Step-by-step full mouth rehabilitation of a nasopharyngeal carcinoma patient with tooth and implant-supported prostheses: A clinical report

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1 [Downloe free from on Wenesy, July 17, 2013, IP: ] Clik here to ownlo free Anroi pplition for this journl Step-y-step full mouth rehilittion of nsophryngel rinom ptient with tooth n implnt-supporte prostheses: A linil report Mrzieh Alikhsi, Mhmoo Kzemi, 1 See Nokr, 1 Arsh Khojsteh, 2 Seigheh Sheikhzeh 3 Astrt This linil report presents 46-yer-ol mn ignose with nsophryngel rinom with the hief omplint of mstitory n speeh efiieny euse of rition therpy. After perio of ontrolling post rition ries, the ptient ws rehilitte with tooth n implnt supporte metl ermi restortions following surgil n enoonti intervention. Keywors: Cse report, implnt-supporte prostheses, nsophryngel rinom, orl rehilittion Introution Nsophrengel rinom (NPC) refers to group of tumors originting from lymphoi tissues. NPC shows three tegories se on histologil exmintion. The first symptom in hlf of the ptients is ervil lymphenopthy whih represents metstti tumor. Although rre in most prts of the worl, NPC is very ommon in southern Chin n Southest Asi. NPC is ssoite with Epshteinr virus infetion, n other prole etiologil ftors re smoking n ouptionl exposure to woo, intke of some kins of foo speilly the ones ontining nitrosmines suh s slte fish. [1,2] Tretment pln for NPC ptients vries from riotherpy lone in primry lesions to juvnt hemotherpy in vne ones. Riotherpy is one of the most ommon tretments for he n nek mlignnies. Exposure perio n totl tretment ose re oth importnt ftors in treting erly stge NPC. Deresing the totl rition time to less thn 12 weeks n not exeeing rition Deprtments of Dentl Reserh n Prosthoontis, 1 Prosthoontis, n 3 Dentl Reserh, Shool of Dentistry, Tehrn University of Meil Sienes, 2 Deprtment of Orl n Mxillofil Surgery, Tleghni Hospitl, Beheshti University of Meil Sienes, Tehrn, Irn Corresponene: Ms. Seigheh Sheikhzeh, Deprtment of Dentl Reserh, Shool of Dentistry, Tehrn University of Meil Sienes, North Amir St., Tehrn, Irn. E-mil: elfsh@yhoo.om Quik Response Coe: Aess this rtile online Wesite: DOI: / X ose of 75 Gy hs prove to show the est results. [3] In suh ses, results re omprle to those otine with surgery euse NPC erly lesions re very sensitive to rition. [4] Although riotherpy is preferre to surgery in erly stges of tretment of NPCs s it reners more hnes of tissue preservtion, it exerts omplitions in sensitive strutures suh s the orl muos, slivry glns, entition n jws. Trismus is one of the ommon sie effets fter riotherpy n hnes for it re 8% to 38%. [5,6] It n e the result of sr formtion or tissue firosis n musle spsm. [7,8] Limite mouth opening n interfere with ptient s ily tivities n ompromise the qulity of life. Dentl mlprtie is lso sequel of this limittion euse the prtitioner woul not hve enough essiility uring entl tretments. Irrition n lso mge the slivry glns n onsequently xerostomi ours. Xerostomi strts s soon s ptients reeive the first frtions of riotherpy n n lst up to 2 yers. [9] Xerostomi n lso use isomfort espeilly in enture werers. [10] Reue slivry flow rte n evelop n inrese inient of rition ries ffeting inisl n ervil prts of teeth. [11] Dentists eing prt of the mngement tem for NPC ptients n ply signifint role. The entl tretments to these ptients hve to e one oth efore n fter the rition. Pretretment entl evlution is onsiste of full linil n riogrphil evlution. Dentl prtitioners must omit infetion soures sine the risk of new infetion is high ue to the ompromise host efense fter ner therpy. [12] There is lso n inrese risk of rio nerosis in the first few months fter riotherpy. Therefore, unrestorle teeth must e extrte efore the rition. The entists shoul esrie the onition n explin the post rition omplitions to the ptients to provie more ompline. During the time ptients re unergoing riotherpy, entists must ontrol ute infetions n voi invsive entl proeures s possile. [12] At the time irrition Contemporry Clinil Dentistry Jul-Sept 2011 Vol 2 Issue 3 256

2 [Downloe free from on Wenesy, July 17, 2013, IP: ] Clik here to ownlo free Anroi pplition for this journl Alikhsi, et l.: Full mouth rehilittion of nsophryngel rinom ptient therpy for NPC omes to en, ptients nee ifferent sorts of entl tretments ue to extensive ries use y erese slivry flow n poor orl hygiene s sequene of ompromise meil sttus. Some entl mterils inluing resin-moifie glss-ionomer, ompomers, n fluorie-relesing resin omposites oul e effetive in preventing seonry ries. [13-15] However, it shoul e emphsize tht mintining orl hygiene n ptient s iet surveying re importnt spets of tretment. Fluorie supplements re effetive in reuing seonry ries n the ptient shoul e ske to use it regulrly. The ptients who hve reeive riotherpy usully nee full mouth rehilittions sine most of them hve h their unrestorle teeth extrte efore n fter the riotherpy to prevent vrious sie effets. The limite mouth opening in these ptients lso uses hllenges in hoosing the type of the prostheti tretment pln. This rtile esries sequentil pproh to the interisiplinry tretment of prtilly eentulous ptient with exessive tooth tissue loss in 46-yer-ol mn with history of riotherpy n hemotherpy. Exessive tooth loss ws ttriute to post rition xerostomi n itrogeni imperfet tretments. Cse Report A 46-yer-ol mn presente to the Deprtment of Prosthoontis t Tehrn University, Shool of Dentistry. His hief omplint ws efiieny in speeh n mstition. His pst meil history revele tht he hs een uner tretment for unifferentite nsophrengel rinom of nek (NPC). Surgery inlue lol tumor resetion n lymph noe issetion. Riotherpy ws omplishe within 100 ys postopertively. He ws irrite with 60 Gry (Gy), t single oses of 2 Gy. Riotherpy prmeters, suh s rition ose n tehnique use, were reore. The ptient h no musle tenerness or fil symmetry n enie ny symptoms of temporomniulr joint isorer or myofil pin ysfuntion. Funtionl mnipultion i not show ny sign of prfuntion, ut mniulr rnge of motion ws not within norml limits n there ws ovious limittion in mouth opening (30 mm). Introrl plption showe sumuosl firosis like onition of orl muos. The sliv ws thik n muous n there ws generlize ries n reurrent ries throughout entition. Clinil exmintion revele missing of mniulr posterior teeth exept left first n seon premolrs. All the teeth exept mxillry inisors n first right premolr h reeive enoonti tretment, though ll were fulty tretments n neee retretment. The mxillry left n right nines, first n seon premolrs n mniulr left seon premolr h omplete overge rowns [Figure 1]. Mrginl opening of ll omplete rowns n rekown n lekge of these restortions were note. 257 Defetive mlgm restortions with mrginl rekown n reurrent ries were present in teeth # 3, 14, n 15, n efetive omposite restortions with mrginl lekge were present in teeth # 8, 9, n 10. The ptient exhiite generlize mil gingivitis n miniml leeing on proing. The ptient ws referre to the ENT eprtment for evlution. However, his meil onsulttion reporte tht he i not hve ny urrent signs or symptoms of NPC. Tretment pln options (fixe versus removle) were presente to the ptient. However, onsiering the ptient s esires, omplete mouth rehilittion with tooth n implnt supporte metl ermi restortions ws suggeste. However, the first step ws ontrolling ries. Therefore, iet evlution ws performe n he reeive ily fluorie tretment with ustom-me rrier n 0.4% stnnous fluorie gel. Besies iet survey n iet moifition, orl helth instrution inluing informing the ptient out isese etiology n orl hygiene instrution, evlution of slivry flow, n presriing xylitol prouts were rrie out for the ptient. Enoonti tretment n retretment were one for ll the remining teeth exept mxillry seon left molr. This tooth ws extrte euse of limite mouth opening n therefore limite ess to it [Figure 2]. The tretment pln inlue initil preprtion n ries removl n omplete mouth linil rown lengthening surgil proeures to expose 1.5 to 2 mm of tooth struture irumferentilly for equte ferrule for resistne n retention forms n to filitte estheti gingivl levels. Sine there ws no eptle posterior support, the ignosti phse involve removle ignosti overenture. This phse lso helpe etermining the length of teeth n evluting phonetis n esthetis. After the removl of filing restortions n ries removl, primry impressions were me n estheti linil rown lengthening ws esigne on the ignosti sts. Then ignosti wx up ws one n vuum forme surgil templte ws frite s referene for the prospetive esire gingivl levels uring the rown lengthening surgil proeures. Full-thikness flps with sllope inisions were elevte to preserve interentl ppille [Figure 3]. Osteotomy ws performe oring to surgil templtes to evelop 2.0 mm of iologil with n 1.0 mm of sululr epth. Tooth #12 ws extrte uring rown lengthening proeure euse of vertil root frture. A entri reltion reor ws otine with reor ses n olusion rims using n interolusl registrtion mteril (Virtul; IvolrVivent, Shn, Liehtenstein). The sts were trnsferre into semi-justle rtiultor (Denttus ARH, Stokholm, Sween) y the entri reltion reor. Prostheti teeth (Mjor; Mjor Prootti Dentri, Torino, Itly) were rrnge for tril insertion. The overly enture ws proesse n ws juste on the remining teeth [Figure 4]. A riogrphi stent for implnts ws frite (luitone ler resin) y upliting the overly enture n oting its teeth surfe with rium sulfte. Then, tomogrphi riogrphs were tken to hek one height n with n proper implnt Contemporry Clinil Dentistry Jul-Sept 2011 Vol 2 Issue 3

3 [Downloe free from on Wenesy, July 17, 2013, IP: ] Clik here to ownlo free Anroi pplition for this journl Alikhsi, et l.: Full mouth rehilittion of nsophryngel rinom ptient Figure 1: Introrl view of pretretment entl sitution: (, ) olusl views. (, ) Left n right lterl views Figure 2: Pnormi riogrph fter enoonti tretments Figure 4: () The overly enture; (,, ): Ajustment of the overly enture on the remining teeth Figure 3: Crown lengthening proeure. (, ): Mxillry n mniulr ignosti sts; () Surgil templtes; () Elevtion of full thikness flp with sllope inisions Figure 5: (, ): Riogrphi templtes; () Evlution of ville one in tomogrphi riogrphs Contemporry Clinil Dentistry Jul-Sept 2011 Vol 2 Issue 3 Figure 6: Progressive one loing. () Right posterior temporry restortions out of olusion; () Left posterior temporry restortions out of olusion; () Three weeks lter, temporry restortions in olusion exept ponti; () Three weeks lter, full olusl ontt 258

4 [Downloe free from on Wenesy, July 17, 2013, IP: ] Clik here to ownlo free Anroi pplition for this journl Alikhsi, et l.: Full mouth rehilittion of nsophryngel rinom ptient Figure 7: Clinil view of post- tretment entition. (, ) olusl views of mxill n mnile; () Frontl view; () Smile view position [Figure 5]. Two mm enostel entl implnts (Institut Strumnn AG, Wlenurg, Switzerln) were ple in eh posterior mniulr qurnt using the surgil guie. All implnts were inserte uner lol nesthesi n were inserte primrily stle. Bulky flps were thinne in the sme session. The following 5 ys, 250 mg of efuroxim (Elots, B Oleslohe, Csn, Germny) ws given twie orlly n ptients rinse their mouth twie ily with 3% hyrogen peroxie; no speifi iet ws followe. After 5 weeks, the stility ws teste with Osstell (Integrtion Dignostis, Gothenurg, Sween). The teeth were prepre n ustom post ptterns were frite oring to vuum silion guie me over overly entures. After finlizing st post in the ll remining teeth, impressions were me of mxillry n mniulr rhes. This impression in mnile not only reor prepre teeth, ut lso ws n implnt level impression. For trnsferring the ext mxillo mniulr reltionship estlishe with overly entures to the finl fixe restortion, the nterior setion of the overlys were remove so tht Lui jig oul e me etween inisors t the existing vertil imension of olusion (VDO). Then, the entri reltion ws me etween posterior mxillry prepre teeth n mniulr reor se long with ross mounting with st me of over impressions of overly entures. A ustom inisl guie tle ws me from GC pttern resin (GC Ameri) while overly entures were on the rtiultor. Wxing ws one oring to the ustomize guie tle on ie sts n onverte to het-proesse ryli temporry restortions. The ignosti interim restortions were moifie until the ptient ws stisfie with phonetis, esthetis, n funtion. During the evlution perio, the ptient s nterior n posterior speking spe n funtion ws ssesse. Furthermore, these restortions were use for progressive loing of implnts. Aryli restortions on the implnts first were me without olusl ontt, with olusl ontt 259 on the utments 4 weeks lter, n full olusl ontt on the utments n ponti fter 8 weeks. The interim restortions were funtione for out 4 months to ssess the ptient s pttion to the propose new vertil imension of olusion n the new linil rown lengths [Figure 6]. Susequently, the gingivl tissue roun the tooth preprtions h mture n efinitive impressions were me with vinyl polysiloxne impression mteril (Affinis; Coltène/Whleent, In, Cuyhog Flls, Ohio). The mxillry n mniulr nterior teeth were restore with efinitive restortions. Centri olusion, even protrusive ontts, n nine guine were estlishe in the efinitive nterior restortion. The omplete rowns n fixe prtil entures (FPD) were prepre n omplete. Crowns were st with gol lloy. After the fit of the st rowns ws verifie introrlly, metl-ermi restortions were omplete (Omeg 900; VITA Zhnfrik, B Skingen, Germny). All rowns were emente with temporry ement. A het proesse hr olusl gur (Luitone Cler, Dentsply, York, PA, USA) ws elivere to evlute the ptient s tolerne of new VDO n proviing the ptient with mutully protete olusion [Figure 7]. Following the efinitive ementtion of ll restortions, neutrl ph soium fluorie (Previ Dent 1.1% Brush-On Gel; Colgte Orl Phrmeutils, New York, NY) ws presrie to prevent seonry ey uner the restortions. The ptient ws vise to return every 6 months for rell evlution. The ptient ws stisfie with the improve esthetis n funtion of his teeth. The ptient hs een followe for 8 months sine the ompletion of his tretment n remins free of ny omplitions. Aitionl instrution ws given on the use of floss threers n superfloss uner the FPD. Disussion Riotherpy in NPC ptients hs rmti effets on their qulity of life. Rehilittion of NPC ptients involves severl steps mong whih preventive mesures suh s orl hygiene instrution n iet survey re very importnt. As sequel of xerostomi, not only there is n inrese risk of ries, ut lso tretment pln is lso ffete. In these ptients, the routine prostheti tretments re not often suessful euse of reue surfe tension etween muos n prosthesis. [15] Therefore, implnt-supporte prosthesis woul e of hoie n hs emonstrte its effiy n seems to e relile. [16-18] However, osge n heling time fter riotherpy re signifint ftors to inite implnt in these ptients. [19,20] Tretment of this se involve suessful restortive tretment fter 3-month perio of preventive evlution phse. Referenes 1. Chpmn KE, Ptton LL. Nsophryngel rinom: A 15-yer retrospetive stuy. Spe Cre Dentist 1993;13: Hilesheim A, Dosemei M, Chn CC, Chen CJ, Cheng YJ, Hsu Contemporry Clinil Dentistry Jul-Sept 2011 Vol 2 Issue 3

5 [Downloe free from on Wenesy, July 17, 2013, IP: ] Clik here to ownlo free Anroi pplition for this journl Alikhsi, et l.: Full mouth rehilittion of nsophryngel rinom ptient MM, et l. Ouptionl exposure to woo, formlehye, n solvents n risk of nsophryngel rinom. Cner Epiemiol Biomrkers Prev 2001;10: Chng JT, See LC, Lio CT, Chen LH, Leung WM, Chen SW, et l. Erly stge nsophryngel rinom: Riotherpy ose n time ftors in tumor ontrol. Jpn J Clin Onol 1998;28: Cponigro F, Longo F, Ionn F, Perri F. Tretment pprohes to nsophryngel rinom: A review. Antiner Drugs 2010;21: Steelmn R, Sokol J. Quntifition of trismus following irrition of the temporomniulr joint. Mo Dent J 1986;66: Thoms F, Oznne F, Mmelle G, Wiult P, Eshwege F. Riotherpy lone for orophryngel rinoms: the role of frtion size (2 Gy. vs 2.5 Gy.) on lol ontrol n erly n lte omplitions. Int J Rit Onol Biol Phys 1988;15: Golstein M, Mxymiw WG, Cum-mings BJ, Woo RE. The effets of ntitumor irrition on mniulr opening n moility: A prospetive stuy of 58 ptients. Orl Surg Orl Me Orl Pthol Orl Riol Eno 1999;88: Dly TE. He n nek: entl re in the irrite ptient. In: Flether GH, eitor. Textook of riotherpy. Philelphi: Le n Feiger; p Jen YM, Lin YC, Wng YB, Wu DM. Drmti n prolonge erese of whole slivry seretion innsophryngel rinom ptients trete with riotherpy. Orl Surg Orl Me Orl Pthol Orl Riol Eno 2006;101: Cssolto SF, Turnull RS. Xerostomi: Clinil spets n tretment. Geroontology 2003;20: Lăătuşu S, Frânu L, Frânu D. Clinil n therpeutil spets of rmpnt ries in ervio-fil irrite ptients. Rev Me Chir So Me Nt Isi 1996;100: Brennn MT, Woo SB, Lokhrt PB. Dentl tretment plnning n mngement in the ptient who hs ner. Dent Clin North Am 2008;52:19-37, Dikmn GE, Arens J. Seonry ries in situ roun fluorierelesing light-uring omposites: A quntitive moel investigtion on four mterils with fluorie ontent etween 0 n 26 vol%. Cries Res 1992;26: Ngmine M, Itot T, Torii Y, Irie M, Stnine M, Inoue K. Effet of resin-moifie glss-ionomer ements on seonry ries. Am J Dent 1997;10: Tm LE, Chn GP, Yim D. In vitro ries inhiition effets y onventionl n resin-moifie glss-ionomer restortions. Oper Dent 1997;22: Roumns ED, Mrkowitz BL, Lornt JA, Clterr TC, Jones NF, Beumer J 3r. Reonstrute mniulr efets: Fiul free flps n osseointegrte implnts. Plst Reonstr Surg 1997;99: Shultes G, Gggl A, Kärher H. Stility of entl implnts in mirovsulr osseous trnsplnts. Plst Reonstr Surg 2002;109: MGhee MA, Stern SJ, Clln D, Shewmke K, Smith T. Osseointegrte implnts in the he n nek ner ptient. He Nek 1997;19: Nishimur RD, Roumns E, Moy PK, Sugi T, Freymiller EG. Osseointegrte implnts n oritl efets: UCLA experiene. J Prosthet Dent 1998;79: Esposito M, Hirsh JM, Lekholm U, Thomsen P. Biologil ftors ontriuting to filures of osseointegrte orl implnts (II). Etiopthogenesis. Eur J Orl Si 1998;106: How to ite this rtile: Alikhsi M, Kzemi M, Nokr S, Khojsteh A, Sheikhzeh S. Step-y-step full mouth rehilittion of nsophryngel rinom ptient with tooth n implnt-supporte prostheses: A linil report. Contemp Clin Dent 2011;2: Soure of Support: Nil. Conflit of Interest: None elre. Announement Anroi App A free pplition to rowse n serh the journl s ontent is now ville for Anroi se moiles n evies. The pplition provies Tle of Contents of the ltest issues, whih re store on the evie for future offline rowsing. Internet onnetion is require to ess the k issues n serh fility. The pplition is omptile with ll the versions of Anroi. The pplition n e ownloe from For suggestions n omments o write k to us. Contemporry Clinil Dentistry Jul-Sept 2011 Vol 2 Issue 3 260