A 50-year-old female patient, partially edentulous, came to the clinic with a history of loss of teeth, loosening of remaining teeth and difficulty in chewing along with burning sensation on taking hot and spicy food since 2 years. Her personal history revealed a habit of chewing supari for around 20 years and has stopped using it in the last 1 year. On thorough clinical examination, the patient was partially edentulous with missing teeth in relation to 15, 13, 12, 22, 23 and 25, supra-erupted teeth in relation to 16, 17, 11, 21, 26. The oral hygiene was poor with gingival inflammation and the periodontal status of remaining teeth was very poor. Generalized pallor and blanching was seen on the palate, buccal mucosa and the labial mucosa with vertical fibrous bands palpable on both sides. The mouth opening was reduced with an interincisal distance of 24mm.
Haematological investigations were made to rule out anemia or any other abnormalities. A provisional diagnosis of OSMF and chronic generalized periodontitis was given and the patient was thoroughly explained about the management of OSMF and various treatment options for replacement of her teeth. The patient wanted to get a fixed prosthesis in minimal amount of time. Since there was a generalized bone loss in both of the arches, and the prognosis was poor, extraction of the remaining teeth followed by full mouth rehabilitation with implants was suggested.
Management of OSMF: The patient had stage III OSMF with a reduced mouth opening of 24mm. this made it slightly difficult for placing any kind of dental instrument in her mouth. Hence the primary aim was to increase the mouth opening to an optimum level. To achieve that, the patient was initially counseled to strictly stop chewing any kind of tobacco products. Antioxidants (SM fibro- twice daily) and Intralesional injections consisting of 2ml dexamethasone, 1000IU hyaluronidase and placentrex has been given twice weekly for two weeks. She was advised to do physiotherapy using wooden spatulas and blowing balloons (for at least an hour under a dentist supervision during the initial 2 weeks) 5-6 times a day until she experiences any discomfort. After this initial treatment, there was a slight improvement of 2 mm in the mouth opening.
Fibrotomy: Since the conventional treatment showed very little improvement in mouth opening, surgical intervention was planned after taking consent from the patient. Fibrotomy was performed with a in pulse mode for initial demarcation of the bands followed by continuous mode to cut the bands[4]. Precise care was taken to include only the mucosal and submucosal areas without affecting the deeper layers. The procedure was performed starting from the pterygomandibular raphe and faucial pillars, continuing through the buccal mucosa at the level of occlusal plane. Primary closure of the surgical area was not done so as to allow the mucosa to epithelise on its own. An interincisal distance of 30mm was achieved immediately after the treatment and the patient was advised to continue physiotherapy. The mouth opening decreased to 25mm on the second postoperative day, as the patient did not do any jaw stretching exercise. Hence the patient was again counseled to strictly continue physiotherapy and topical corticosteroid (kenocart 0.1% cream thrice daily) was given. The mouth opening gradually increased to 28mm within the next 14 days and surgical intervention for implant placement was done on the following day.
Full mouth rehabilitation with basal implants: A total of 16 teeth were present with fixed prosthesis between 13 to 23 and 33 to 43. Remaining teeth were mobile with compromised periodontal status and hence were advised for extraction. Panoramic radiograph and CBCT scan were taken to identify suitable sites for implant placement. Extractions of the teeth have been done under local anesthesia followed by complete curettage of the sockets. Immediately after extraction, 12 maxillary (2pterygoid) and 10 mandibular single piece basal implants were placed with minimal intervention using flapless technique. Single stage impressions of both the arches were made using 3M ESPE monophase polyether impression material. Tentative intermaxillary records were made using high viscosity polyvinylsiloxane (coltene jetbite) and temporization was done.
Casts were poured and the models have been mounted on the articulator. The casts were scanned using 3 shape CAD CAM and zirconia framework was designed according to the intermaxillary relation. Following day, abutments were trimmed, accordingly and definitive intermaxillary records were taken. The overall length and bucco-lingual widths of the crowns were reduced to increase the space between the maxillary and the mandibular teeth and also to lessen the trauma, which will be implicated on the cheeks otherwise. The implants were functionally loaded with final framework of glazed zirconia crowns using 3MESPE resin cement.
The patient was advised to continue physiotherapy and use antioxidants and multivitamins and is under follow up. There has been a good improvement in the overall functional ability of the patient and no recurrence of trismus was noted.
