CASE REPORT Total Rehabilitation Of Poor Edentulous Arches With Metal Denture Bases And Finger Prosthesis. Dr. Rajni Kalla, Dr. Sunil Kumar M V 2, Dr. Harikesh Rao 3, 1- M.D.S., Senior Lecturer; 2- Professor & Head; 3- Professor; Department of Prosthodontics, Jaipur Dental College and Hospital, Kukas, Jaipur, Rajasthan, INDIA Abstract In routine dental practice, cases are encountered with a compromised ridge. Metal dentures have been used successfully these days and their popularity has gained heights because of their ability to decrease the amount of bone resorption, enhanced stability and retention provided with close adaptation to the underlying tissues. Hand deformities severely affect esthetics, function & psychology of a person. In the following case report, an old denture wearer patient aged 72yrs with an amputed ring and little finger of right hand is rehabilitated with a full upper and lower metal denture framework and finger prosthesis in routine clinical setup. Keywords: Metal denture bases, silicone, finger prosthesis Dr. Rajni Kalla, Dr. Sunil Kumar M V, Dr. Harikesh Rao. Total Rehabilitation Of Poor Edentulous Arches With Metal Denture Bases And Finger Prosthesis. International Journal of Prosthetic Dentistry2013:4(1):31-35. 2013 International Journal of Prosthetic Dentistry. Published by Publishing Division, Celesta Software Private Limited. All Rights Reserved. Received on: 24/02/2013 Accepted on: 24/04/2013 Introduction: The use of metal bases for complete dentures has the advantages being-excellent strength to volume ratio, good adaptation to the supporting tissues, enhanced control of denture plaque, high thermal conductivity, high biocompatibility, no dimensional changes in time through fluids absorption, and no interferences with phonation 1. The fabrication of digital prosthesis is as much an art as it is a science. Prosthetic form, texture & coloration must be as indiscernible as possible from the surrounding tissues. The ideally constructed prosthesis must duplicate the missing feature so precisely that the casual observer notices nothing that would draw attention towards the prosthetic reconstruction 2. This paper presents rehabilitation of resorbed edentulous ridges with metal denture bases and prosthetic rehabilitation of amputed fingers with heat cure silicone material. Case report: A 72 yr old male patient reported to the Department of Prosthodontics for replacement of missing upper & lower teeth. The patient was a previous single upper denture wearer since 20 yrs. He lost his teeth in an accident, alongwith a ring and little finger of right hand. On extra oral examination, patient had a square-tapering facial form with a normal profile, cosmetic index being medium. (Fig: 1). Shrinked distal phalange of the ring finger & completely amputed little finger with a 1/4 th remaining stump and no signs of infection (fig: 2). Intra oral examination revealed that maxillary ridge was low well rounded & mandibular being 2013 International Journal of Prosthetic Dentistry. Published by Publishing Division, Celesta Software Private Limited. All Rights Reserved Page 31
(Figure:2 Patients Extra-Oral profile ) final impressions (impression compound, green stick compound, zinc oxide eugenol impression paste, Y-dent, DPI). The master cast was duplicated in reversible hydrocolloid impression material (Agar) which was eventually hardened. A wax pattern was fabricated on both the edentulous casts. Finally investing was followed by casting using 8 capsules of Co- Cr alloy (DENTSPLY). The framework was then sandblasted, finished & polished (fig: 4). Occlusal rims were fabricated over the metal bases, jaw relationships made and monoplane teeth of appropriate shade were selected (Primadent teeth). (Figure:2 amputed ring finger and little finger of right hand) flat. OPG showed highly resorbed ridges (Fig: 3). Healthy class I mucosa, arch sizes were medium with a U-shaped palatal vault. Ridge relation was Normognathic & the Inter Arch Space was adequate. (Figure: 3 Patients OPG Radiograph) After radiographic and clinical evaluation, metal denture bases were planned. Also, his amputed fingers were acceptable for prosthetic rehabilitation. An informed consent was taken from the patient. Technique for oral rehabilitation: Upper &lower primary compound impressions made with a lower wash impression followed by border molding and (Figure: 4 Metal frameworks for upper & lower arches) Characterization was given for lower left lateral incisor, giving a crowded appearance, and also the monoplane posterior teeth were characterized giving the appearance of anatomic teeth. Dentures were tried-in, finished, polished inserted and occlusion checked. (Fig: 5). (Figure5: Dentures finished, polished, inserted & occlusion checked) 2013 International Journal of Prosthetic Dentistry. Published by Publishing Division, Celesta Software Private Limited. All Rights Reserved Page 32
the lower half of the flask, making sure that the rings were embedded in plaster to avoid undercuts for the counter flasking. (Figure:6 Alginate impressions of right & left hands, poured in dental stone) Technique for finger prosthesis: Patient s left hand was lubricated with a thin layer of petroleum jelly, preventing the hydrocolloid impression material from adhering to the tissue surface. The area around the hand was boxed, the material impression was placed over the palmer side first & then the dorsal side. The patient was instructed to keep the hand in normal resting position. Another impression of the affected right hand was made in the same manner. The impressions poured in dental stone (fig: 6). The positive replicas of both the hands were retrieved and prosthesis of the missing finger was sculpted in modeling wax on the stone replica of left hand, so as to exactly copy the left side fingers to replace the missing ones on the right hand. Currently, the methods for prosthesis retention to the remaining part of the finger include ring, double ring, adhesives and osseo-integrated implants. 3,4 Retention is the primary determinant factor for the success of prosthetic restoration in any part of the body. It is important for aesthetics, function, and comfort, thereby improving the patient s quality of life 5.The stump of the amputated finger should be minimally 1.5 cm in length to fit the standard finger prosthesis 6. Two silver rings with centrally split design were attached to the wax pattern with the help of self-cure resin for enhancing retention. During try-in stage, the fit, stability & seating of the wax pattern was evaluated along with the shape & size of the pattern (figure: 7). The pattern was then flasked in Figure: 7 (Fingers wax patterns made and tried) The pattern was flasked to enhance the accuracy at the time of shade matching, such that the dorsal & ventral side of the fingers was separable. Separating medium was applied between the two pours. After dewaxing, the mould was allowed to cool (fig: 8). (Figure:8 flasking & dewaxing procedures ) Shade matching was done in natural daylight. Packing was done with silicone rubber (MP Sai, Mumbai), also some intrinsic pigments were employed to induce shade onto the palmer & dorsal surfaces respectively. The material was allowed to bench cure overnight. Once the final 2013 International Journal of Prosthetic Dentistry. Published by Publishing Division, Celesta Software Private Limited. All Rights Reserved Page 33
prosthesis was retrieved, the flash was trimmed& the final finishing was accomplished. The cured silicone fingers color matched with the color of the skin and were painted using extrinsic oil paints (Camlin-brown, red & yellow ochre). (Figure: 9 Final finger prosthesis in place) To complete the prosthesis, appropriate sized artificial nails were adapted into place & the nails were shaped according to the nails of the natural fingers. The most gratifying step was to place the prosthesis on the patients hand in lieu of the missing fingers. Patient was instructed & demonstrated about the use & maintenance of the prosthesis. (Fig: 9). Summary & conclusion: Numerous investigators have recognized that metal base dentures are more tissue tolerant and resistant to deformation than plastic base dentures. The few disadvantages are far outweighed by the many advantages. The possibility of allergy to the metal, although a valid concern, varies with the composition and electrochemical properties of the alloy and the susceptibility of the patient. With metal bases for dentures, the patient benefits by having a more comfortable, better fitting, and stronger prosthesis. Currently, many injuries and traumatic amputations of fingers can be rescued by micro-surgery through reimplantation. However, in some cases, reconstruction is either not advisable or partiallysuccessful 7. The acrylic resin and silicone are the most common materials used for rehabilitation. Although resin can beeasily characterized and presents great durability, it is a very hard material and uncomfortable for the patient. On the other hand, silicone has texture and flexibility similar to the skin, provides a more comfortable prosthesis and presents better capacity for skin-prosthesis linkage 8. A custom fitted silicone prosthesis replaces a portion of or all of an absent finger. If the patient has movement in the remaining portion of the finger, the prosthesis will restore the function of the finger. Both psychological and functional effects of the prosthesis enhance rehabilitation by restoring fingerloss and normal professional and social life. 10 References: 1. Corina M, Luciana G, Anca J, Enikö D. Titanium complete denture base in a patient with heavy bruxism: A clinical report. Journal of Experimental Medical & Surgical Research 2008; 15(3):96-99. 2. S Nazir, S A Gangadhar, S Manvi. Fabrication of silicone finger prosthesis. A clinical report. J Indian Prosthodont Soc. 2006; 6(4):199-201. 3. Pilley MJ, Quinton DN. Digital prostheses for single finger amputations. J Hand Surg Br 1999 Oct; 24(5):539-41. 4. Yazdanie N. Prosthetic rehabilitation of an amputated thumb. J Coll Physicians Surg Pak 2003; 13(6):355-6. 5. Scolozzi P, Jaques B. Treatment of mid facial defects using prostheses supported by ITI dental implants. Plast Reconstr Surg 2004; 114(6):1395-404. 2013 International Journal of Prosthetic Dentistry. Published by Publishing Division, Celesta Software Private Limited. All Rights Reserved Page 34
6. McKinstry RE. Fundamentals of facial prosthetics. Arlington: ABI Professional Publications; 1995. 7. Wilson RL, Carter-Wilson MS. Rehabilitation after amputations in the hand. Orthop Clin North Am 1983; 14(4):851-72. 9. Marcelo Coelho Goiato, Daniela Nardi Mancuso, Pedro Paulo Marques Ferreira, Daniela Micheline dos Santos. Finger Prosthesis: The Art of Reconstruction Journal of the College of Physicians and Surgeons Pakistan 2009; 19(10):670-671. 8. Gary JJ, Huget EF, Powell LD. Accelerated colour change in a maxillofacial elastomer with and without pigmentation. J Prosthet Dent 2001; 85(6):614-20. Address of correspondence Dr. Rajni Kalla, Assistant professor Department of Prosthodontics, Jaipur Dental College & Hospital, Kukas, Jaipur, Rajasthan, INDIA Email: rajnikalla209@gmail.com No conflict of interest reported 2013 International Journal of Prosthetic Dentistry. Published by Publishing Division, Celesta Software Private Limited. All Rights Reserved Page 35