a patient with microstomia. J PROSTHET DENT 1989;61:645-7. rehabilitation in the geriatric dental program 8. Langer A. Prosthodontic 1960-1970. Internal report. Malben-J.D.C., Israel Medical Dept, Dental Division, 1972. removable partial denture 9. Kelly E. Changes caused by a mandibular opposing a maxillary complete denture. J PROSTHET DENT 1971; 27~140-50. RP. The maxillary complete den10. Saunders TR, Gillis RE, Desjardins ture opposing the mandibular bilateral distal-extension partial denture: treatment considerations. J PROSTHET DENT 1979;41:124-8. Reprint requests to: DR. YAIR LANGER DEPARTMENT OF ORAL REHABILITATION THE MAURICE AND GABRIELA GOLDSCHLEGER SCHOOL OF DENTAL MEDICINE TEL AVIV UNIVERSITY TEL AVIV 69978 ISRAEL
875
Harold PhDC
The Maurice Aviv. Israel
Goldschleger
and
Gabriela
in the treatment report
S. Cardash, School
BDS,
of Dental
cleroderma is a disease leading to fibrosis of connective tissue and blood vessels, characterized by hardening and contracture of the skin.l Microstomia is a common complication of scleroderma.ls 2 The limited accessto the oral cavity hinders dental treatment and may prevent the insertion of removable dentures or impression trays. Residual alveolar ridges and border extension regions are subject to constricting distortion. The insertion and removal of prostheses may be complicated by the patient’s loss of tactile sensation and his or her finger deformity.3 The disease is progressive, but not life-threatening. Treatment should be completed while accessto the oral cavity is still available. Treatment planning should include provision for future worsening of the condition. Various methods of treatment for patients with microstomia are recorded in the literature. Naylor2 and Naylor and Manor4 suggest exercises to maintain the patency of the oral aperture. Devices that apply pressure bilaterally to the oral commissures to reduce the severity of microsto-
aInstructor, Department of Oral Rehabilitation. bSenior Clinical Lecturer, Department of Oral CAssociate Professor and Chairman, Department
Rehabilitation. of Peridontology.
10/l/41680
Fig. 1. Patient demonstrating maximum opening.
THE
JOURNAL
OF PROSTHETIC
DENTISTRY
LDS, Medicine,
of patients
wit
RCS,b Tel
Aviv
University,
Tel
mia have been described.5, 6 A sectional denture7 has been advocated for severe cases of microstomia. The prosthodontic treatment described for a patient with scleroderma, edentulous, with microstomia, includes the use of two dental implants to retain and support a maxillary complete overdenture with an embedded colbatchrome mesh reinforcement and a clip attachement.s Any future alterations in the form of dimensions of the maxillary complete overdenture caused by the progressive course of scleroderma and microstomia would not appreciably affect the retention of the maxillary overdenture.g, lo
CLINICAL
FINDINGS
This report describes the treatment of a 54-year-old woman who had had scleroderma for approximately 10 years. The patient complained of difficulty in eating and of retaining a maxillary removable partial denture. The only teeth remaining in the maxilla were the second permanent molars, which although mobile, retained a removable partial denture. Some mobile tissue was present at the crest of the anterior maxillary ridge. The mandibular incisors were missing and had been replaced by an acrylic resin fixed partial denture supported by the canine teeth. The mandibular right first permanent molar was also absent. Maximum vertical opening measured 28 mm (Fig. 1). Moderate to advanced adult generalized chronic periodontitis was
Fig.
2. Panoramic radiograph shows implants in place. 873
LANGER,
Fig. 3. Maxillary impression incorporating connector and dowel pins. Shallow distorted in region of right tuberosity.
Fig.
intramobile sulcus is seen
4. Bar attachment.
associated with the mandibular teeth. Bone loss around these teeth ranged from 20 % to 60 % , and probing depth was 2 to 7 mm. The radiographs showed some widening of the periodontal ligament.
CLINICAL
TREATMENT
The maxillary second molars were extracted and a maxillary immediate complete denture was inserted. Healing of the extraction sockets was very slow, and the retention of the complete denture was poor despite relining with tissue conditioner (Softliner, G. C. Dental Industrial Co-op, Tokyo, Japan) and subsequently with visible light-cured acrylic resin (Triad, L. D. Caulk Division, Dentsply Internation Co., Milford, Del.). This was mainly a result of the almost nonexistent turberosities and buccal spaces. Radiographs indicated a sufficient quantity of bone in the canine region of the maxilla. A 3.3 mm diameter, 10 mm
874
Fig.
CARDASH,
5. Bar in place with intramobile
Fig. 6. Reinforced ment.
maxillary
overdenture
AND
TAL
elements.
and clip attach-
long, plasma-sprayed titanium I.M.Z. implant (Interpore International, Irvine, Calif.) was surgically placed in each maxillary canine area (Fig. 2). Healing was uneventful, during which the mandibular posterior teeth were restored and periodontal treatment was provided. An acrylic resin veneer fixed partial denture was inserted, extending from the mandibular right canine to the left first premolar (Fig. 2). The mandibular posterior teeth were equilibrated to obtain an acceptable occlusal plane. After 6 months, the implants were exposed and a border molded impression was made with impression posts in the implants. Dowel pins with laboratory intramobile connectors were screwed into the impression posts (Fig. 3) and the impression was boxed and poured. A bar attachment was constructed (Fig. 4) and was screwed into the implants together with shock-absorbing intramobile elements (Fig. 5). The casts were mounted on a semiadjustable articulator in
DECEMBER
1992
VOLUME
66
NUMBER
6
DENTAL
IMPLANTS
AND
MICROSTOMIA
Fig. 7. Completed prosthesis in mouth.
Fig. 8. Instrument that enables patient to remove denture.
centric relation at the established vertical dimension and the maxillary artificial teeth were set in bilateral balanced occlusion. In accordance with the manufacturer’s instructions, a 0.75 mm space was created between the bar and the clip. A maxillary complete overdenture reinforced by a cast chrome cobalt mesh was processed and inserted (Figs. 6 and 7). The mesh reinforcement was considered necessary to prevent fracture, because the maxillary denture was opposed by mandibular natural teeth and was supported by both the rigid implants and the resilient mucosa.4 The patient was supplied with an instrument to enable her to remove the denture despite her finger deformity (Fig. 8).
have dislodged the denture if auxiliary retention had not been provided by the clip-bar attachment.
DISCUSSION The history of the patient indicated that progressive microstomia as a result of scleroderma was present. In anticipation of future changes in the denture border region of the mouth necessitating alterations in the denture with a possible reduction of denture retention and stability, it was decided to place a maxillary overdenture retained by osseointegrated implants. Other reasons were (1) retention of the complete immediate denture was poor; (2) the possibility of reducing the denture flanges at some future date to insert the denture would lead to a further loss of retention; (3) the need to prevent a possible increase in flabby tissue that might occur as a result of a maxillary complete denture opposed by mandibular natural teeth5, $ and (4) the pressure of the scarred lip on maxillary anterior denture teeth placed according to esthetic requirements would
THE
JOURNAL
OF PROSTHETIC
DENTISTRY
REFERENCES 1. Burket LW. Burket’s oral medicine, diagnosis and treatment. 8th ed. Philadelphia: JB Lippincott, 1984:798. 2. Naylor WP. Oral management of the scleroderma patient. J Am Dent Assoc 1982;105:814-7. 3. Pare1 SM. Scleroderma: a prosthetic problem. J PROSTWET DENT 1972; 25~560-4. of a flexible prosthesis for the 4. Naylor WP, Manor RC. Fabrication edentulous scleroderma patient with microstomia. J PROSTHET DENT 1983;50:536-8. J PROS5. Koumjian JH, Firtell DN. A prosthesis to control microstomia. THET DENT 1990;64:502-3. P. The Vancouver microsto6. Canine TA, Carlow DL, Stevenson-Moore mia orthosis. J PROSTHET DENT 1989;61:476-83. I. McCord JF, Tyson KW, Blair IS. A sectional complete denture for a patient with microstomia. J PROSTHET DENT 1989;61:645-7. rehabilitation in the geriatric dental program 8. Langer A. Prosthodontic 1960-1970. Internal report. Malben-J.D.C., Israel Medical Dept, Dental Division, 1972. removable partial denture 9. Kelly E. Changes caused by a mandibular opposing a maxillary complete denture. J PROSTHET DENT 1971; 27~140-50. RP. The maxillary complete den10. Saunders TR, Gillis RE, Desjardins ture opposing the mandibular bilateral distal-extension partial denture: treatment considerations. J PROSTHET DENT 1979;41:124-8. Reprint requests to: DR. YAIR LANGER DEPARTMENT OF ORAL REHABILITATION THE MAURICE AND GABRIELA GOLDSCHLEGER SCHOOL OF DENTAL MEDICINE TEL AVIV UNIVERSITY TEL AVIV 69978 ISRAEL
875
