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Clinical Report
Prosthodontic rehabilitation of an edentulous patient
affected with oral submucous fibrosis
Shivangi Gajwani, Krishna Prasad, Chethan Hegde, N Sridhar Shetty, Manoj Shetty,
Pranav Mody
Department of Prosthodontics including Crown, Bridge and Implantology, A. B. Shetty Memorial Institute of
Dental Sciences, Deralakatte, Mangalore, Karnataka, India
For correspondence
Dr. Shivangi Gajwani, Department of Prosthodontics including Crown, Bridge And Implantology, A. B. Shetty Memorial Institute of Dental
Sciences, Deralakatte, Mangalore, Karnataka, India. E-mail: shivangi_11@yahoo.co.in
Oral Submucous Fibrosis is a disease condition considered to be pre-cancerous in nature. Its malignant predilection has been
extensively studied by Pindborg and Sirsat. According to a study, this disease condition is found to be in 4 in 1000 adults in rural
India with the incidence of malignant transformation ranging from 3-19%. As it occurs chiefly in southern India, we as dental
surgeons specifically in Karnataka region often come across such patients, due to the prevalence of betel nut chewing and
lack of awareness among the general population. A clinical case in which the patient presented with Oral Submucous Fibrosis
along with complete edentulism and salivary gland hypo function is discussed. In this report, a patient with Oral Submucous
Fibrosis and related problems in prosthodontic rehabilitation is presented and a technique that improves retention, stability
and maximizes functional esthetic and comfort aspects with a conservative approach is highlighted.
Key words: Oral submucous fibrosis, soft liner
DOI: 10.4103/0972-4052.49190
IN TRODUCTION
Oral Submucous Fibrosis (O.S.M.F.) is an insidious
chronic condition affecting the oral cavity and sometimes
the pharynx, first reported among 5 East African women
of Indian origin by Schwartz under the term, atrophia
Idiopathica.[1]
It is characterized by a burning sensation of the mouth,
accompanied or followed by the formation of vesicles.
Mucosa eventually becomes blanched and fibrotic bands
appear, involving buccal mucosa, soft palate, lips and
tongue, leading to stiffness of the oral mucosa causing
trismus.[2]
It is most common between 20 to 40 years of age with
a female to male ratio of 3:1.[3] When it affects geriatric
patients with partial or complete edentulism, the task
of restoring function becomes all the more challenging.
CAS E REPORT
A 52-year-old female patient reported to the Department
of Prosthodontics including crown, bridge and
implantology, A.B. Shetty Memorial Institute of Dental
Sciences, Deralakatte, Mangalore, India, complaining of
reduced mouth opening, inability to masticate and a
burning sensation affecting the oral mucosa. The patient
gave history of betel nut chewing since 30 years.
On intraoral examination the buccal and labial
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mucosa were found to be pale and showed evidence
of thickening [Figure 1]. Dense fibrous bands could
be palpated within the oral cavity. Mouth opening
was restricted to 27 mm measured from crest of
the maxillary and mandibular alveolar ridges in the
anterior region. The patient presented with edentulous
resorbed maxillary and mandibular ridges, with fibers
extending from buccal mucosa to the ridge resulting
in shallow buccal vestibule, insufficient depth of
lingual vestibule with atrophic mucosa and salivary
gland hypo-function.
A clinical diagnosis of Oral Submucous Fibrosis with
complete edentulism was made in consultation with
clinicians from the Department of Oral Medicine and
Radiology. The patient was advised physiotherapy
(opening and closing the mouth wide with maximum
effort for 15-20 minutes at least 4 times a day) along
with cessation of the habit of chewing betel nut
quid. Local topical corticosteroid, (Tenovate, Apex)
application and intra lesional injection containing
Dexamethasone, Placentrix, Lignocaine in the ratio of
2:2:1, multi vitamin capsules (Becosule-Z, Phyzer), along
with Chlorhexidine mouth wash was administered.
Following this conservative management for a period
of 3 months, an increase in mouth opening was
noticed.
After the required investigations and preliminary
management, the definitive prosthetic treatment was
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Gajwani, et al.: Prosthodontic Rehab. of an Edentulous Patient affected with O.S.M.F
Figure 1: Intra oral view
Figure 2: Waxed up Balanced denture
Figure 3: Final relined complete denture prosthesis
Figure 4: Post treatment
Figure 5: Closed mouth impression with extra light body silicone
started in a conventional manner. The patient was
made to use a saliva substitute (Wetmouth, ICPA,
India) before making impressions. Small size stock
trays were selected and primary impressions made
with irreversible hydrocolloid (Tropicalgin, Zhermack,
Italy).
Since the mouth opening was limited, single stage
peripheral tracing was accomplished with putty vinyl
polysilioxane impression material (3M ESPE, Express,
U.S.A.). Due to the patient’s complaint of burning
sensation in the mouth, light body vinyl polysilioxane
impression material (3M ESPE, Express, U.S.A.) was
preferred to make secondary impressions.
The next step constituted transfer of orientation
relation using Artex Quickmount face bow and
recording centric relation by interocclusal wax
registration [Figure 2]. Jaw relations were secured on
a semi adjustable articulator (Girrbach-TR). Artificial
denture teeth (Acry-Rock, Ruthenium) of small
mold size S60, I60, D33 were selected and arranged
accordingly. The patient’s jaw relation presented and
recorded was Class II relation. Due to the deficiency
of space in mandibular posterior residual ridge region
and to facilitate arrangement of posterior teeth in
desired class I relation, second premolars on either
side (35, 45) were deleted from the teeth arrangement.
After the trial of waxed up denture, it was processed
in a conventional manner.[4] To achieve improved
results for the patient with such compromised oral
conditions, the conventional denture was modified.
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Gajwani, et al.: Prosthodontic Rehab. of an Edentulous Patient affected with O.S.M.F
The intaglio surface of the finished denture was
trimmed around 1-2 mm. Once the borders and tissue
surface were trimmed as well as roughened, another
impression with extra light body vinyl polysilioxane
impression material (3M ESPE, Express, U.S.A.),
was made with closed mouth impression technique
[Figure 5]. Maxillary and mandibular dentures with
these impressions were thereafter flasked directly.
This elastomeric impression material was replaced
by a permanent silicon soft liner[5] [Figure 3] (G.C.
Company, Japan) with the life expectancy of one year
at the most. After a minimum of 2 hours of bench
curing under clamp pressure, the flasks were placed
in water at a constant temperature of 70° C for 3 hours
according to the manufacturer’s recommendations. The
relined denture was tried in the patient’s mouth and
improvement in results was evident [Figure 4]. The
patient was advised to change the permanent liner
every 10-12 months to compensate for the changes in
the material as well as the oral conditions.
DIS CUS S ION
Oral Submucous Fibrosis is a chronic, progressive
disease condition which is pre-cancerous[6] in nature
with multifactorial etiology. [7] There is currently
no definitive treatment for this condition and with
increase in general life expectancy, there is a higher
percentage of individuals reaching old age with
O.S.M.F. at different grades of intensity.
In spite of the high prevalence of this condition in
geriatric patients in our country, there is a lacuna in
literature regarding prosthetic management of completely
edentulous patients suffering from O.S.M.F.
In the present case, a conventional complete denture
prosthesis was fabricated. The finished denture when
tried in the patient’s mouth fulfilled esthetic criteria
but the mandibular denture was not retentive and
comfortable to the patient. Due to presence of salivary
deficiency, the hard acrylic denture was not the ideal
solution for the atrophic mucosa, thus the denture
was modified.[8] The subsequent use of a permanent
reline material rendered a cushioning effect to the
atrophied mucosa enhancing patient comfort to a
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great extent- A softer option.[9]
The soft liner did not abrade the tissues which had
undergone atrophy, and adapted precisely onto the
residual alveolar ridge for a better fit. This report
highlights the benefits of relining a complete denture
prosthesis with a permanent soft liner in O.S.M.F.
cases. As seen in this case, using a permanent reline
material made the patient much more comfortable
and confident.
CON CLUS ION
In the present case, taking into consideration the signs,
symptoms and needs of the patient suffering from
Oral Submucous Fibrosis, the conventional denture
was modified by relining it with a permanent silicon
soft liner using a closed mouth technique.
REFEREN CES
1. Schwartz J. Atrophia idiopathica tropica mucosa oris.
11th Int Dent Congress. London: 1952.
2. Pindborg JJ, Sirsat SM. Oral submucous fibrosis. Oral
Surg Oral Med Oral Pathol 1966;22:764-79.
3. Jayanthi V, Probert CS, Sher KS, Mayberry JF. Oral
submucous fibrosis: A preventable disease. Gut
1992;33:4-6.
4. Zarb GA, Bolender CL, Carlsson GE. Boucher’s
prosthodontic treatment for edentulous patients. 11th
ed. St Louis: Mosby; 1997. p. 244-6.
5. Ryan JE. Twenty-five years of clinical application of a
heat-cured silicone rubber. J Prosthet Dent 1991;65:65861.
6. Lund TW, Cohen JI. Trismus appliances and indications
for use. Quintessence Int 1993;24:275-9.
7. Canniff JP, Harvey W, Harris M. Oral submucous
fibrosis: Its pathogenesis and management. Br Dent J
1986;160:429-34.
8. Näkki K, Siirilä HS. The pressure exerted by the circumoral
muscles in the vestibular fold of edentulous persons;
with closed and open mouth impression techniques.
Proc Finn Dent Soc 1976;72:2-6.
9. Williamson RT. Clinical application of a soft denture
liner: A case report. Quintessence Int 1995;26:413-8.
Source of Support: Nil, Conflict of Interest: None declared.
The Journal of Indian Prosthodontic Society | December 2008 | Vol 8 | Issue 4