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Table of Contents
CASE REPORT
Year : 2020  |  Volume : 10  |  Issue : 3  |  Page : 126-131

Rehabilitating a maxillectomy patient by interdisciplinary alveolar bone preservation technique using submergence of teeth roots


1 Department of Prosthodontics, Govt. Dental College, Trivandrum, Kerala, India
2 Department of Periodontics, Govt. Dental College, Trivandrum, Kerala, India

Date of Submission07-May-2019
Date of Acceptance22-Jul-2020
Date of Web Publication21-Dec-2020

Correspondence Address:
Dr. C Femil Jilta
No. 4 Implant Clinic, Department of Prosthodontics, Govt. Dental College, Medical College Campus, Ulloor, Trivandrum, Kerala
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/jid.jid_17_19

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   Abstract 


Retention for edentulous maxillary obturator is always challenging. Although implants offer good retention in edentulous patients, lack of tissue beds, less predictable integration, economic constraints may preclude implantation. Therefore, the preservation of residual alveolar ridge is mandatory to enhance the retention, support, and stability of the removable obturator prosthesis. Retaining roots through “Root submergence technique” maintains the attachment apparatus and aids in decreasing the resorptive pattern, thereby preserving the residual ridge to some extent. Here, we report a case in which nonvital root submergence is carried out in a partial maxillectomy patient to prevent alveolar ridge resorption adhering to DeVan's dictum “Perpetual preservation” of what remains is more important than the meticulous replacement of what is missing.

Keywords: Partial maxillectomy, residual alveolar ridge, retention, root submergence


How to cite this article:
Jilta C F, Sreeraj R S, Ravichandran R, Kumar K H. Rehabilitating a maxillectomy patient by interdisciplinary alveolar bone preservation technique using submergence of teeth roots. J Interdiscip Dentistry 2020;10:126-31

How to cite this URL:
Jilta C F, Sreeraj R S, Ravichandran R, Kumar K H. Rehabilitating a maxillectomy patient by interdisciplinary alveolar bone preservation technique using submergence of teeth roots. J Interdiscip Dentistry [serial online] 2020 [cited 2021 Jan 22];10:126-31. Available from: https://www.jidonline.com/text.asp?2020/10/3/126/304150




   Clinical Relevance to Interdisciplinary Dentistry Top


The root submergence technique in a completely edentulous maxillary defect patient enhances the retention, support, and stability of the obturator by preventing residual ridge resorption.


   Introduction Top


Residual ridge resorption has long been considered an irreversible consequence of tooth extraction, due to physiologic bone remodeling. The preservation of the residual ridge is of utmost important in prosthodontics as it enhances the retention, support, and stability of removable obturator prosthesis. In edentulous maxillectomy patients, the bone loss will further hamper them impairing the basic physiological activities. The present case describes a relatively bloodless and minimally invasive root submergence technique (RST) for an edentulous partial maxillectomy patient to enhance the prognosis of the obturator treatment by minimizing residual ridge resorption.


   Case Report Top


A 70-year-old male reported to the department of prosthodontics for the replacement of his old maxillary obturator which was ill-fitting [Figure 1]. Medical history revealed that he underwent partial maxillectomy of his left maxilla 10 years before due to a tumor. Clinical examination revealed the presence of teeth 12, 13, and 14 [Figure 2] among which 12 and 14 had poor periodontal prognosis. The patient was briefed about the importance of root submergence which would prevent the problem of bone resorption associated with obturator placement. When the patient showed interest in the proposed treatment plan, nonvital root submergence was elected to preserve the ridge.
Figure 1: Preoperative extraoral pic

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Figure 2: Preoperative intraoral pic

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Procedure

Periodontally, compromised 12 and 14 teeth were advised for the extraction [Figure 3] and [Figure 4], and subsequently, an endodontic procedure was performed in tooth 13. After endodontic therapy, the patient was followed for a month to verify the root canal procedures. Nonvital root submergence procedure was carried on by raising a full-thickness flap [Figure 5]. The coronal structure of the tooth was reduced to the level of the alveolar crest [Figure 6]. After reduction, gutta-percha was burnished with a ball burnisher. The flap was sutured, and primary closure obtained [Figure 7] and [Figure 8]. Healing was uneventful, and a 1-month recall visit revealed complete tissue coverage [Figure 9] and [Figure 10] with a good prognosis of endodontic therapy. The patient was subsequently scheduled for the fabrication of the obturator. The primary maxillary and mandibular impression were made with irreversible hydrocolloid material-alginate (Zelgan 2002; Dentsply-India, Gurgaon, India) [Figure 11], and the cast was poured with Plaster of paris (type II) (Kalstone; Kalabhai Karson, Mumbai, India). The maxillary cast was surveyed, the undercuts were observed, and the necessary mouth preparations were done. Functional moulding of the borders were done using low fusing impression compound; tray adhesive (Caulk tray adhesive, Dentsply Sirona, Delhi, India) was used; and the final impression was recorded using light-body addition silicone material (Aquasil LV; Dentsply International, Milford, Delaware, USA) [Figure 12]. This impression was poured with dental stone (type III) (Kalstone; Kalabhai Karson, Mumbai, India).Occlusal rim was made with modeling wax; Centric jaw relation record was obtained; and the casts were mounted on a semi-adjustable articulator (Whip Mix, Whip Mix Corporation, Louisville, USA). Acrylic denture teeth were arranged adopting bilateral balanced occlusal scheme, and the prosthesis was tried to verify the occlusion with the mandibular teeth, esthetic appearance, and support for the underlying tissues. The prosthesis was cured with heat-cured acrylic resin (DPI Heat Cure, India) and properly finished and polished [Figure 13]. The prosthesis was finally inserted, and occlusal interferences were corrected intraorally, and stability of the obturator was ensured [Figure 14] and [Figure 15]. The patient was educated regarding oral hygiene and future maintenance of the prosthesis. The patient was re-viewed for initial 3 months, and 1-year follow-up is done [Figure 16].
Figure 3: Extracted 12 and 14

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Figure 4: Intraoral periapical showing 13

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Figure 5: Flap elevation

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Figure 6: Decoronation

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Figure 7: Submergence of root

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Figure 8: Suturing done

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Figure 9: Healed surgical wound

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Figure 10: Intraoral periapical showing submerged root of 13

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Figure 11: Primary impression

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Figure 12: Secondary impression

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Figure 13: Final prosthesis

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Figure 14: Obturator inserted

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Figure 15: Postoperative extraoral view

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Figure 16: Review intraoral periapical

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   Discussion Top


Retention for obturator prostheses is commonly obtained through contact with the remaining dentition, and optimum engagement of the available soft-tissue undercuts found within the defect space.[1] The dentition typically provides the most effective means for retention. However, loss of all maxillary teeth significantly compromises the retentive potential for obturator prosthesis. Although endosseous implants offer a means to augment obturator retention in edentulous patients, problems such as the lack of tissue beds suitable for implantation, less predictable integration, and economic constraints may preclude implant treatment for many patients. Therefore, preservation of residual alveolar ridge is mandatory to enhance the retention, support and stability of the removable obturator prosthesis in a completely edentulous patient. The loss of teeth and periodontal ligaments and their replacement by complete dentures inevitably change the pattern of force distribution resulting in bone resorption.[2] Atwood observed that the reduction of residual ridges should be recognized as a major unsolved oral disease causing physical, psychological, and economical problems to many people.[3] Moreover, retaining tooth maintains the integrity of the supportive oral tissues by transmitting functional and parafunctional forces to the surrounding bone.[4] Both objective and subjective findings clearly indicate the significant benefits of the tooth retention since the extraction of few remaining teeth is a serious decision.[5]

To prevent this ridge resorption, tooth-supported overdenture treatment came as an option. However, in tooth supported over denture treatment, the abutment teeth are prone to caries and periodontal diseases hence evolved the vital or nonvital root submergence concept.[6] “Root submergence technique” (RST) is a procedure where the tooth whether vital or nonvital is decoronated and submerged at or below the alveolar bone level to maintain the attachment complex of the tooth, which will prevent the alveolar bone resorption. After a thorough radiographic and clinical examination, roots are submerged in the alveolar ridge making it a preventive prosthodontic treatment.[7] The vital and nonvital root submergence treatment is of importance in the aged, the handicapped and those with little or poor oral health maintenance.[8] The use of retained submerged roots in over denture reduces loss of alveolar bone and increases stability of the over denture.[9]

In 1959, Simpson examined a number of retained roots in humans and suggested that root fragments, which were originally unaffected, could be safely left in position.[10] The first published report of intentional root submersion was by Bjorn in 1961.[2] In 1970, Howell reported a clinical study of submerged endodontically treated roots to preserve alveolar bone. He claimed that there was no apparent loss of bone in this long-term study and appears to be the first to utilize this technique for bone preservation under complete dentures.[11] Taking all these evidences, we adopted the RST in a completely edentulous maxillary defect patient to enhance the retention and stability of the obturator.

The advantages of the root submergence treatment are the preservation of the alveolar bone from resorption which enhances the retention and stability of the prosthesis, vertical dimension of occlusion is maintained, and the tactile perception to load for denture wearers are also maintained. In this method, there is no criterion for the preservation of teeth unlike conventional over dentures where the configuration or location of the teeth has to be considered. Hence, the preservation of any number of teeth can be made possible. It is comparatively inexpensive and maintenance procedure like application of fluoride on the remaining natural teeth is also not required as in conventional overdenture treatment.[3]

The root submergence treatment also has few disadvantages like it is a surgical procedure which at times may not be advised in medically compromised patients, clinical exposure of the submerged roots is also noticed as a problem in few cases, future extraction of the retained roots may cause instability of the denture, patient may have a stretched appearance of the lips due to the preservation of the bone over which the denture flange lies, this also leads to loss of vestibular depth due to surgery.[12]

Considering the disadvantage of vital tooth submergence being a future occurrence of periapical pathology, we have opted for nonvital tooth submergence in this case. Thus, proper diagnosis and endodontic treatment of submucosally retained roots lead to an excellent tissue acceptance and ridge preservation, which in turn improves the prognosis of the obturator prosthesis.


   Conclusion Top


Mucosal coverage of roots as a means of preserving the residual alveolar ridge is a sound clinical method for those patients where the entire tooth or teeth cannot be preserved. The undisturbed root attached to the alveolar bone by the periodontal ligament is the “perfect” implant, and by this method of treatment, many teeth possibly can be preserved in turn maintaining the alveolar bone integrity and rather improves the treatment prognosis either.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
   References Top

1.
Desjardins RP. Obturator prosthesis design for acquired maxillary defects. J Prosthet Dent 1978;39:424-35.  Back to cited text no. 1
    
2.
Brewer AA, Morrow RM. Overdentures. Mosby, St Louis; 1975.  Back to cited text no. 2
    
3.
Garver DG, Fenster RK, Baker R, Johnson DL. Vital root retention in humans: A preliminary report. J Prosthet Dent 1978;40:23-8.  Back to cited text no. 3
    
4.
Johnson DL, Kelly JF, Flinton RJ, Cornell MT. Histologic evaluation of vital root retention. J Oral Surg 1974;32:829-33.  Back to cited text no. 4
    
5.
DeFranco RJ. Overdentures. Dent Clin North Am 1977;21:379.  Back to cited text no. 5
    
6.
Hiremath HP, Doshi YS, Kulkarni SS, Purbay SK. Endodontic treatment in submerged roots: A case report. J Dent Res Dent Clin Dent Prospect 2010;4:64.  Back to cited text no. 6
    
7.
Srinivas KJ. A preliminary report on over denture retained by submerged vital roots. Ind J Dent Sci 2010;1:38-40.  Back to cited text no. 7
    
8.
Salama M, Ishikawa T, Salama H, Funato A, Garber D. Advantages of the root submergence technique for pontic site development in esthetic implant therapy. Int J Periodontics Restorative Dent 2007;27:521-7.  Back to cited text no. 8
    
9.
Miller PA. Complete dentures supported by natural teeth. J Prosthet Dent 1958;8:924-8.  Back to cited text no. 9
    
10.
Morrow RM, Feldmann EE, Rudd KD. Trovillion HM Tooth-supported complete dentures: An approach to preventive prosthodontics. J Prosthet Dent 1969;21:513-22.  Back to cited text no. 10
    
11.
Casey DM, Lauciello FR. A review of the submerged-root concept. J Prosthet Dent 1980;43:128-32.  Back to cited text no. 11
    
12.
ShanKaR YR, Srinivas K, Surapaneni H, Reddy SS. Prosthodontic treatment using vital and non vital submerged roots-two case reports. J Clin Diagn Res 2013;7:2396.  Back to cited text no. 12
    


    Figures

  [Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5], [Figure 6], [Figure 7], [Figure 8], [Figure 9], [Figure 10], [Figure 11], [Figure 12], [Figure 13], [Figure 14], [Figure 15], [Figure 16]



 

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