|Year : 2015 | Volume
| Issue : 2 | Page : 139-143
An innovative prosthodontic approach in managing oral submucous fibrosis patient
Mandar Kajave, Santosh Shingote, Rashmi Mankude, Kirti Chodankar
Department of Prosthodontics, Crown and Bridge, Vasantdada Patil Dental College and Hospital, Sangli, Maharashtra, India
|Date of Web Publication||20-Apr-2015|
19/717, Shraddha Colony, Near Shri Hari Theatre, Ichalkaranji - 416 115, Maharashtra
The branch of prosthodontics is not only science, but also an art of handling patients who present with limitations in continuing with normal impression procedures. One such limitation is the difficulty in mouth opening. It may be due to fracture, trauma, oral submucous fibrosis, temporomandibular joint ankylosis, etc. This case report describes the innovative technique of primary impression, sectional custom tray, sectional denture base and "customized hinge" for hinge denture.
Keywords: Hinge, hinge denture, microstomia, sectional
|How to cite this article:|
Kajave M, Shingote S, Mankude R, Chodankar K. An innovative prosthodontic approach in managing oral submucous fibrosis patient. SRM J Res Dent Sci 2015;6:139-43
|How to cite this URL:|
Kajave M, Shingote S, Mankude R, Chodankar K. An innovative prosthodontic approach in managing oral submucous fibrosis patient. SRM J Res Dent Sci [serial online] 2015 [cited 2020 Aug 13];6:139-43. Available from: http://www.srmjrds.in/text.asp?2015/6/2/139/155479
| Introduction|| |
Oral submucous fibrosis (OSMF) is defined as a chronic disease of the oral mucosa characterized by inflammation and progressive fibrosis of the lamina propria and deeper connective tissue layers. A number of factors trigger the disease process by causing juxta epithelial inflammatory reaction in the oral mucosa. Suggested contributory factors include areca nut chewing, ingestion of chillies, nutritional deficiencies, genetic and immunologic processes and other factors. OSMF is a potential premalignant condition with an incidence of oral cancer in 3-7.6% cases.  The presenting symptoms of OSMF are burning pain, progressive inability to open the mouth, difficulty in mastication and swallowing. It is most common between 20 and 40 years of age with a female:male ratio of 3:1.  When it affects geriatric patients with partial or complete edentulism; the task of restoring function becomes a challenge to the prosthodontist due to the patient's clinical presentation.
A restricted mouth opening which seems smaller than the size of a complete denture can make prosthetic treatment challenging. Several techniques have been described for use when either standard impression trays or the denture itself becomes too difficult to insert and remove from the mouth. During impression procedures, wide mouth opening is required for proper tray placement. In restricted opening ability, a modification of the standard impression procedure is often necessary to accomplish this fundamental step in the fabrication of a successful prosthesis. 
Several methods of prosthodontic treatment for patients with microstomia , have been presented, and numerous devices to expand oral commissure have been described. ,,, Watanabe et al.,  Sonune and Dange  described the fabrication of conventional complete denture with minimal pressure technique and using polyether elastic impression material for the OSMF patient. Shivasakthy and Asharaf Ali  have modified the technique of primary impression by using the plastic stock tray and the press button attachments. Whitsitt and Battle  introduced a procedure for primary impressions of dentulous arches using putty silicone as a flexible tray, washed with light body silicone to obtain more detail. Bachhav and Aras  described the technique of making final impression by using metal sleeves and dual die pins. Caculo et al., described the fabrication of the sectional custom tray for maxilla in the OSMF patient. 
This case report describes innovative techniques of primary impression, sectional custom tray, sectional denture base and fabrication of "customized hinge" for hinged mandibular denture.
| Case report|| |
A 58-year-old patient came with the chief complaint of missing teeth in both the arches and wanted restoration of the same. History revealed that anterior teeth were lost due to poor oral hygeine, and the posteriors were extracted due to caries. The patient also gave the history of chewing tobacco for the past 25 years and thus was a known case of OSMF not under medication. The diagnosis was done on the basis of clinical observation.
On examination, the mouth opening was almost 28 mm (interridge distance) [Figure 1]. On palpation, the fibrotic bands were felt on the buccal mucosa extending up to mandibular ridge and also on the floor of the mouth. Patient refused for surgical opening of mouth aperture so, fabrication of denture prosthesis with altered impression procedure was planned.
- It was impossible to insert standard impression tray for mandibular preliminary impression, so modification of the treatment plan was adopted only for mandibular denture.
- As upper lip could be retracted slightly, maxillary preliminary impression [Figure 2] was made with stock tray of small size with impression compound (Y-Dent, MDM Corp. India).
- For mandibular impression, plastic stock tray was selected and cut on the lingual side at the midline that made it to flex and also the borders were modified according to the ridge. Molding of lingual sulcus and distobuccal part was done with impression compound, and putty impression (Aquasil, Dentsply, India) was made. Elasticity of silicone impression material and cut in midline of tray allowed flexibility to impression while inserting and removing it from the mouth [Figure 3].
- For fabricating mandibular sectional custom tray, dowel pin with special plastic sleeve was incorporated in the handle of the autopolymerized resin tray and then it was sectioned [Figure 4]. Sectional border molding was performed with low fusing compound (DPI Pinnacle, India) and final impression was made with light body addition silicone (Aquasil, Dentsply, India). Two sections were re-joined outside the mouth [Figure 5] and poured in dental stone. Maxillary border molding and final impression was performed in the usual manner.
- While fabricating autopolymerized resin (DPI RR self cure resin, DPI, Fort, Mumbai, India) mandibular denture base, two 5 mm orthodontic wire of 20 gauges with retentive bends at one end were prepared and incorporated at midline in such way that retentive end of one wire was on the right side of the denture base and the other end was on the left side of the denture base. Denture bases were then sectioned and pulled to get sectional base with one pin and one hole on each side for re-joining [Figure 6].
- Occlusal rims were fabricated with modeling wax (MAARC modeling wax, Shiva Products, Thane, India). It was easy re-joining mandibular sectional denture base in the mouth with pin and hole adjustments [Figure 7]. Jaw relation records were obtained [Figure 8] and transferred to a mean value articulator with the use of occlusion rims oriented to the established vertical dimension of occlusion, the anatomic occlusal plane, and the patient's centric relation. The artificial teeth (ACRY ROCK ruthinium teeth no. 14, Ruthinium dental products, NEW GIDC, Valsad) were arranged with the use of remaining maxillary teeth and the anatomical landmarks of the mandibular residual ridge. The try-in sectional denture was evaluated to verify jaw relations and tooth arrangement.
- Customizing hinge - it was planned to attach the hinge on the lingual side of the mandibular denture at midline and part of the hinge extending on the ridge for better support and rigidity. Vertical height available for hinge at midline was less for any prefabricated hinge, so hinge customization was planned. Two rods of pattern resin (GC Dental Corp, Japan) were formed in a shape as like key and keyway locks and they were extended onto the ridge for extra support and retention [Figure 9]. They were united together and with the help of the surveyor and micro motor a hole was drilled in the center of the lock. Two resin parts (GC Dental Corp, Japan) then were separated and casted separately with Co-Cr alloy. After casting they were finished and polished. With the help of pattern resin, the middle rod was fabricated in the plates where hole was drilled. The rod was then cast and finished. Hence, we got three casted parts. Rod was then fitted in the central hole, and its end was soldered. Thus, customized hinge was ready for attachment [Figure 10].
- Space for hinge attachment was prepared on the lingual side of the mandibular denture after try-in appointment. The space was prepared by trimming the lingual part of the acrylic teeth, and the denture base till the hinge is properly fitted.
- Afterwards the denture was fabricated with the hinge incorporated in it and it was then finished and polished [Figure 11]. During insertion appointment, maxillary denture can be inserted with retracting upper lip and mandibular denture can be inserted by folding the denture with the help of the hinge [Figure 12]. Patient was instructed about use and care of denture and hinge attachment. Patient was then recalled for follow-up.
- Follow-up was continued over 6 months with satisfactory results. The patient expressed his satisfaction with this method of placement.
| Discussion|| |
In cases where microstomia is not manageable with surgery or dynamic opening devices, modified impression techniques and prosthesis designs facilitates rehabilitation.
Several techniques have been described in the literature for the fabrication of sectional and hinged tray/complete denture utilizing various mechanisms for connecting each component. ,,,,, In literature use of sectional stock tray or use of putty as a tray was advised but in this case, plastic stock tray was modified to make putty impression, which in all becomes one unit and flexible. Hence, the aim of making impression with complete tray support was achieved. Dowel pin with plastic sleeve which is used with pindex system (Crosspin, India) was cheaper, easily available option. Locking system present between dowel and sleeve act as antirotation, was inserted in handle of custom tray makes it sectional and easy for reattachment. Sectional occlusal rims are not good option unless it is joined together. Attachments for the sectional denture bases will interfere with jaw relation and teeth arrangement. Orthodontic wire of 20 gauge, which was as thick as denture base was a better option to prevent it.
Hinge for sectional denture was best option than other complicated devices. Space present to attach hinge to mandibular denture is less, so customization of hinge provides a better option, gives better results and reduces cost of the prosthesis.
| Conclusion|| |
Limited mouth opening often complicates and compromises the treatment of patients. However, Careful treatment planning and prudent designing of sectional prosthesis should be done for overall well-being of the patient. Different methods of overcoming impression difficulties should be planned to obtain a better impression. Resultant prosthesis from such techniques should be stable, functional and easy to use.
| References|| |
Rajendran R. Oral submucous fibrosis: Etiology, pathogenesis, and future research. Bull World Health Organ 1994;72:985-96.
McCord JF, Tyson KW, Blair IS. A sectional complete denture for a patient with microstomia. J Prosthet Dent 1989;61:645-7.
Moghadam BK. Preliminary impression in patients with microstomia. J Prosthet Dent 1992;67:23-5.
Whitsitt JA, Battle LW. Technique for making flexible impression trays for the microstomic patient. J Prosthet Dent 1984;52:608-9.
Suzuki Y, Abe M, Hosoi T, Kurtz KS. Sectional collapsed denture for a partially edentulous patient with microstomia: A clinical report. J Prosthet Dent 2000;84:256-9.
Watanabe I, Tanaka Y, Ohkubo C, Miller AW. Application of cast magnetic attachments to sectional complete dentures for a patient with microstomia: A clinical report. J Prosthet Dent 2002;88:573-7.
Sonune SJ, Dange SP. Oral submucous fibrosis recuperated with prosthodontic approach - A case report. J Dent Med Sci 2012;3:19-21.
Shivasakthy M, Asharaf Ali S. Customized sectional stock tray for a patient with a restricted oral opening. J Clin Diagn Res 2011;5:1686-7.
Bachhav VC, Aras MA. A simple method for fabricating custom sectional impression trays for making definitive impressions in patients with microstomia. Eur J Dent 2012;6:244-7.
Caculo SP, Aras MA, Chitre V. Fabrication of custom sectional impression tray for a patient with oral submucous fibrosis. J Orofac Res 2013;3:140-3.
[Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5], [Figure 6], [Figure 7], [Figure 8], [Figure 9], [Figure 10], [Figure 11], [Figure 12]