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Hydantoin-associated gingival hyperplasia caused by prolonged use of an anliconvul.saiU drug (hydanloln) it was decided to extract all the remaining teeth and restore function and esthetics. Cephalometric analysis was used to determine the degree io which the teeth had drifted.
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Prosthodontic Treatment for a Patient With Advanced Hydantoin-Associated Gingival Hyperplasia- A Case Report
Hydantoin-associated gingival hyperplasia caused by prolonged use of an anliconvul.saiU drug (hydanloln) it was decided to extract all the remaining teeth and restore function and esthetics. Cephalometric analysis was used to determine the degree io which the teeth had drifted.
Hydantoin-associated gingival hyperplasia caused by prolonged use of an anliconvul.saiU drug (hydanloln) it was decided to extract all the remaining teeth and restore function and esthetics. Cephalometric analysis was used to determine the degree io which the teeth had drifted.
Prosthodontic treatment for a patient with advanced hydantoin-
associated gingival hyperplasia: A case report Iwao Hayakawa*/Eiji Osada**/Masayuki Morisawa***/Yoko Nakagawa****/lkki Watanabe** Abstract A pan'em in whom gingival hyperplasia was caused by prolonged use of an anliconvul.saiU drug (hydanloln) is described. Advanced gingival hyperplasia and significant displacement ofthe remaining teeth caused severe damage, especially to the patients appearance. It was not possible to cure the problems completely with routine periodontal treatment. It was decided to extract all the remaining teeth and restore function and esthetics early with complete dentures. Cephalometric analysis was used to determine the degree io which the teeth had drifted. During fabrication ofthe dentures, the analysis was very useful in deciding the position ofthe anterior teeth and checking the vertical dimension of occlusion. (Quintessence Int I996;27:235~24L) Introduction In patients with generalized, advanced periodontal disease, local periodontal therapies are sometimes repeated uselessly, and the condition gradually worsens beyond salvage. In these cases, a point is reached when it is confirmed that no conservative treatment can cure the severe condition; at this time, prosthodontic treatment should be ehosen as the best alternative. In such an event, the hopeless teeth must be extracted without hesitation. This will allow early restoration of the lost function and morphology and also rebuild the confidence ofthe patient. * Associate Professor, Department of Geriatric Dentistry, Tokyo Medical and Dental University, Tokyo. Japan, ** Graduate Student, Department of Geriatric Dentistry. Tokyo Medical and Dental University, Tokyo. Japan. ** Assistant Professor, Department of Geriatric Dentistr>'. Tokyo Medical and Dental University, Tokyo, Japan, **** Instructor, Department of Geriatric Dentistr>', Tokyo Medical and Dental University. Tokyo, Japan. Reprint requests: Dr Iwao Hayakawa, Associate Professor, Department of Geriatric Dentistry. Tokyo Medical and Dental University, 5-45, Yushima I-chome. Bunkyo-ku. Tokyo 113, Japan, A case is presented in which gingival hyperplasia was caused by prolonged use of the anticonvulsant drug, hydantoin. In this patient, the maxillar>' and mandibuiar gingiva showed extensive hyperplasia. The dental history ofthe patient indicated that the condi- tion could not be improved by routine periodontal treatment, such as brushing, scaling, gingivectomy, and so on. Therefore all teeth were extracted, and alveolar plastic surgery was performed. Subsequently complete dentures were fabricated after adequate healing. As a result, the patient's chief complaints, esthetic and masticator^' problems, were resolved. Case report A 39-year-old woman presented with the chief com- plaints of dissatisfaction with her appearance and inability to masticate food efficiently. She had started taking anticonvulsant medication 15 years previously because of epilepsy. Two years later, fibrous hyper- plasia was found in the region ofthe anterior teeth. The hyperplasia progressively expanded to the molar region. Although she underwent six gingivectomies and thorough plaque removal at a dental office, the hyper- plasia recurred repeatedly. The condition worsened. Quintessence Intemationai Volume 27, Number 4/1996 235 Hayakawa et al Fig l a The facial view reveals iip incompetence. Fig l b The gingival hyperplasia has caused the protrusion ot the anterior teeth. Figs 2a and 2b The advanced gingivai hyperpiasia has oaused significant dispiacemant of the remaining teeth. and the hyperplasia became much more extensive. There was no alleviation of gingival bleeding or the halitosis. Because it was not possible to reduce the dosage ofthe antjconvulsant. and conservative therapy could not fundamentally solve her problems, she was referred to the Faculty of Dentistry, Tokyo Medical and Dental University. Tntraoral examination On initial examination, her upper face showed no anomalies. In the lower face, lip incompetence was notable because ofthe remarkable hyperplasia and the protrusion of the anterior teeth caused by the hyper- plasia (Figs la and lb). There was no disturbance of tnouth opening. The oral hygiene was very poor, and severe, dark- red swelling was present extensively on the gingiva of both arches. This tissue tended to bleed easily, and debris was present between the fissures. The patient had notably foul breath. The first molars on both sides ofthe maxilla and the ftrst and second moiars on both sides ofthe mandible were missing. Some of the remaining teeth were covered with the hyperplastic gingiva. No swollen mueosa was present over the maxillary hard palate or the mandibuiar edentulous molar regions. The maxil- lary anterior teeth protruded and were severely iti- clined labially; consequently wide separatioti occurred between each tooth. There were many residual roots in the mandibular anterior region. Tooth contacts were present only between the maxillary and mandibular premolars on both sides (Figs 2a and 2b). The anterior teeth in both arches were remarkably mobile, and deep 236 Quintessence International Volume 27, Number 4/i gg H aya ka wa et al periodontal pockets were detected oti all the retnaining teeth. Radiographic examination Radiographic exatnitiation revealed that tbe remaining teeth had horizomal bone loss. The tnaxillary anterior teetb were displaced significantly, and hypertrophy of alveolar bone had followed the displacemetit. Figures 3a and 3b show the lateral cephalomeftic radiograph and its analysis. The skeletal analysis revealed that the mandibular plane angle was steep and the gonial angle was slightly greater than tbe mean value for Japanese women, Cephalometric analysis of the dentitioti indicated that the interincisal angle was signiftcantly more acute than the mean value, because of the marked labial tipping of both the maxillary and mandibular anterior teeth. The esthetic plane indicated the protrusion of the anterior segments of both arches. The ratios of the upper facia! height (nasion-anterior nasal spine) and lower facial height (anterior nasal spine-gnathion) to the total facial height were within the normal range (Table 1). Treatment Plan To er!hance esthetics and to maintain the existing vertical dimension of occlusion, it was thought that immediate dentures should be made first. However, it seemed too difficult to extract all the remaining teeth in one appointment at the outpatient department, because the operative area would he extensive. There- fore the fabrication of the maxillary denture was planned first. So that the patient might masticate with the immediate denture, it was planned that fabrication would be statied after the molars were extracted and the wounds had healed. According to the cephalometric analysis, the skel- etal pattern was clinically acceptable; therefore, the treatment was focused on improving the dental rela- tionships. So that the patient's appearance might be improved, it was decided that the maxillary anterior teeth should be retruded on the denture after the extraction of the anterior teeth and gingivectomy of the hyperplastic gingiva. The positions of the maxillary incisors were deter- mined on the cephalometric tracing so that the value of maxillary incisor to the nasion-pogonion plane was brought near to the mean. The position was marked on the cast referring to the position of the mandibular incisors or! the tracing and the cast (Fig 4), The Fig 3a Pretrealmenl lateral cephalomettic radiograph. anterior teeth of the maxillary immediate denture were arranged according to the markings on the cast. The vertical dimension of occlusion was maintained as it Procedures The maxillary premolars and molars that had no contact with the opposing mandibular teeth were extracted, and the hyperplastic gitigiva around them was removed. Two months later, the maxillar>' impression was taken. Putty-type silicone impression material (Xanto- pren function, Bayer Dental) was used for horder molding, and the final impression was taken with a light-bodied silicone impression material. The occlusal relationships were recorded with occlusion rims and polyether rubber for occlusal Quintessence International Volume 27, Number 4/1996 237 Hayakawa et al Facial angle Conve^ly AB plane Mandibular plane Y- a xi s Occlusal plane InlerincisaM'' L1 to Occlusal^ L1 to Mandibular U - 1 ID AP plane FH to 3N plane SNA SNB SNASNB diff U1 to NP plane U1 to FH plane U - 1 to SN plane Gomal angle Ramua inclination 7.S8 4.4a 28.81 65.38 11.42 12*09: 23.84 196.33 3.92 6.19 32.32 78.90 3.39 11.74 111.13 104.54 122.23 2.93 3.05 4.95 3.50 5.23 5.63 3.S4 - 7. S3- " 5.23 5.73 1.88 2,39 3.45 3.45 1.77 2.73 5.54 5.55 4.51 4.40 82.3 7. 9 4. 0 39. n 70.3 9.0 "73 "4" 5.5 110.5 20.5 7. 1 79.0 75.8 3. 1 23.2 137,1 130.0 1?9.8 0,8 (Standard by IizukaIshikawa) Fig 3b The patient's cephalomelric measurements (dotted lit>e) were compared to normal values for Japa- nese women (solid line) (reported by lizuka and IshJkawa"'). Mandibular incisor (L-1]; maxiiiary ncisor (U-1); (A-P), Frankfort horizontal (FH]; sella- nasion (S-Nl, seiia-nasion-point A (SNA!; seiia-nasion-poinf B (SNB); nasion-pogonjon N-P]. * Interincisai angle. t L-1 I0 occiusal plane, + L-1 lo mandJbuiar plane. Table I Facial height and esthetic plane Patient Norm* N-ANS/N-Gn{%) ANS-Gn/N-Gn i%) Esthetic plane to lower lip (mm) Esthetic plane to upper lip (mm) 45.9 44.4 2.0 54.2 55.6 2. 0 9.0 2.3 2. 5 4. S 0.6 2.4 * Normal value for Japanese women, as reported by Matsumolo.' N = nasiorii ANS = anlerior nasal spine- Cn - ynalhiun. registration (Ramitec. ESPE). Occlusal contact was made between opposing premolars (Eig 5). As a guide for gingivectomy and alveolectomy. a template was prepared on the maxillary cast, on which all teeth were removed, and the area of the alveolar ridge was modified to form a smooth surface. Anterior teeth were arranged according to the line previously marked on the cast, and then the immediate denture was made conventionally. After extraction of all the remaining maxiUary teeth, from left first premolar to right first premolar, the gingivectomy and alveolectomy were performed ac- cording to the template. The immediate demure was inserted after the template was shown to fit over the denture-bearing area without causing tissue blanching (Fig 6). Two weeks after insertion of the maxillary denture, all the mandibular anterior teeth were extracted, and a gingivectomy was performed. After the wounds had healed, an impression was taken in the same way as for the maxilla and the occlusal relationships were 238 Quintessence International Volume 27, Number 4/1995 Havakawa et al Fig 4 The positions of the maxillary incisors (dotted line) were determined on the cephalomelric iracing so that Ihe value of the maxillary incisor to the nasion-pogonion N-Pog) plane was brought near to the mean ot Japanese women. Fig 5 The maxillomandibular relationship was recorded wilh occlusion between the opposing premolars. Fig 6 A template has boen prepared as a guide fcr gingivectomy and alveolectomy. recorded, using the contacts in the premolar regions as a guide. The immediate denture was made on the mandibular cast, on which the premolars were removed. The immediate denture was inserted after all the mandib- ular remaining teeth were extracted. Three months after insertion of the immediate dentures, cephalometric analysis revealed that the vertical dimension had decreased a little. To restore it to the preoperative situation, the posterior teeth were built up with an autopolymerizating acrylic resin. Subsequently, new complete dentures were con- structed with conventional methods. To check the vertical dimension of occlusion and the position of the anterior teeth, cephalograms were prepared each time the occlusai rims and the trial dentures were inserted in the mouth. Furthermore, when the triai dentures were inserted, the position of the anterior teeth was evaiuated by assessing the patient's appearance. On the cephalogram taken with the new dentures in situ, the anterior teeth and lips were greatiy retruded compared with their positions on the preoperative cephalogram. The value of the maxillary incisor to the nasion-pogonion plane was brought nearly to the mean value for Japanese women, and the esthetic plane was improved. It was also obvious from the patient's appearance that esthetics was greatly improved (Figs 7 to 9). The dentures fit weli, and the patient's chief complaint was solved to her satisfaction. Quintessence Intemational Volume 27, Number 4/1996 239 Hayakawa et al Fig 7 New complete dentures are intended to maintain the vertical dimension of occlusion and restore lip compe- tence. Fig 8 (Right) Superimposition of the preoperative ceph- alometric tracing (solid lines)\ and the tracing with new dentures (dotted lines). Esthetic plane (E-pi). \ Figs 9a and 9b The new dentures greatly improve esthetics. Discussion In this case, the advanced gingival hyperplasia and significant displacement of remaining teeth caused severe damage to the patient's appearance. The patient was eager for esthetic improvement. The cephalometric analysis was used to determine the degree to which the teeth had drifted. The analyses used were Downs' analysis^ and the Northwestern analysis.^ usually used in orthodontics, and Ricketts' analysis'' and Mastumoto's analysis,- used in prostho- dontic treatment. According to the analyses, although the mandibular plane angle ofthe patient was steeper than the mean value for Japanese women, it was clinically acceptable. Labial tipping of the anterior leeth caused by the alveolar hyperplasia was the problem that needed to be solved. 240 Quintessence Intemationai Volume 27, Number 4/1996 Hayakawa et al Because it was thought that a successful result could not be attained by periodontal treatment, it was decided that the appearance could be improved by insertion of complete dentures after extraction of all Ihe remaining hopeless teeth. During fabrication of immediate complete dentures, the cephalometric analysis was very useful in deciding the position ofthe anterior teeth. To bring the esthetic plane close to the mean value, the anterior teeth ofthe immediate dentures were arranged by referring to the value of maxillary incisor to the nasion-pogonion plane. The occlusion ofthe opposing premolars and pre- operative cephalograms were helpftil in maintaining the vertical dimension of occlusion. The lower facial height decreased by 3.5 mm 3 months after insertion ofthe immediate dentures. This reduction was believed to be caused by a decrease of the gingival swelling and rsorption of alveolar bone. The vertical dimension of occlusion was restored by building up the posterior teeth with an autopoly- merizing acrylic resin. Although enough time was allowed for wound healing before the fabrication of new dentures, it is necessary to continue assessing the rsorption of alveolar bone, because of the extraction of all the remaining teeth and the extensive alveolar plastic surgery that was peribrmed. Summary The mild form of hydantoin-associated gingival hyper- plasia may be improved by reduction ofthe dosage of the anticonvulsant drug and thorough plaque control. In the severe form of drug-induced hyperplasia, it is not possible to cure the problems completely by gingivectomy or plaque control. In the present case, it was decided to extract all the patient's remaining teeth and restore Ilinction and esthetics early with complete dentures. References 1. lizuka T, Ishikawa F. Normal standards for various cephatomelric analysis in Japanese adults. J Jpn Orthod Soc I957;I6:4-I2. 2. Matsumoto T. A roentgenographic cephalometric study on vertical dimension. J Jpn Prosthodom Soc 197hl5:209-220. 3. Downs W. Variation in facial relationships: Their significance in treatment and prognosis. Am J Orthod 1948:34:812-840. 4. Graber TM. A critical review of clinical cephalometric radiography. Am J Orthod 1954:40:1-26. 5. Rickeits [IM. A foundation for cephalometric communication. Am J Orthod 1960:46:330-357. D Quintessence Intemational Voiume 27, Number 4/1996 J.Thomas Lambrecht 3-D Modeling Technology in Oral and Maxillofacial Surgery US SI40 145 pp: 292 illus (227 m color) ISBN 0-86715-287-7 T his book explores 3-D niodelinu; of indi- vidual patients undergoing oral and nuL\- illofacial surgeiy/reconstruction. Models facilitate treatment planning and snrgery by allowing surgeons to stiidv a patients bony stnictnre. In addition to applications in pre- prosthetic and tumor surger\\ 3-D modeling can assist in surgical correction ofmalocclu- sion and congenital deformities. An introduc- tion to the 3-D modeling processincluding computed tomography, magnetic resonance tomography, and molel abricationand nuineroiis case studies are presented. Contents includes: / General Ilistoiyof 3-D Technolog)' / Visualization / Model Construction / Limitations and Potential Applications / Computerized Tomography / Model Fabrication / Magnetic Resonance Tomography / Utilities / Nineteen Case Stndies / Bibliography / Manufacturers and Related Information Order Today Toll free 1-800-621-0387 Fax 708 682-3288 book/
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