Specialties

HOW PATIENTS BENEFIT

FR O M S U R G IO A L -O R T H O D O N T IC CARE P E TE R M. SINCLAIR, D.D.S., M.S.D. W ILLIAM R. PROFFIT, D.D.S., PH.D.

(C orrection of severe jaw deformi­ ties may improve not only dental health but also the patient’s selfimage. Such treatment can trigger personality changes: when patients look better, they have a more enthu­ siastic approach to life. Determining when a combined surgery and orthodontic treatment is needed depends on the patient’s age and whether a significant severe skeletal jaw discrepancy exists. If the jaw relationship is correct, crowded and malaligned teeth can nearly always be corrected by orthodontic tooth movement. When a severe malocclusion includes a jaw discrepancy, there are three treatment possibilities: Modification of growth or dentofacial orthopedics, which involves altering growth patterns to improve the dentofacial deformity. Camouflage, which displaces the teeth to obtain proper function despite the jaw deformity, and pro­ duces a dental compensation for the skeletal discrepancy. This often involves the extraction of teeth and may be carried out with growth modification in growing children. In an adult patient with a jaw dis­ crepancy, the only possibility for orthodontic treatment is camou­ flage by displacement of the teeth relative to the jaws.

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If an adult’s jaw discrepancy is too great to compensate and camou­ flage by tooth movement alone, surgery is the only way to reposi­ tion the jaws or dentoalveolar seg­ ments to achieve optimum occlusal, functional and esthetic results. The shorter orthodontic treat­ ment time and the improved occlu­ sion resulting from orthognathic procedures can also minimize potential side effects—root resorp­ tion, TM problems and periodontal disease. Surgery can also occasion­ ally be used to solve a problem in a child that is too severe for orthodontic treatment alone. Most surgical-orthodontic treat­ ment is performed on adults in whom a relatively stable, unchang­ ing relationship of the jaws is pre­ sent so that definitive treatment can be completed in one stage. The exceptions include young patients with cleft palates and craniofacial syndromes, as well as the child whose skeletal deformity is so severe as to be physically and psychosocially disfiguring. Many patients with anteroposte­ rior problems have a significantly increased incisor overjet (Class II, Division I malocclusion). When the overjet exceeds seven millimeters and the patient has no growth remaining, it’s extremely rare to be

able to camouflage the dentofacial deformity satisfactorily. A camouflage plan involving the extraction of maxillary premo­ lars and the subsequent retraction of maxillary incisors also requires a great deal of patient cooperation with headgear and elastic bands to reduce the excessive overjet. Apart from the likely detrimental effect on facial appearance caused by the posterior movement of the upper lip as the incisors are retracted, there is also an increased risk of maxillary incisor root resorption if these teeth con­ tact the lingual cortical plate. O t ’s important to recognize that in most of these Class II cases the problem really lies with a skeletally deficient mandible and that once the overjet approaches seven mil­ limeters, functional and esthetic concerns are rarely met by orthodontics alone. In such cases surgical mandibu­ lar advancement is a logical choice to correct rather than camouflage the underlying skeletal deformity. This option also has the advantages of fewer extractions and a consider­ ably shorter treatment time. Class III skeletal problems in adults, which may be the result of a protrusive mandible or a retrusive

maxilla, also usually require orthognathic surgery. In many cases, once a negative (reverse) overjet of greater than three mil­ limeters is present, it is virtually impossible to effect significant esthetic and functional improve­ ment by orthodontics alone, even with the most common camouflage treatment plan that involves extrac­ tion of two mandibular premolars and retraction of the mandibular incisors. A better solution would be to : attack the skele: tal problems with : either a maxil: lary advancement j or a mandibular i setback, or, in Dr. Sinclair is asso-

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Carolina. j approach permits the maximum correction of each component of the malocclusion while achieving optimum facial change and minimizing potential side effects.12 he Class II, Division 2 malocclu­ sion, in which the patient has retroclined maxillary incisors and almost always a severe deep bite, is often thought of as an anteroposterior problem. It should really be considered as more of a vertical problem. This is particu­ larly true in adults for whom a deep bite of six millimeters or more is extremely difficult to correct with camouflage treatment. With no growth potential and with intrusion of incisors limited to one to two millimeters, these cases should be considered as strong candidates for surgical orthodontic procedures if an opti­ mum correction of the esthetic (often a short lower face) and func­ tional problems are desired. This

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will often involve orthodontically flaring the maxillary incisors to make the case look like a Class II, Division 1 problem—then surgically advancing the mandible and rotat­ ing it downward anteriorly to reduce the overbite, lengthen the face and advance the chin. An adult with an anterior open bite of greater than three millime­ ters should be considered a potential candidate for surgical orthodontic treatment, particularly if the patient has a long face characterized by a display of excessive maxillary teeth and a recessive chin. Orthodontic camouflage is extremely limited in its ability to correct problems of this type. Significant dental extrusion of the maxillary incisors has been unsta­ ble and may worsen the appearance of the maxillary incisors relative to the patient’s lips. In some cases, surgery to reposi­ tion the maxilla superiorly (either in single or multiple segments) has been a highly effective, stable, esthetic solution for the open-bite,

long-face combination. A genioplasty to improve chin esthetics often is needed in conjunction with the max­ illary surgery. Mandibular defi­ ciency is reduced as the mandible rotates upward and forward. n treating actively growing patients with transverse problems, the clinician can use several tech­ niques. Functional and rapid palatal expansion appliances pro­ duce skeletal changes, while expanded arch wires and cross­ elastics are effective for local den­ tal crossbites. In adults, some degree of arch wire expansion and cross-elastic treatment is possible when only one or two teeth are involved in dental crossbites. When the crossbite is skeletal in nature and involves sev­ eral teeth, the only effective and stable solution is surgical expan­ sion of the maxilla. Many patients have a centricrelation to centric-occlusion slide, which frequently masks the true nature and extent of the crossbite.

A n a d u lt p a tie n t had a C la s s II ske le ta l re la tio n sh ip c a u s e d b y a d e fic ie n t m a n d ib le c o m b in e d w ith a d e c re a s e d lo w e r facial h e ig h t, m a lo c c lu s io n a n d d e e p b ite . O rth o d o n tic a n d s u rg ic a l p ro c e d u re s fla re d th e m a x illa ry in c is o rs a n d a d v a n c e d th e m a n d ib le d o w n w a r d a n d fo rw a rd . T h e d e e p bite h a s b e e n c o r ­ re c te d a n d th e c o n v e x p ro file a n d lo w e r facial h e ig h t im p ro v e d .

Thus, diagnosis is performed best with the patient’s teeth one or two millimeters out of occlusion so that the true nature of the crossbite can be determined before the point of initial contact is reached and the slide is initiated. Segmental maxillary oste­ otomies in combination with mod­ ern bone grafting and rigid fixation techniques have been highly suc­ cessful in correcting this deformity. In planning treatment, dentists must consider the patient’s con­ cerns, not impose their own stan­ dards. In turn, the patient must understand and accept the discom­ fort and inconvenience of treatment with a realistic expectation of the results.3'5In addition, in planning a surgical-orthodontic case, the pri­ mary objective is nearly always skeletal change rather than dental compensation. Thus it is virtually impossible in most cases to attempt to correct the patient’s problems by first using a conventional orthodon­ tic treatment plan and then consid­ ering surgery. Both the patient and clinician must be clear about the need for a surgical-orthodontic approach to the dentofacial defor­ mity from the outset.6 1^1 any dentofacial deformities involve complex problems that require combined treatment by the patient’s general practitioner, orthodontist, oral and maxillofacial surgeon and other specialists such as the periodontist and prosthodon­ tist. At the outset of treatment, active disease must be brought under control before any orthodon­ tic appliances are placed.78 Active periodontal disease also must be brought under control with scaling and curettage before initiat­ ing treatment. The patient’s role in home care must be reinforced, par­ ticularly in anticipation of having orthodontic appliances in place for 18-24 months.

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Some periodontal surgical proce­ dures (such as crown lengthening) should be deferred until occlusion is established. Some gingival grafting can improve the quality of the sup­ porting soft tissue. The tissue overlying the mandibular incisors needs special attention as it is often reduced in height and thickness in patients with dentofacial deformities.^ (^1 any potential surgicalorthodontic patients have multiple fixed or removable partial den­ tures. The clinician responsible for any future restorative work must be involved at the outset of treatment. Some TM symptoms (reciprocal click, pain, limited opening) or a centric relation to centric occlusion slide may be present. In these cases, conservative therapy can alleviate the symptoms and allow the patient to achieve a comfort­ able, unstrained mandibular posi­ tion before definitive treatment planning. When the post-surgical orthodontic phase of treatment is completed, definitive periodontic and restorative procedures can be accomplished. The periodontal sta­ tus of the teeth should be reassessed and, if required, crown lengthening along with flap proce­ dures should be done. Definitive restorative dentistry including fixed and removable prostheses is the final step in treatment for orthodontic-surgical patients. If correctly executed in a highly motivated, cooperative patient, orthodontic-surgical treatment may benefit the patient far more than conventional orthodontics alone. Dramatic esthetic improve­ ments can be produced when the skeletal, dental and soft tissues are altered to address the patient’s ini­ tial problems. Finally there are three types of risks with surgical-orthodontic treatment:

™ A very small but not zero chance of a catastrophic event, such as an anesthetic accident (approximately one chance in 25,000); “ Complications at stirgery (such as a postoperative infection) that create temporary inconve­ nience but do not affect the long-term outcome (approxi­ mately one chance in 15); ■■ An altered sensation in the lips or gingiva (approximately one chance in two that a change can be detected on careful testing, one chance in 20 : Dr. Proffit is profesthat it will be : sor and chairman, : Department of enough to | Orthodontics, School : of Dentistry, bother the : University of North patient). : Carolina. It is importan that the patient understand these risks, and that they be placed in correct perspective—neither ignored nor overblown, 1. Linge BO, Linge L: Apical root resorption in upper anterior teeth. Eur J Orthod 5:173-183,1983. 2. Reidel RA: Retention and relapse. J Clin Orthod 10:454-472,1976. 3. Peterson LJ, Topazian RG: Psychological evaluation of candidates for dentofacial surgery. In Bell WH, Proffit WR, White RP (eds): surgical correction of dentofacial deformities, p. 90-104, Philadelphia, Saunders, 1980. 4. Flannary CM, Barnwell GM, Alexander JM: Patient perceptions of orthognathic surgery Am J Orthod 88:137-145,1985. 5. Kiyak HA, West RA, Hohl T, McNeill RW: The psy­ chological impact of orthodontic surgery: A 9-month followup. Am J Orthod 81:404-412,1982. 6. Jacobs JJ, Sinclair PM: Principles of orthodontic mechanics in orthognathic surgery cases. Am J Orthod 84:399-407,1983. 7. Fields HW: Orthodontic restorative treatment for rel­ ative mandibular excess tooth-size problems. Am J Orthod 79:176-183,1981. 8. Tliverson DL: Anterior interocclusal relations. Am J Orthod 78:361-370,1980. 9. Boyd RL: Mucogingival considerations and their relationship to orthodontics. J Periodontol 49:67-76,1978.

Address requestsfor reprints to Dr. Sinclair, School ofDentistry, University of North Carolina, Chapel Hill, N.C. 27599-7450.

WHAT TO DO ABOUT DRY MOUTH M A R G O T L. VAN DIS, D-D.S., M.S.

Q 60-year-old man was having difficulty with his lower removable partial denture. During the first inter­ view, the man said that he had noticed a “pasty”feeling in his mouth and that his saliva had been “thick and foamy” for the past two or three years. He said, too, that he had previously visited a dentist “every year or so” for routine care. The man’s medical history showed a diagnosis of hypertension three years earlier and a cholecystectomy five years before that. He had also been smoking one and a half packs of cigarettes daily for 35 years. The patient was taking a prescribed antihyperten­ sive combination of 25 milligrams of chlorothiazide and 250 milligrams of methyldopa daily. His blood pres­ sure during the first visit was 154/84. He said he had no other medical problems, hospitalization or medications. Clinical examination showed accumulations of materia alba (whitish deposits) at the cervical aspects of the teeth. Also, heavy calculus deposits and brown stains were present on the lingual surfaces of the mandibular anterior teeth. There was recurrent decay around the margins of Class V restorations on teeth no. 20 and 28 and a carious lesion was present just coronal to the free gingival margin on the buccal surface of tooth no. 27. Demineralization was seen at the cervical aspects of the other anterior teeth. There was no pit and fissure caries and radiographs did not show any interproximal lesions. The saliva was viscous and would “string” from a gauze square.

In some patients, stimulating salivary flow is successful in curbing xerostomia. Mechanical stimulation—chewing sugarless gums orfoods like carrots and cel­ ery—may provide temporary relief. Based on the pattern of the carious lesions, the nature of the saliva and the patient’s complaint of a “pasty” mouth, a clinical diagnosis of xerostomia was made. A definitive diagnosis would require measurement of the salivary flow rate (rates less that 0.25 millimeters/ minute are considered diagnostic for xerostomia). Xerostomia can be attributed to a variety of factors. The more common causes include heavy smoking,

chronic alcohol intake and prescribed or over-the-counter drugs. The patient’s smoking habits and high blood pres­ sure medication were the most likely contributors. Xerostomia is a difficult condition to manage. Eliminating or reducing contributing factors is the first step. In the case of this patient, curtailing or eliminat­ ing his smoking habit might help. Identifying an antihy­ pertensive medication with a less drying effect might also be beneficial. But, medication substitution is not always feasible and another drug might have a similar side effect. In some patients, stimulating salivary flow is suc­ cessful in curbing xerostomia. Mechanical stimula­ tion-chewing sugarless gums or foods like carrots and celery—may provide temporary relief. Pood and drinks containing citric acid promote sali­ vation but should be used with caution. Their low pH may promote demineralization of dental enamel. Such pharmacologic agents as pilocarpine maybe adminis­ tered to stimulate salivary flow. But pilocarpine is a cholinergic agonist and may affect heart rate and blood pressure; it would not be a good management method for the patient described here. Saliva substitutes may provide temporary relief for some patients but have only limited usefulness. Fluoride gels may be used to prevent the smooth sur­ face caries that may develop with xerostomia. Antifungal agents in the form of nystatin or chlotrimazole troches are also recommended if candidiasis occurs. Patients with xerostomia should be followed carefully to monitor their oral hygiene, caries development and condition of the oral mucosa. More frequent recall exami­ nations and prophylaxes will help pre­ vent and control the effects of the condition. Patients also will need fre­ quent encouragement as they deal with the discomfort and inconvenience of a perpetually dry mouth. Appointments as often as every Dr. Van Dis is associ­ three months are warranted for a ate professor, Dental patient with severe xerostomia. Less Diagnostic Sciences, School of Dentistry, severe cases may not require such Indiana University, 1121 W. Michigan frequent visits. St., Indianapolis, Ind. 46202-5186. Address

This paper was reviewed by the members of the Organi­ zation of Teachers of Oral Diagnosis.

reprint requests to the author.

COMBINING ENDODONTIC, PERIODONTIC AND RESTORATIVE TREATMENTS

J E F F F L E M IN G , D .D .S ., M .S .

A S H R A F F. F O U A D , B .D .S .,M .S .

Q 20-year-old white female who began root canal treatment on her mandibular left second molar returned three days later with severe, throbbing pain in the tooth. The tooth had a probing depth of five millimeters and bled when probed. Based on the emergency clinical examination and radio­ graphs, the patient was diagnosed with pulp necrosis and acute apical abscess. Though it was impossible to com­ pletely isolate the tooth for drainage and debridement of the canal because it had caries three to four millimeters apical to the gingival margin on the distal, satisfactory drainage was gained through its single large canal after removing the temporary filling. The patient was prescribed a non­ steroidal anti-inflammatory medica­ tion and scheduled for a combined crown-lengthening and root canal treatment. The combined procedure included the following steps: ■■ Buccal and lingual internal bevel gingival incisions were made with a buccal oblique releasing inci­ sion. A distal wedge of gingival tis­ sue was excised and flaps were reflected. " The crestal bone, almost level with the distal gingival seat of the cavity preparation, was reduced three millimeters below the cavity margin with a surgical bur. ■■ With flaps still reflected, a rubber dam was applied and the temporary restoration was removed. ■■ Root canal treatment was completed, short post space was created and an amalcore restora­ tion, extending four to five millime­ ters into the canal and overlaying the undermined distal buccal cusp, was placed.13

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R IC H A R D E. W A LTO N , D .D .S ., M .S .

P H IL L IP L A IN S O N , D .D .S ., M .S.

™ The rubber dam was removed and the buccal flap was apically positioned and sutured with 4-0 gut suture. No periodontal pack was applied. The amalcore restoration, fulfilling the requirements of strength, retention and cusp protec­ tion, was the final restoration. The patient was instructed to use Peridex mouthwash for three days, and was examined at three, seven and 14 days after the procedure. The wound healed satisfactorily. A procedure that combines sur­ gical crown lengthening, endodon­ tic and restorative treatments can be performed on patients with deep subgingival caries in endodonti-

one, and no minimum width has been established as a standard nec­ essary for gingival health.1214 Surgical crown lengthening shouldn’t be attempted when caries extend into the middle third of the root, or if the osseous surgical pro­ cedure would create a poor crownroot ratio or excessive mobility.6 Before starting a crown-lengthening procedure, the dentist should thoroughly excavate the carious lesion and remove or reduce most unsupported tooth structure. Excavation makes it easier to eval­ uate the tooth’s restorability and the extent of bone removal neces­ sary.

Surgical crown lengthen­ ing shouldn't be attempted when caries extend into the middle third of the root, or if the osseous surgical procedure would create a poor crown-root ration or excessive mobility.

n this case, the amalcore restoration was the final restora­ tion. Retention was obtained from the pulp chamber and from irregu­ larities and undercuts in the cervi­ cal portion of the canal. Amalcore provides good coronal seal to the canal system, adequate resistance to fracture, good support for the remaining tooth structure and is relatively fast and inexpensive.1618 The load required to fracture amalcore restorations is very high and has been reported in in vitro studies to range from averages of 305 to 661 pounds, well above the mean maximum clenching force of healthy patients—about 162 pounds.16,18'19 Zinc-free amalgam was used since the amalgam Dr. Fleming is a extended subgin- former graduate student at the givally, and University of Iowa recent studies College of Dentistry, Department of show that zincPeriodontics, and a containing amal­ private practiioner in Chico, Calif. gam has higher

cally involved posterior teeth. This combined treatment can have good results if the dentist considers sev­ eral factors when selecting a case or planning treatment. Dentists should perform crown lengthening cautiously on a multi­ rooted tooth because of the possibil­ ity of furcation exposure. Though some studies show that a width of attached gingiva of less than two millimeters may result in inflamed marginal gingiva when improperly maintained, several studies have challenged the con­ cept that a wide band is more pro­ tective against accumulation of plaque than a thin or nonexistent

cytotoxicity in vitro than other types of amal­ gam.20 A single-visit endodontic pro­ Dr. Fouad is clinical cedure on a assistant professor, tooth with Department of Endodontics, necrotic pulp College of Dentistry, and acute apical University of Iowa. abscess is not generally recommended because of patients’ apprehension and higher incidence of endodontic postopera­ tive pain and swelling.21Further debridement of the canal may be necessary when such flare-ups occur, but there is no evidence that a single-visit endodontic procedure will result in a flare-up or failure. The entire procedure described took about two hours, and the patient appreciated the fact that no addi­ tional appointments were necessary. Duration and number of appoint­ ments must be discussed with patients to obtain their cooperation. Several other techniques can be used to isolate badly broken-down teeth, including special rubber dam clamps to retract gingival tis­ sues, gingival recontouring, crown build-ups or banding the tooth.1 They are time consuming with extensive temporary build-up pro­ cedures, and cannot save periodon­ tal tissues, especially the biologic width. iologic width is the distance between the crest of alveolar bone and the base of the gingival sulcus. The combined dimensions of con­ nective tissue and junctional epithelium average 2.04 millime­ ters above the crestal bone level.2,3 Biologic width is adequate when the level of alveolar bone is at least three millimeters apical to the gin­ gival margin, an important consid­ eration in the periodontal preparation of the tooth. Many crown-lengthening proce­

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dures have been described in detail.410Obvious advantages in per­ forming crown lengthening before restorative and/or endodontic treat­ ment include easier isolation and access to the canal system as well as preparation and restoration. Flap reflection makes it easier to treat the periodontal lesion and may reduce probing depths. It also provides access for correcting osseous defects, for removal of remaining plaque and calculus or can be used with periodontal surgery in adjacent areas.5 hough crown lengthening may also occur as a result of tissue shrink­ age following elimination of local irri­ tants by scaling and root planing—traditionally by gingivectomy, apical positioning of flaps, osseous surgery or induced tooth eruption—in this report, crown lengthening refers to the technique of internal bevel incision, osseous contouring and apical flap position­ ing.5 One problem in performing crown lengthening before root canal therapy is that there is a delay of at least four weeks after surgery for heal­ ing before clamp placement for isolation, which may not be feasi­ ble for a patient : Dr. Walton is and head, with endodontic :i professor Department of pain requiring : Endodontics, immediate treat­ : College off Dentistry, : University of Iowa. ment. In those cases, a combined single-appoint­ ment procedure is a viable option. Antonson and Collins described a combined periodontal and operative procedure to manage subgingival caries.4This surgical procedure exposed the caries to complete the restoration in a single visit. This pro­ cedure improves the quality of the final restoration and is cost effective.

Address requestsfor reprints to Dr. Walton, Department of Endodontics, College of Dentistry, University of Iowa, Iowa City 52242. 1. Antrim DD. Endodontics and the rubber dam: a review of techniques. Gen Dent 1983; 31(4):294-9. Dr. Lainson is 2. Cohen DW. Biologic professor and head, width. (Lecture). Department of Washington,D.C. Walter Reed Army Medical Center, Periodontics, June 3,1963. College of Dentistry, 3. Gargiulo AW, Wentz FM, University of Iowa. Orban B. Dimensions and relations of the dentogingival junctions in humans. J Periodontol 1967; 32:261-7. 4. Antonson DE, Collins JF. Managing subgingival lesions with a combined operative and periodontal approach. Gen Dent 1983; 31:268-71. 5 Palomo F, Kopczyk RA. Rationale and methods of crown lengthening. JADA 1978;96:257-60. 6. Barkmeier, Williams. Surgical methods of gingival retraction for restorative dentistry. JADA 1978; 96:1002- 7. 7. Kaldahl WB, Becker CM, Wentz FM. Periodontal surgi­ cal preparation for specific problems in restorative den­ tistry. J Prosthet Dent 1984; 51:36-41. 8. Kohavi D, Stern N. Crown lengthening procedure. Part I: Clinical aspects. Compend Contin Educ Dent 1983; 4:34754. 9. Kohavi D, Stern N. Crown lengthening procedure. Part II: Treatment planning and surgical considerations. Compend Contin Educ Dent 1983:4:413-9. 10. Pruthi VK. Surgical crown lengthening in periodon­ tics. Can Dent Assoc J 1987; 53:911-5. 11. Markley MR. Amalgam restorations for Class V cavi­ ties. JADA 1955; 50:301. 12. Lang NP, Loe H. The relationship between the width of keratinized gingiva and gingival health. J Periodontol 1972; 43:623. 13. Dorfman HS, Kennedy JE, Bird WC. Longitudinal evaluation of free gingival grafts. A four-year report. J Periodontol 1982; 53:349-52. 14. Wennstrom J, Lindhe J. Plaque-induced gingival inflammation in the absence of attached gingiva in dogs. J Clin Periodontol 1983; 10:266-76. 15. Nayyar A, Walton RE, Leonard L. An amalgam coro­ nal - radicular dowel and core technique for endodontically treated posterior teeth. J Prosthet Dent 1980; 43:511. 16. Michelich R, Nayyar A, Leonard L. Mechanical prop­ erties of amalgam core buildups for endodontically treated premolars (Abstract). J Dent Res 1981; 60:630. 17. Michelich R, Dillard T, Nayyar A. Mechanical proper­ ties of amalgam core buildups for endodontically treated molars (Abstract). J Dent Res 1980; 59:381. 18. Kane JJ, Burgess JO, Summitt JB. Fracture resistance of amalgam coronal-radicular restorations. J Prosthet Dent 1990; 63:607-13. 19. Gibbs CH, Mahan PE, Lundeen HC, Brehnan K, Walsh EK, Holbrook WB. Occlusal force during chewing and swal­ lowing as measured by sound transmission. J Prosthet Dent 1981; 46:443-9. 20. Kaga M, Seale NS, Hanawa T, Ferracane JL, Okabe T. Cytotoxicity of am algam s. J Dent Res 1988; 67(9) :1221-4. 21. Walton RE, Fouad AF. Interappointment flare-ups: incidence and related factors (Abstract]). J Dent Res 1990; 69:300.

T R E A T I N G A P A T IE N T W IT H

M ICH A EL GLICK, D.M.D. A R T H U R NIMMO, D.D.S.

35 year-old white man was treated at the Infection Disease Center at Temple University School of Dentistry in Philadelphia. His medical history included hepatitis B virus carrier state, positive serum HIV antibody test and dis­ seminated Kaposi’s sarcoma. The KS had been present for 24 months and was the initial diagno­ sis of AIDS. Medications included AZT and alpha-interferon IM injec­ tions for the past three months. The man’s general health was good. Numerous KS lesions were present in the head and neck region as well as on the arms and legs. Bilateral posterior cervical lymphadenopathy was present. The intraoral examination showed a palatal lesion consistent with KS and carious infected teeth. The maxillary teeth were quite mobile. The tooth mobility was attributed to periodontitis, compli­ cated by the patients inability to dean the teeth properly as the KS lesion created deep pseudopocketing. An occlusal radiograph did not reveal any palatal bone resorption. The patient reported the palatal KS lesion had decreased in size since alpha-interferon treatment was started. 106

Initial therapy included scaling, curettage and extraction of nonrestorable maxillary molars. The healing after extraction was unre­ markable. An acrylic removable partial denture with wrought wire clasps was made to replace missing mandibular teeth and to provide more favorable occlusal contacts with the maxillary arch. To stabilize the maxillary denti­ tion, two five-unit resin-bonded retainers were fabricated with Rexillium III. The metal was electrolytically etched, and the abut­ ment teeth were etched with phosphoric acid. The RBRs were cemented with Comspan. The patient’s occlusion was adjusted to produce good con­ tacts in centric occlusion and ante­ rior guidance with immediate posterior disclusion in excursions. The patient was educated in oral hygiene procedures to minimize periodontal inflammation. To avoid irritation of the KS palatal lesion,

Kaposi’s sarcoma, orKS, is the most common neoplas­ tic lesion associated with AIDS, and often is the ini­ tial sign of this neoplasmi. the patient was instructed to use a floss threader, using a palatal approach to start the threader. Stabilization of periodontally compromised teeth can be accom­ plished using a number of methods. Splinted fixed restorations can be placed or a removable partial den­ ture can be used to provide cross arch stability, u l ? l ecanse of the large KS lesion on the palate, a conventional remov­ able partial denture with a palatal major connector to stabilize the maxillary teeth was contraindicated. Complex fixed prosthodontic

rehabilitation was contraindicated for our patient because of the poor prognosis associated with his HIV infection. Additionally, the high cost of medications used with the treatment of HIV patients usually precludes expensive fixed prosthodontic treatment. An alternative approach to con­ ventional fixed prosthodontic stabi­ lization is an RBR. The RBR restoration was used for this patient as it is economical, does not involve many appointments and provides stabilization without cov­ ering or irritating the KS palatal lesion. 3-5 ^ w o separate RBR restorations were placed because of the diffi­ culty in seating a long-span casting. A nonrigid interlock was created by having both RBRs terminate on the same abutment.« About one million Americans are infected with the human immunodeficiency virus, the AIDS virus, t During the next decade, 90 percent of these individuals will develop AIDS, associated with major opportunistic infections and neoplasms.» Kaposi’s sarcoma, or KS, is the most common neoplastic lesion associated with AIDS, and often is the initial sign of this neoplasm. Ninety percent of all intraoral cases will appear on the hard or soft palate, and tooth mobility and bone resorption may occur. Prosthodontic stabilization can be done conservatively, as des­ cribed here. AIDS-associated KS in individu­ als without a history of opportunis­ tic infections and an absolute T-helper lymphocyte count above 300 cells/L has a median survival time of over 30 months. ^ With the addition of drug ther­ apy, the survival time is going to increase. The patient described

here has improved since the start of alpha-interferon treatment. And today, three years after his AIDS was diagnosed, he is asymptomatic except for KS, which has been sta­ ble for the past year. The question no longer is, “When will there be a cure for AIDS?” Instead we need to ask how we are going to treat patients with HIV infection. New challenges are going to be posed in all dental-related specialties. To treat patients infected with HIV, we need to con­ sider parameters such as prognosis and mortality. The treatment should address the patient’s needs using a practical approach based on all factors. 1. Stewart KL, Rudd KD. Stabilizing periodontally weakened teeth with remov­ able partial dentures. J Prosthet Dent 1968;19:47582. 2. Kratochvil FJ. Maintaining supporting structures with a removable partial denture prosthesis. J Prosthet Dent 1971;25:167-74. Dr. Glick is assistant 3. Livaditis GJ, Thompson VP. Etched castings: an professor, improved retentive mecha­ Department of Oral nism for resin-bonded Medicine, School of retainers. J Prosthet Dent Dentistry, and 1982;472:52-8. Director, Infectious 4. Wood M. Etched casting resin bonded retainers: an Disease Center, improved technique for peri­ Temple University, odontal splinting. Int J Philadelphia. Periodontics Restorative Dent 1982;2:9-25. 5. Barrack G. Recent advances in etched cast restora­ tions. J Prosthet Dent 1984;52:619-26. 6. Rothschild HL. Cross-arch splinting with resin-bonded retainers. J Prosthet Dent 1985;53:627-8. 7. Estimates of HIV prevalence and projected AIDS cases: Summary of a workshop, Oct. 31- Nov. 1,1989. MMWR 1990;39:110-9. 8. Lui KZ, Darrow WW, Rutherford GW. A model-based estimate of the mean incubation period for AIDS in homo­ sexual men. Science 1988;240:1333-5. 9. Gropman JE. AIDS-related Kaposi’s sarcoma: Therapeutic modalities. Semin Hematol 1987;24 (3 suppl 2): 5-8. 10. Silverman S Jr, Migliorati CA, Lozada-Nur F Greenspan D, Conant MA. Oral findings in people with or at high risk for AIDS: a study of 375 homosexual males. JADA 1986;112:187-92. 11. Chaudhry AP, Chachoua A, Saltzman BR, Friedmankien AE. AIDS-associated with Kaposi’s sarcoma. JADA 1987;115:824-5. 12. Chachoua A, Krigel R, Lafleur F, et al. Prognostic fac­ tors and staging classification of patients with epidemic Kaposi’s sarcoma. J Clin Oncol 1989;7:774-80.

G i r t h S e a lO ff e r

.JMÜk

Dr. Nimmo is professor and Director, Division of Removable Prosthodontics, Temple University, Philadelphia. Address requestsfor reprints to Dr. Glick, Temple University School of Dentistry, Infectious Disease Center, 3223N. Broad St., Philadelphia, 19140.

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