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Importance of Periodic Control after Fitting a Total Prosthesis - Case Report
Marcelo Oliveira MAZZETTO
Wilson ABRÃO
Marco Antonio M. RODRIGUES DA SILVA
Faculdade de Odontologia de Ribeirão Preto Universidade de
São Paula, Ribeirão Preto, SP Brasil
Braz Dent J (1990) 1(1): 51-54 ISSN 0103-6440
| Introduction | Care
Report | Discussion | References
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A patient was seen at the Total Prosthesis Clinic complaining of facial
pain after using the same prosthesis for 46 years. Clinical examination
revealed TMJ disturbance due to a loss of the vertical dimension caused
by a wearing of the teeth. Diagnosis indicated replacement with new prostheses,
with a gradual recuperation in the vertical dimension by the application
of resin over the lower teeth and a reconditioning of the support tissues.
After the alleviation of pain, correction of the dysfunction and reestablishment
of the vertical dimension of occlusion, new prostheses were made. At the
end of treatment, the patient felt a relaxed facial musculature, lifting
the mandible to a resting position instead of constantly maintaining it
in occlusion as before. The patient was given instructions as to use, conservation
and hygiene of the prostheses and oriented to return for annual evaluation
of occlusion and of the supporting oral structures, as well as the stability
of the prostheses.
Key words: total prosthesis, vertical dimension, conservation.
Introduction
The Clinic of the School of Dentistry of Ribeirão Preto frequently
receives patients with total prostheses with more than 10 years of use.
Upon inquiring if at the time of installing the prostheses they had received
orientation as to how to use, preserve and conserve the prostheses, as
well as of the necessity of periodic evaluation, the response was always
negative. This demonstrates the lack of general attention shown to edentulous
patients even today. This could lead to the false impression that, while
other dental specialities have evolved, especially in the area of prevention,
the area of Total Prostheses remains as it was in its early days. However,
this is not really the case. What actually occurs is that, in fact, most
dentists, especially in a general clinic, offer this type of information
to their patients without adequate training and even without sufficient
knowledge to do this satisfactorily. Often the professional only takes
the impressions of the patient, leaving the rest of the work - from the
making of the models to the selection of the form and size of the teeth
- to the laboratory technicians.
According to Nagle et al. (1%5), a total prosthesis which follows all
of the technical requirements during its construction ought to be seen
at least once a year. After this time, detailed examination not only of
its actual condition but also of the structures of support is necessary.
Really, if one considers that during this period physiologic bone reabsorption
and a wearing of the occlusion surfaces of the artificial teeth occur,
a reduction in the vertical dimension is expected to occur, besides a compromise
in the retention, stability and support of the prosthesis. Thus, periodic
control is indispensable.
Case Report
A 66 year old female patient, having used the same total prosthesis for
46 years (Figure 1A,B), was seen at the Clinic of the Dental School of
Ribeirão Preto, complaining of facial pain. Upon clinical examination,
a temporomandibular joint dysfunction caused by an exaggerated loss of
vertical dimension was found. According to Weinberg (1979, 1980a,b), this
problem was caused by the dislocation of the condyle in the interior of
the glenoid fossa to a position posterior and/or superior, initially causing
an inflammation of the region and then osteoarthritis with pain. On examination
of the prostheses, a complete wasting of the mandibular teeth was found,
caused by attrition of the porcelain teeth of the maxillary prosthesis
against the acrylic teeth of the mandibular prosthesis (Figure lA), causing
a loss of vertical dimension (Figure lB). The supporting tissues showed
moderate, generalized inflammation, especially of the maxilla.
The clinical picture indicated the need of new prostheses, with a gradual
recuperation in the vertical dimension and reconditioning of the support
tissues. Thus, already on the first visit, the vertical dimension was recuperated
about 2 mm by the addition of autopolymerized acrylic resin over the teeth
of the lower prosthesis in use. (Figure lC), forming a straight, smooth
plane. At the same time, the prosthesis was filled with "Resil", to recuperate
the tissues.
Fifteen days later, the patient returned to the Clinic with less facial
pain, complaining only of difficulty in chewing. A new 2-mm layer of resin
was applied to the prosthesis. Twenty days later, the patient returned
without any type of pain, but still complaining of difficulty in chewing.
Having eliminated the causes and symptoms of pain and the temporomandibular
dysfunction, new prostheses were constructed using the actual vertical
dimension of the patient with her old prostheses in occlusion to register
the intermaxillary relations since the correct vertical dimension had been
restored (Figure 1D).
The centric relation was recorded with an intraoral Gothic arc tracer
and the models were placed in a semiadjustable articulator (Gnatus). A
straight occlusal plane (without the curve of Spee) was followed in the
mounting of the teeth, especially the posterior ones, with only the second
maxillary molars in an inclined position, in order to form a ramp to permit
free lateral movements and avoid the "Chistensen" phenomenon when in protrusion,
thus permitting balancing in the protrusion position.
The functional fitting showed good centric contact and adequate occlusal
balance in lateral movements. At each phase, the vertical dimension was
always confirmed and tested. Upon final fitting of the prostheses (Figure
1E, F), the patient was asked to return the following day for adjustment.
Upon returning, the patient's principal complaint was of pain at the
alveolar crest. The vertical dimension, confirmed by phonetic measurements
and methods, was correct. A few adjustments in occlusion and trimmings
of the lateral faces of the mandibular prosthesis were made. Upon return
72 hours later, the patient no longer complained of any functional discomfort.
The border sensibility was lessened. One week later, without complaints,
the patient was requested to return after 90 days for another evaluation.
Discussion
After her last visit, the patient was completely comfortable with her new
prostheses, being able to speak and chew, and was satisfied with the esthetic
appearance.
The pain disappeared and according to the patient inicial discomfort
upon awakening had disappeared. She felt a relaxing of the facial muscles,
being able to easily maintain the mandible at rest contrary to the constant
occlusion position. before treatment.
Periodic visits to the dentist by patients with total prostheses are
an important factor for the success of treatment, not only in terms of
the prostheses duration but also in terms of patient comfort. Thus, besides
routine instruction regarding use, conservation and hygiene of the prostheses,
the dental surgeon ought to orient his patients to return to his office
at least once a year to evaluate occlusion, vertical dimension, prosthetic
stability and the condition of supporting tissues. Only in this manner
can situations as the case presented be avoided.
References
Nagle RJ, Lears VH: Protesis dental - Dentaduras completas. 2nd ed. Toray
SA, Barcelona 1965 .
Weinberg LA: The etiology, diagnosis and treatment of TMJ. Disfunction-pain
syndrome. Part I: Etiology. J Prosth Dent 42: 654-663, 1979
Weinberg LA: The etiology, diagnosis and treatment of TMJ. Disfunction-pain
syndrome. Part II: Differential diagnosis. J Prosth Dent 43: 58-70, 1980a
Weinberg LA: The etiology, diagnosis and treatment of TMJ. Disfunction-pain
syndrome. Part III: Treatment. J Prosth Dent 43: 86-195, 1980b
Correspondence: Dr. Marcelo Oliveira Mazzetto, Departamento de
Odontologia Restauradora, Faculdade de Odontologia de Ribeirão Preto,
USP, 14050 Ribeirão Preto, SP, Brasil.
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