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Prosthetic management of an acromegaly patient
Prosthetic management of an acromegaly patient
Richard J. Goodkind, DMD, MS, Minneapolis
Specific problems associated with treatment of an edentulous patient with acromegaly provide an in teresting prosthetic challenge.
Acromegaly is a disease associated with the hy persecretion of the anterior lobe of the pituitary gland occurring most often during the third and fourth decades of life.1 Hamwi and others2 and W einmann and Sicher3 have written thorough medical evaluations of the typical acromegalic individual. Because the disease is an insidious one, its onset is difficult to determine. The condi tion is usually discovered after changes in tissue morphology have occurred (Fig 1). The patient with acromegaly can provide the dentist with an interesting prosthetic challenge.4 The following history deals with the more specific problems associated with treatm ent of such a patient. M anagement of this 7 3-year-old edentu lous patient with acromegaly involved a working relationship between his internist, oral surgeon, and prosthodontist.
because of periodontitis and dental decay. M al occlusion associated with the acromegalic condi tion could have been a contributing factor. The patient had worn removable maxillary and m andibular partial dentures for 20 years; new prostheses had been made from time to time as changes were noted. Inasmuch as no maxillary abutments remained, the patient held the remov able partial denture in place by means of his tongue. There was very little occlusal contact with his present partial dentures. Consequently he was unable to masticate properly (Fig 2). As changes in the size of the jaws had occurred, obvious diastemas had developed between the maxillary and m andibular teeth; tremendous pressures were placed on these regions by the patient’s hypertrophic tongue.
Oral e x a m in a tio n When the existing prostheses were removed, the tongue position was favorable. The muscles of mastication and facial expression were hyper-
P a s t m ed ica l a n d d e n ta l history Decided thickening of the tissues of the fingers and toes, caused by a benign pituitary-gland tu m or, led to the diagnosis of the patient’s condi tion when he was in his middle forties. Treatm ent consisted of radiation to the skull. Some years later diabetes mellitus was detected; this tendency has been observed by G ordon1 in 50% of his re ported cases. Consultation with the patient’s phy sician revealed that oral hypoglycemic drugs and diet kept the diabetes under control. The acro megaly had become inactive. A rthritis " of the spine and synovitis of the left knee placed some limitations on the patient’s mobility. Questioning revealed that the patient had lost teeth periodically during the previous 25 years
F ig l ■ Seventy-three-year-old acrom egaly p a tie nt. N o te e nlarged nose, p ro m in e n t supraorbital arches and thickened lower lip. 1327
Fig 2 ■ E xistin g rem ovable pa rtia l denture prostheses p rior to prosth o d o n tic trea tm e nt. Note enlarged tongue holding m axillary prosthesis in position.
Fig 3 ■ Note discrepancies in w id th between norm al man d ib le on le ft and acrom egalic m an d ib le on rig ht.
trophic in appearance. Labial and buccal frena attachments were located close to the crest of the ridge in both arches. The form of the mandibular ridge was low and V-shaped. The retromylohyoid area was moderate in depth. The maxillary throat form had 3 to 5 mm of immovable tissue beyond the hard palate. Oral examination also revealed a grossly en larged mandible dwarfing a comparatively small maxilla in an Angle Class 111 malocclusion. M an dibular movement was not severely hampered in eccentric excursions. Two periodontally involved teeth, the left lateral incisor and canine (Fig 3) were in severe labioversion; the roots of the left maxillary central incisor and right third molar re mained. Palpation of the soft tissue regions dis closed maxillary bilateral tuberosity undercuts and a sharp right mylohyoid ridge. A rather vis cous saliva was present. Intraoral and occlusal radiographs revealed no evidence of osteoporosis. Lateral jaw films (Fig
4) revealed a gonial angle of 124° which is con sistent with the findings of Steinbach and others.5 The patient’s philosophical outlook greatly en hanced the prognosis in view of these difficult oral conditions.
Fig 4 ■ Lateral jaw film reveal ing a gonial angle of 124°
1328 ■ JADA, Vol. 77, December 1968
T re a tm e n t plan Because the remaining teeth were beyond resto ration, complete denture prosthesis was the treat ment of choice. Surgical correction of the existing bony protuberances was also indicated. The pa tient strongly indicated the need for immediate dentures; his desires were met. At the request of his internist, all surgical procedures were per formed in the hospital with the patient under lo cal anesthesia. ■ Prosthodontic treatment: Prosthetic treatment of this patient with acromegaly was complicated
by many factors. It is the intent of this paper to discuss the difficult areas encountered. N o attem pt will be made to describe a step-by-step technic in complete denture prosthesis. Initial problems were encountered in making impressions because of the extremely large m an dible. The largest stock rim-lock tray, modified with modeling composition on the distal flange, was used to register the preliminary irreversible hydrocolloid impression. A custom-made acrylic resin tray was first border-molded with impression plastic. Final tissue detail was achieved with a m ercaptan rubber-base material. Elastic impres sion material was selected because of the severe hard and soft tissue undercuts present on the m an dibular ridge. The patient habitually allowed his enlarged lower lip to droop, thereby unintention ally developing an overextended labial flange. The tendency to overextend the peripheries is common in the patient with acromegaly. More forceful border molding was necessary to over come this difficulty. A similar procedure was followed on the maxillary arch except that zinc oxide and eugenol impression paste was used. ■ Vertical dimension: The vertical dimension of occlusion was recorded; rest position, swallow ing, and phonetics were used as guides. Although the results varied slightly, a compromise interocclusal registration was accepted as the most de sirable vertical dimension of occlusion. The basic reason for the problem encountered in determ in ing vertical dimension was that the patient’s inter arch distance was so great. In addition, an Angle Class III relationship of the teeth with a severe bilateral buccal cross-bite complicated the occlu sal scheme. There was no precedent for determining the vertical dimension for a patient with acromegaly. An interocclusal distance of 6 to 8 mm was es tablished for this patient. This enabled him to m aintain a space between his teeth during speech and at least 6 mm of space while his mandible was in a relaxed position. This selection of the vertical dimension of occlusion enhanced the setting of posterior teeth because it provided for maximum occlusal contact, even with the disparity in width between the opposing ridges. The op posing ridges were parallel; consequently, stresses would be borne perpendicular to the residual ridges (Fig 5). ■ Selection o f teeth: Existing oral conditions favored the use of a monoplane occlusion. The
Fig 5 ■ M ounted m axillary and m an d ib u la r casts a t the ve rtica l dim ension of occlusion. Note p arallelism of existin g ridges.
posterior teeth were arranged in a bilateral buc cal cross-bite. In addition to this, three premolars were used in the m andibular arch to provide the patient with an additional occlusal table. The posterior maxillary teeth had metal occlusal in serts and in the m andible porcelain monoplane posterior teeth were used. In order to achieve more favorable maxillary retention, the posterior teeth were set incorporating a slight buccolingual curve. If the vertical dimension of occlusion had been increased beyond the selected position, the poste rior teeth would have been sufficiently removed from their respective ridges to create unfavorable leverages. In addition, an elevated occlusal table would have made it virtually impossible for the tongue to function normally. Furtherm ore, an in creased vertical dimension would not have been in accord with Weinmann and Sicher’s work3 which reported that even with an increased total facial height of 25 % in the acromegalic individual, the distance between the lower border of the zygomatic bone and m andibular angle remained normal because of resorption of the lower border of the mandible. Phonetic tests and swallowing procedures with this patient lent support to their work and contraindicated increasing the vertical dimension of occlusion. If the vertical dimension of occlusion had been decreased to provide even more interocclusal dis tance, occlusal contact of the posterior teeth would have been greatly reduced, because if the wider posterior segment of the mandible had been
G oodkind: PROSTHETIC MANAGEMENT OF ACROMEGALY PATIENT ■ 1329
Fig 6 ■ Processed com plete dentures. Note the use of the th ird prem olar.
Fig 7 ■ New prostheses in position.
brought further forward in closure, it would have come into apposition with the anterior segment of the maxillary arch which was narrower. In ad dition, stresses would have been brought further anteriorly because of the natural upward and for ward movement of the mandible in hinge closure6 and there would have been a loss of retention of the maxillary prosthesis. The lower anterior teeth were given a slight labial axial inclination and set in a Class III re lationship so as not to crowd the grossly enlarged tongue (Fig 6).
changes justify a replacement. The first appli ance will greatly reduce the initial difficulties en countered and will give the prosthodontist a model from which to fabricate the next prosthesis.
P o stin se rtio n c a re The patient recovered from his extractions and healed without complications. However, his ad justm ent to the prosthodontic appliances was not without difficulties. His problems were mainly in mastication. He had considerable difficulty in manipulating the bolus of food, and food would often lodge under his m andibular denture. This problem was caused in part by his hypertrophic tongue, his exaggerated oral anatomy, and his awkwardness, at age 73, in handling a new pros thesis (Fig 7). In addition, a habit of bruxism made his ad justm ent to the new prosthesis more difficult. Counseling, selective grinding, and removal of the prosthesis at night helped to alleviate some what the discomfort caused by this habit. The prosthesis produced a definite speech im provement. A second prosthesis to replace the immediate dentures is planned for this patient when oral 1330 ■ JADA, Vol. 77, December 1968
C o n clu sio n s Prosthetic treatm ent of the patient with acro megaly often requires close cooperation between the various medical and dental specialties. U n usual problems can be expected because of the large mandible, relatively small maxilla, hyper trophic tongue and the vertical dimension. Bi lateral buccal cross-bite is a common occlusal ar rangement which often necessitates the use of additional teeth and a monoplane occlusion. Post insertion care of such a patient required addition al time and effort to enhance his acceptance of the new prosthesis.
D octor Goodkind is assistant professor and d ire c to r of graduate prosthodontics, School o f Dentistry, U niversity of M innesota, M inneapolis, 55455,
1. Gordon, D.A.; H ill, F.M., and Ezrin, C. Acrom egaly: a review of 100 cases. Canad Med Ass J 87:1106 Nov 24, 1962. 2. Hamwi, G.J.; S killm an, T.G., and Tufts, K.C., Jr. Acro megaly. Am er J Med 29:690 Oct 1960. 3. W einm ann, J.P., and Sicher, H. Bone and bones, ed. 2, St. Louis, C. V. Mosby Co., 1955. 4. Sacherman, R.H. Com plete denture prosthesis fo r a case o f acrom egaly. J Prosth Dent 5:186 March 1955. 5. S teinbach, H.L.; Feldman, R., and Goldberg, M.B. Acromegaly. Radiology 72:535 A p ril 1959. 6. Goodkind, R.J. M andibular movem ent w ith changes in the ve rtica l dim ension. J Prosth Dent 18:438 Nov 1967.
Richard J. Goodkind, DMD, MS, Minneapolis
Specific problems associated with treatment of an edentulous patient with acromegaly provide an in teresting prosthetic challenge.
Acromegaly is a disease associated with the hy persecretion of the anterior lobe of the pituitary gland occurring most often during the third and fourth decades of life.1 Hamwi and others2 and W einmann and Sicher3 have written thorough medical evaluations of the typical acromegalic individual. Because the disease is an insidious one, its onset is difficult to determine. The condi tion is usually discovered after changes in tissue morphology have occurred (Fig 1). The patient with acromegaly can provide the dentist with an interesting prosthetic challenge.4 The following history deals with the more specific problems associated with treatm ent of such a patient. M anagement of this 7 3-year-old edentu lous patient with acromegaly involved a working relationship between his internist, oral surgeon, and prosthodontist.
because of periodontitis and dental decay. M al occlusion associated with the acromegalic condi tion could have been a contributing factor. The patient had worn removable maxillary and m andibular partial dentures for 20 years; new prostheses had been made from time to time as changes were noted. Inasmuch as no maxillary abutments remained, the patient held the remov able partial denture in place by means of his tongue. There was very little occlusal contact with his present partial dentures. Consequently he was unable to masticate properly (Fig 2). As changes in the size of the jaws had occurred, obvious diastemas had developed between the maxillary and m andibular teeth; tremendous pressures were placed on these regions by the patient’s hypertrophic tongue.
Oral e x a m in a tio n When the existing prostheses were removed, the tongue position was favorable. The muscles of mastication and facial expression were hyper-
P a s t m ed ica l a n d d e n ta l history Decided thickening of the tissues of the fingers and toes, caused by a benign pituitary-gland tu m or, led to the diagnosis of the patient’s condi tion when he was in his middle forties. Treatm ent consisted of radiation to the skull. Some years later diabetes mellitus was detected; this tendency has been observed by G ordon1 in 50% of his re ported cases. Consultation with the patient’s phy sician revealed that oral hypoglycemic drugs and diet kept the diabetes under control. The acro megaly had become inactive. A rthritis " of the spine and synovitis of the left knee placed some limitations on the patient’s mobility. Questioning revealed that the patient had lost teeth periodically during the previous 25 years
F ig l ■ Seventy-three-year-old acrom egaly p a tie nt. N o te e nlarged nose, p ro m in e n t supraorbital arches and thickened lower lip. 1327
Fig 2 ■ E xistin g rem ovable pa rtia l denture prostheses p rior to prosth o d o n tic trea tm e nt. Note enlarged tongue holding m axillary prosthesis in position.
Fig 3 ■ Note discrepancies in w id th between norm al man d ib le on le ft and acrom egalic m an d ib le on rig ht.
trophic in appearance. Labial and buccal frena attachments were located close to the crest of the ridge in both arches. The form of the mandibular ridge was low and V-shaped. The retromylohyoid area was moderate in depth. The maxillary throat form had 3 to 5 mm of immovable tissue beyond the hard palate. Oral examination also revealed a grossly en larged mandible dwarfing a comparatively small maxilla in an Angle Class 111 malocclusion. M an dibular movement was not severely hampered in eccentric excursions. Two periodontally involved teeth, the left lateral incisor and canine (Fig 3) were in severe labioversion; the roots of the left maxillary central incisor and right third molar re mained. Palpation of the soft tissue regions dis closed maxillary bilateral tuberosity undercuts and a sharp right mylohyoid ridge. A rather vis cous saliva was present. Intraoral and occlusal radiographs revealed no evidence of osteoporosis. Lateral jaw films (Fig
4) revealed a gonial angle of 124° which is con sistent with the findings of Steinbach and others.5 The patient’s philosophical outlook greatly en hanced the prognosis in view of these difficult oral conditions.
Fig 4 ■ Lateral jaw film reveal ing a gonial angle of 124°
1328 ■ JADA, Vol. 77, December 1968
T re a tm e n t plan Because the remaining teeth were beyond resto ration, complete denture prosthesis was the treat ment of choice. Surgical correction of the existing bony protuberances was also indicated. The pa tient strongly indicated the need for immediate dentures; his desires were met. At the request of his internist, all surgical procedures were per formed in the hospital with the patient under lo cal anesthesia. ■ Prosthodontic treatment: Prosthetic treatment of this patient with acromegaly was complicated
by many factors. It is the intent of this paper to discuss the difficult areas encountered. N o attem pt will be made to describe a step-by-step technic in complete denture prosthesis. Initial problems were encountered in making impressions because of the extremely large m an dible. The largest stock rim-lock tray, modified with modeling composition on the distal flange, was used to register the preliminary irreversible hydrocolloid impression. A custom-made acrylic resin tray was first border-molded with impression plastic. Final tissue detail was achieved with a m ercaptan rubber-base material. Elastic impres sion material was selected because of the severe hard and soft tissue undercuts present on the m an dibular ridge. The patient habitually allowed his enlarged lower lip to droop, thereby unintention ally developing an overextended labial flange. The tendency to overextend the peripheries is common in the patient with acromegaly. More forceful border molding was necessary to over come this difficulty. A similar procedure was followed on the maxillary arch except that zinc oxide and eugenol impression paste was used. ■ Vertical dimension: The vertical dimension of occlusion was recorded; rest position, swallow ing, and phonetics were used as guides. Although the results varied slightly, a compromise interocclusal registration was accepted as the most de sirable vertical dimension of occlusion. The basic reason for the problem encountered in determ in ing vertical dimension was that the patient’s inter arch distance was so great. In addition, an Angle Class III relationship of the teeth with a severe bilateral buccal cross-bite complicated the occlu sal scheme. There was no precedent for determining the vertical dimension for a patient with acromegaly. An interocclusal distance of 6 to 8 mm was es tablished for this patient. This enabled him to m aintain a space between his teeth during speech and at least 6 mm of space while his mandible was in a relaxed position. This selection of the vertical dimension of occlusion enhanced the setting of posterior teeth because it provided for maximum occlusal contact, even with the disparity in width between the opposing ridges. The op posing ridges were parallel; consequently, stresses would be borne perpendicular to the residual ridges (Fig 5). ■ Selection o f teeth: Existing oral conditions favored the use of a monoplane occlusion. The
Fig 5 ■ M ounted m axillary and m an d ib u la r casts a t the ve rtica l dim ension of occlusion. Note p arallelism of existin g ridges.
posterior teeth were arranged in a bilateral buc cal cross-bite. In addition to this, three premolars were used in the m andibular arch to provide the patient with an additional occlusal table. The posterior maxillary teeth had metal occlusal in serts and in the m andible porcelain monoplane posterior teeth were used. In order to achieve more favorable maxillary retention, the posterior teeth were set incorporating a slight buccolingual curve. If the vertical dimension of occlusion had been increased beyond the selected position, the poste rior teeth would have been sufficiently removed from their respective ridges to create unfavorable leverages. In addition, an elevated occlusal table would have made it virtually impossible for the tongue to function normally. Furtherm ore, an in creased vertical dimension would not have been in accord with Weinmann and Sicher’s work3 which reported that even with an increased total facial height of 25 % in the acromegalic individual, the distance between the lower border of the zygomatic bone and m andibular angle remained normal because of resorption of the lower border of the mandible. Phonetic tests and swallowing procedures with this patient lent support to their work and contraindicated increasing the vertical dimension of occlusion. If the vertical dimension of occlusion had been decreased to provide even more interocclusal dis tance, occlusal contact of the posterior teeth would have been greatly reduced, because if the wider posterior segment of the mandible had been
G oodkind: PROSTHETIC MANAGEMENT OF ACROMEGALY PATIENT ■ 1329
Fig 6 ■ Processed com plete dentures. Note the use of the th ird prem olar.
Fig 7 ■ New prostheses in position.
brought further forward in closure, it would have come into apposition with the anterior segment of the maxillary arch which was narrower. In ad dition, stresses would have been brought further anteriorly because of the natural upward and for ward movement of the mandible in hinge closure6 and there would have been a loss of retention of the maxillary prosthesis. The lower anterior teeth were given a slight labial axial inclination and set in a Class III re lationship so as not to crowd the grossly enlarged tongue (Fig 6).
changes justify a replacement. The first appli ance will greatly reduce the initial difficulties en countered and will give the prosthodontist a model from which to fabricate the next prosthesis.
P o stin se rtio n c a re The patient recovered from his extractions and healed without complications. However, his ad justm ent to the prosthodontic appliances was not without difficulties. His problems were mainly in mastication. He had considerable difficulty in manipulating the bolus of food, and food would often lodge under his m andibular denture. This problem was caused in part by his hypertrophic tongue, his exaggerated oral anatomy, and his awkwardness, at age 73, in handling a new pros thesis (Fig 7). In addition, a habit of bruxism made his ad justm ent to the new prosthesis more difficult. Counseling, selective grinding, and removal of the prosthesis at night helped to alleviate some what the discomfort caused by this habit. The prosthesis produced a definite speech im provement. A second prosthesis to replace the immediate dentures is planned for this patient when oral 1330 ■ JADA, Vol. 77, December 1968
C o n clu sio n s Prosthetic treatm ent of the patient with acro megaly often requires close cooperation between the various medical and dental specialties. U n usual problems can be expected because of the large mandible, relatively small maxilla, hyper trophic tongue and the vertical dimension. Bi lateral buccal cross-bite is a common occlusal ar rangement which often necessitates the use of additional teeth and a monoplane occlusion. Post insertion care of such a patient required addition al time and effort to enhance his acceptance of the new prosthesis.
D octor Goodkind is assistant professor and d ire c to r of graduate prosthodontics, School o f Dentistry, U niversity of M innesota, M inneapolis, 55455,
1. Gordon, D.A.; H ill, F.M., and Ezrin, C. Acrom egaly: a review of 100 cases. Canad Med Ass J 87:1106 Nov 24, 1962. 2. Hamwi, G.J.; S killm an, T.G., and Tufts, K.C., Jr. Acro megaly. Am er J Med 29:690 Oct 1960. 3. W einm ann, J.P., and Sicher, H. Bone and bones, ed. 2, St. Louis, C. V. Mosby Co., 1955. 4. Sacherman, R.H. Com plete denture prosthesis fo r a case o f acrom egaly. J Prosth Dent 5:186 March 1955. 5. S teinbach, H.L.; Feldman, R., and Goldberg, M.B. Acromegaly. Radiology 72:535 A p ril 1959. 6. Goodkind, R.J. M andibular movem ent w ith changes in the ve rtica l dim ension. J Prosth Dent 18:438 Nov 1967.