STRATEGIES OF COMPLETE ORAL REHABILITATION IN PATIENTS WITH DISFUNCTIONAL SYNDROM OF THE STOMATOGNATE SYSTEM

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1 Gnathology STRATEGIES OF COMPLETE ORAL REHABILITATION IN PATIENTS WITH DISFUNCTIONAL SYNDROM OF THE STOMATOGNATE SYSTEM Vasile BURLUI 1, Oana CUCOVEICĂ, Aurel APINTILIESEI 3, Alexandru Vasile BURLUI, Ecaterina COVALCIUC, Cătălina GÎRBEA 5, Carmen STADOLEANU 1 1 Prof. PhD, Faculty of Dental Medicine, Apollonia University of Iasi PhD student, Technical University Gheorghe Asachi from Iasi 3 PhD, Faculty of Dental Medicine, Apollonia University of Iasi Univ. Assist., PhD, Faculty of Dental Medicine, Apollonia University of Iasi 5 Assit. Prof., PhD, Faculty of Dental Medicine, Apollonia University of Iasi Corresponding author: oanacucoveica@yahoo.com Abstract The complete oral and dental rehabilitation (ROC) or (CODR) requires an advanced understanding level, based on the capacity to prepare and successfully fix the complete strategy for the complex oral rehabilitation had in view. The method applied was to subject a representative group of patients to the algorithm of diagnosis and clinical solution. The strategies of complete oral rehabilitation applied included surgical-periodontal, implanto-surgical, implanto-prosthetic rehabilitation techniques. Keywords: complete oral rehabilitation, interdisciplinary clinical approach, modern technologies. 1. INTRODUCTION The stomatology of the third millenium defines itself by new valencies and dimensions, resulted from the very concepts of diagnosis and treatment, under the influence of both the modern and complex technology now in use and of some newly-emerging psycho-social aspects. Clinical experience shows that some patients suffer from diseases which cannot be treated through simple prothesizing. The life quality of a prosthezied patient who cannot adapt himself to the conventional therapy or is subjected to an incomplete rehabilitation therapy is considerably affected.therapeutical complexity requires thorough knowledge from the part of the dentist, on all known stomatological manoeuvres usually recommended, and even more, if considering the multitude of factors involved, so that no medical solution should leave apart an interdisciplinary clinical approach. Such a therapy requires multiple, continued sessions and application of a series of standard strategic methodologies of individualized approach on specific objectives, such as: odontal rehabilitation, elimination of infectious centers; strategies for the rehabilitation of the muco-bone support; skeletal reorganization; rehabilitation through prosthetic means; rehabilitation through orthodontic methods; rehabilitation through implants; maintenance strategies.. MATERIALS AND METHOD Out of a group of 37 subjects (3 men and 1 women) with an average age of years (youngest age: 1, oldest age: 76), with a deviation from the standard of 1., who addressed the Clinic of Complete Oral Rehabilitation of Apollonia University between asking for complete oral rehabilitation through both traditional and modern methods, a series of 1 patients (5 women and 9 men) were selected, as representative for their complex pathology and variety of diseases the stomatologist is expected to manage and cure. The method applied was to subject a representative group of patients to the algorithm of diagnosis and clinical solution. The strategies of complete oral rehabilitation applied included surgical-periodontal, implanto-surgical, implanto-prosthetic rehabilitation techniques [1,]. The pacients were subjected to the protocol of clinical and paraclinical examination for establishing their general and local condition. Additionally, 3D International Journal of Medical Dentistry 307

2 Vasile BURLUI, Oana CUCOVEICĂ, Aurel APINTILIESEI, Alexandru Vasile BURLUI, Ecaterina COVALCIUC, Cătălina GÎRBEA, Carmen STADOLEANU radiographies and ATM tomographies were done. In periodonthic patients, the clinical situation was recorded by means of periodontogrammes, which permitted to follow the evolution of the disease. 3. RESULTS AND DISCUSSIONS The results of the clinical examination were correlated, completed and compared with those obtained by paraclinical investigations [3,]. In Fig. 1 is presented the distribution of patients as a function of age and in Fig. the distribution of patients according to the causes of presentation years 0-9 years clinical examination of all apparata and systems, determination of the type of constitution, the psycho-somatic development of the patient, correlated with his biological age. The patients have also obtained a complete biochemical and haematologic bulletin. In Fig. 3 is presented the patients with vertical and transversal asymmetries and in Fig. the percent ratio of clinical signs during ATM examination. The clinical diagnosis of the the general health condition controls the magnitude and moment of the intervention, and also choice of the therapeutical plane (Vasile Burlui). In Fig. 5 is shown the exam of the oro-facial muscles and of the neighbouring region. Results of NOT-S testing and in Fig. 6 is presented the graphical representation of the modification of mandible s position versus the cranium years years The local-regional clinical examination years 0-9 years Fig. 1. Distribution of patients as a function of age 3 Vertical plane Transverse plane Pain, 1% Masticatory disorders, 9% Vertical and transverse plane Fig. 3. Patients with vertical and transversal asymmetries Masticatory and Physiognomic disorders, 50% Physiognomic disorders, 7% 5% % Asymmentric, asynergistic, unevenin-amplitude condyle shifts Fig.. Distribution of patients according to the causes of presentation Articular click Diagnosis of the general health condition There have been evaluated: the degree of temporal-spatial orientation of the patient, his bio-psycho-social behaviour, his response to verbal and painful stimuli, followed by a general 31% Painful end-filling Fig.. Percent ratio of clinical signs during ATM examination 308 Volume 5 Issue October / December 015

3 STRATEGIES OF COMPLETE ORAL REHABILITATION IN PATIENTS WITH DISFUNCTIONAL SYNDROM OF THE STOMATOGNATE SYSTEM Fig. 5. Exam of the oro-facial muscles and of the neighbouring region. Results of NOT-S testing Numerical distribution of patients regarding: Intense vomit effect Mixed respiration Vicious habits Types of suction Dry motuh sensation Facial asymmetries Muscular disorder of muscle trophicity and tonus ATM problems Phonetic disorders Fig. 6. Graphical representation of the modification of mandible s position versus the cranium Paraclinical investigation was based on conventional means: model analysis of study, orthopantomography, CT with SCANORA technical tridimensional reconstruction Table 1. The study group distribution on edentation classes and jaws EDENTATION FORM Maxillary Mandible Women Men Women Men Class I Kennedy Class II Kennedy Class III Kennedy Class IV Kennedy ClasasV Kennedy-Applegate Class VI Kennedy Applegate Total edentation Therapeutical strategies The therapeutical strategies represent the practical application of the therapeutical scheme, which involves a succession of interventions meant at rehabilitation through surgical, orthodontic, prosthetic, implantary, etc. methods. The succession of stages the patients have to follow includes subdivided strategies which together build up the strategy of complete oral rehabilitation (V. Burlui). No surgical intervention was performed in the absence of a stable general health condition of the patient. Strategies for the application of the ethiotropic therapy Objectives: pro-active participation elimination of the infectious centers International Journal of Medical Dentistry 309

4 Vasile BURLUI, Oana CUCOVEICĂ, Aurel APINTILIESEI, Alexandru Vasile BURLUI, Ecaterina COVALCIUC, Cătălina GÎRBEA, Carmen STADOLEANU There followed: curettage of the osteitic centers and of the granulation tissue in open field, followed by gingivectomia and modelling gingivoalveoloplastia, with bone addition resorbable membranes made of collagen were applied for bone graft protection the flap was immobilized The threads were removed 1 days after the intervention [5,6]. Fig. 7. Application of the ethiotropic therapy For seven patients, the prosthetic-surgical solution, involving mixed prosthesizing on implants and transformation of edentation into a pseudo-edentation, were preferred. Fig. 8. Transformation of total edentation into a pseudo-edentation 310 Volume 5 Issue October / December 015

5 STRATEGIES OF COMPLETE ORAL REHABILITATION IN PATIENTS WITH DISFUNCTIONAL SYNDROM OF THE STOMATOGNATE SYSTEM Fig. 9. Extraction with a flap at.1, alveolar bone plastia and bone addition Curettage of the osteitic center and of the urgent prosthesizing granulation tissue, frenectomia with frenoplastia of the upper lip Fig. 10. Extractions, curettage in closed field, application of implants, sinus lift Fig. 11. Digitalized simulation of implants positioning International Journal of Medical Dentistry 311

6 Vasile BURLUI, Oana CUCOVEICĂ, Aurel APINTILIESEI, Alexandru Vasile BURLUI, Ecaterina COVALCIUC, Cătălina GÎRBEA, Carmen STADOLEANU Strategies of occlusal re-balancing and cranial -mandibulary repositioning Objective: - mandibular repositioning and equilibration of the mandibulo-cranial static and dynamic relations through conventional and modern methods. Technique: Registration of the occlusion on the experimental model Wax-up realization. Checking of the clinical and paraclinical marks. Realization of a simulation tray Contention through provisional prosthesizing Application of the final treatment [7,8] Fig. 1. Occlusal re-balancing and cranial -mandibulary repositioning 31 Volume 5 Issue October / December 015

7 STRATEGIES OF COMPLETE ORAL REHABILITATION IN PATIENTS WITH DISFUNCTIONAL SYNDROM OF THE STOMATOGNATE SYSTEM Bimaxillaryglobal in three times impression 36 % Optical impression 8% Provisional prosthesizing by the CAD technique with fixed devices 36% Fig. 13. Distribution of patients as a function of the technique and contention method applied Modern strategies of prosthetic rehabilitation Present-day tendencies of imprinting in conjunct prosthesizing 9 9 Functional dental-periodontal impression V.Burlui Optical impression Fig. 1. Secondary study determination of the efficiency of the imprinting method The materials utilized for conventional imprinting are: Zeta Plus and Impregum Penta, applied through manual and automated malaxation. The principle of the techniques of functional dental-periodontal imprinting: prophylaxy protection of the organic substructure prepared For five of the subjects included in the experimental group, the finite gnato-prosthetic device was realized by the CAD/CAM technique CONCLUSIONS 1. Prosthetic strategies for functional, occlusal, articular, muscular rehabilitation, as well as for rehabilitation of the lower part dimensions have been applied.. Prognosis appears as encouraging. No local irritations and no complications occurred after surgical intervention. Post-surgery pains disappeared within about two weeks. Temporary contention was preferred, for testing whether the patients accept treatments involving mandibular repositioning, rebuliding of the occlusion plan, raising of the lower part. 3. The finite conjunct devices applied were made of ceramics (zirconium/metal). The patients were asked about their masticatory efficiency, physiognomic improvements, prosthesis hygienization, phonetic function.. Key elements: Interdisciplinary approach Minute planning Therapeutical simulation Theoretical support 5. The statistical results provided by the literature of the field indicate a high, quite predictible success ratio of these strategies. 6. The strategy applied in the present investigation proposes a treatment method with no orthognate surgery, which means that an adequate multidisciplinary planning of the intervention is absolutely necessary. 7. The present study outlined that most of the analyzed affections involve a mandibulo-cranial malposition, whose repositioning was successfully performed with prosthetico-surgical means, which demostrated that a holistic and interdisciplinary approach of such cases is the key for their complete rehabilitation. 8. The whole assembly of therapeutical measures here mentioned may assure a homeostasic equililbrium of the stomatognate system, which appears as the essential element for the success of a complete oral rehabilitation treatment. 9. A good command over the therapeutical principles in force, clinical experience, a complete International Journal of Medical Dentistry 313

8 Vasile BURLUI, Oana CUCOVEICĂ, Aurel APINTILIESEI, Alexandru Vasile BURLUI, Ecaterina COVALCIUC, Cătălina GÎRBEA, Carmen STADOLEANU and complex diagnosis will grant therapeutical success. 10. The prosthetic-surgical strategy should be supported by alternative therapies, such as balneophysio-therapy, kineto-therapy, drug miorelaxation therapy. 11. The osteo-integrated dental implants have immensely contributed to the success of the strategy, improving the quality of patients life through functional rehabilitation. To conclude with, success of the complete oral rehabilitation therapy requires a careful interdisciplinary approach, based on a judicious planning and observance of the main biological and mechanical principles. References 1. Burlui V, Morăraşu C. Gnatologie. Iaşi: Apollonia Publishing House; 01.. Burlui V, Morăraşu C. Reabilitare Orală complexă. Iasi: Apollonia Publishing House; Burlui V, Stadoleanu C, Vasiliu MP. Clinica şi terapia edentatiei partiale intercalate reduse. Iasi:Apollonia Publishing House; 01.. Buurma BJ. Tissue engineering of the dental pulp [PhD thesis]. Ann Arbor:University of Michigan; Rasperini G, Pilipchuk SP, Flanagan CL, Park CH, Pagni G, Hollister SJ, Giannobile WV. 3D-printed Bioresorbable Scaffold for. JDR Clinical Research Supplement. 015;XX (X):1S-5S. 6. Obregon F, Vaquette C, Ivanovski S, Hutmacher DW, Bertassoni L.E. Three-Dimensional Bioprinting for Regenerative Dentistry and Craniofacial Tissue Engineering. J Dent Res. 015; 9(9 Suppl):13S-5S. 7. Xue SH, Lv PJ, Wang Y, Zhao Y, Zhang T. Three dimensional bioprinting technology of human dental pulp cells mixtures. Beijing Da Xue Xue Bao. 013;5(1): Fradeani M, Barducci G. Esthetic Rehabilitation în Fixed Prosthodontics: Prosthetic Treatment: A Systematic Approach to Esthetic, Biologic, and Functional Integration(1 edition). Hanover Park, Illinois:Quintessence Pub Co; Volume 5 Issue October / December 015