Prosthodontics

Prosthodontic treatment for a patient with advanced hydantoin-

associated gingival hyperplasia: A case report
Iwao Hayakawa*/Eiji Osada**/Masayuki Morisawa***/Yoko Nakagawa****/lkki Watanabe**
Abstract A pan'em in whom gingival hyperplasia was caused by prolonged use of an
anliconvul.saiU drug (hydanloln) is described. Advanced gingival hyperplasia and
significant displacement ofthe remaining teeth caused severe damage, especially to
the patients appearance. It was not possible to cure the problems completely with
routine periodontal treatment. It was decided to extract all the remaining teeth and
restore function and esthetics early with complete dentures. Cephalometric analysis
was used to determine the degree io which the teeth had drifted. During fabrication
ofthe dentures, the analysis was very useful in deciding the position ofthe
anterior teeth and checking the vertical dimension of occlusion.
(Quintessence Int I996;27:235~24L)
Introduction
In patients with generalized, advanced periodontal
disease, local periodontal therapies are sometimes
repeated uselessly, and the condition gradually worsens
beyond salvage. In these cases, a point is reached when
it is confirmed that no conservative treatment can cure
the severe condition; at this time, prosthodontic
treatment should be ehosen as the best alternative. In
such an event, the hopeless teeth must be extracted
without hesitation. This will allow early restoration of
the lost function and morphology and also rebuild the
confidence ofthe patient.
* Associate Professor, Department of Geriatric Dentistry, Tokyo
Medical and Dental University, Tokyo. Japan,
** Graduate Student, Department of Geriatric Dentistry. Tokyo
Medical and Dental University, Tokyo. Japan.
** Assistant Professor, Department of Geriatric Dentistr>'. Tokyo
Medical and Dental University, Tokyo, Japan,
**** Instructor, Department of Geriatric Dentistr>', Tokyo Medical and
Dental University. Tokyo, Japan.
Reprint requests: Dr Iwao Hayakawa, Associate Professor, Department
of Geriatric Dentistry. Tokyo Medical and Dental University, 5-45,
Yushima I-chome. Bunkyo-ku. Tokyo 113, Japan,
A case is presented in which gingival hyperplasia
was caused by prolonged use of the anticonvulsant
drug, hydantoin. In this patient, the maxillar>' and
mandibuiar gingiva showed extensive hyperplasia. The
dental history ofthe patient indicated that the condi-
tion could not be improved by routine periodontal
treatment, such as brushing, scaling, gingivectomy,
and so on. Therefore all teeth were extracted, and
alveolar plastic surgery was performed. Subsequently
complete dentures were fabricated after adequate
healing. As a result, the patient's chief complaints,
esthetic and masticator^' problems, were resolved.
Case report
A 39-year-old woman presented with the chief com-
plaints of dissatisfaction with her appearance and
inability to masticate food efficiently. She had started
taking anticonvulsant medication 15 years previously
because of epilepsy. Two years later, fibrous hyper-
plasia was found in the region ofthe anterior teeth. The
hyperplasia progressively expanded to the molar
region. Although she underwent six gingivectomies
and thorough plaque removal at a dental office, the hyper-
plasia recurred repeatedly. The condition worsened.
Quintessence Intemationai Volume 27, Number 4/1996 235
Hayakawa et al
Fig l a The facial view reveals iip incompetence.
Fig l b The gingival hyperplasia has caused the protrusion
ot the anterior teeth.
Figs 2a and 2b The advanced gingivai hyperpiasia has oaused significant dispiacemant of the remaining teeth.
and the hyperplasia became much more extensive.
There was no alleviation of gingival bleeding or the
halitosis. Because it was not possible to reduce the
dosage ofthe antjconvulsant. and conservative therapy
could not fundamentally solve her problems, she was
referred to the Faculty of Dentistry, Tokyo Medical and
Dental University.
Tntraoral examination
On initial examination, her upper face showed no
anomalies. In the lower face, lip incompetence was
notable because ofthe remarkable hyperplasia and the
protrusion of the anterior teeth caused by the hyper-
plasia (Figs la and lb). There was no disturbance of
tnouth opening.
The oral hygiene was very poor, and severe, dark-
red swelling was present extensively on the gingiva of
both arches. This tissue tended to bleed easily, and
debris was present between the fissures. The patient
had notably foul breath.
The first molars on both sides ofthe maxilla and the
ftrst and second moiars on both sides ofthe mandible
were missing. Some of the remaining teeth were
covered with the hyperplastic gingiva. No swollen
mueosa was present over the maxillary hard palate or
the mandibuiar edentulous molar regions. The maxil-
lary anterior teeth protruded and were severely iti-
clined labially; consequently wide separatioti occurred
between each tooth. There were many residual roots in
the mandibular anterior region. Tooth contacts were
present only between the maxillary and mandibular
premolars on both sides (Figs 2a and 2b). The anterior
teeth in both arches were remarkably mobile, and deep
236
Quintessence International Volume 27, Number 4/i gg
H aya ka wa et al
periodontal pockets were detected oti all the retnaining
teeth.
Radiographic examination
Radiographic exatnitiation revealed that tbe remaining
teeth had horizomal bone loss. The tnaxillary anterior
teetb were displaced significantly, and hypertrophy of
alveolar bone had followed the displacemetit.
Figures 3a and 3b show the lateral cephalomeftic
radiograph and its analysis. The skeletal analysis
revealed that the mandibular plane angle was steep and
the gonial angle was slightly greater than tbe mean
value for Japanese women, Cephalometric analysis of
the dentitioti indicated that the interincisal angle was
signiftcantly more acute than the mean value, because
of the marked labial tipping of both the maxillary and
mandibular anterior teeth.
The esthetic plane indicated the protrusion of the
anterior segments of both arches. The ratios of the
upper facia! height (nasion-anterior nasal spine) and
lower facial height (anterior nasal spine-gnathion) to
the total facial height were within the normal range
(Table 1).
Treatment Plan
To er!hance esthetics and to maintain the existing
vertical dimension of occlusion, it was thought that
immediate dentures should be made first. However, it
seemed too difficult to extract all the remaining teeth
in one appointment at the outpatient department,
because the operative area would he extensive. There-
fore the fabrication of the maxillary denture was
planned first. So that the patient might masticate with
the immediate denture, it was planned that fabrication
would be statied after the molars were extracted and
the wounds had healed.
According to the cephalometric analysis, the skel-
etal pattern was clinically acceptable; therefore, the
treatment was focused on improving the dental rela-
tionships. So that the patient's appearance might be
improved, it was decided that the maxillary anterior
teeth should be retruded on the denture after the
extraction of the anterior teeth and gingivectomy of the
hyperplastic gingiva.
The positions of the maxillary incisors were deter-
mined on the cephalometric tracing so that the value of
maxillary incisor to the nasion-pogonion plane was
brought near to the mean. The position was marked on
the cast referring to the position of the mandibular
incisors or! the tracing and the cast (Fig 4), The
Fig 3a Pretrealmenl lateral cephalomettic radiograph.
anterior teeth of the maxillary immediate denture were
arranged according to the markings on the cast. The
vertical dimension of occlusion was maintained as it
Procedures
The maxillary premolars and molars that had no
contact with the opposing mandibular teeth were
extracted, and the hyperplastic gitigiva around them
was removed.
Two months later, the maxillar>' impression was
taken. Putty-type silicone impression material (Xanto-
pren function, Bayer Dental) was used for horder
molding, and the final impression was taken with a
light-bodied silicone impression material.
The occlusal relationships were recorded with
occlusion rims and polyether rubber for occlusal
Quintessence International Volume 27, Number 4/1996 237
Hayakawa et al
Facial angle
Conve^ly
AB plane
Mandibular plane
Y- a xi s
Occlusal plane
InlerincisaM''
L1 to Occlusal^
L1 to Mandibular
U - 1 ID AP plane
FH to 3N plane
SNA
SNB
SNASNB diff
U1 to NP plane
U1 to FH plane
U - 1 to SN plane
Gomal angle
Ramua inclination
7.S8
4.4a
28.81
65.38
11.42
12*09:
23.84
196.33
3.92
6.19
32.32
78.90
3.39
11.74
111.13
104.54
122.23
2.93
3.05
4.95
3.50
5.23
5.63
3.S4
- 7. S3- "
5.23
5.73
1.88
2,39
3.45
3.45
1.77
2.73
5.54
5.55
4.51
4.40
82.3
7. 9
4. 0
39. n
70.3
9.0
"73 "4"
5.5
110.5
20.5
7. 1
79.0
75.8
3. 1
23.2
137,1
130.0
1?9.8
0,8
(Standard by IizukaIshikawa)
Fig 3b The patient's cephalomelric
measurements (dotted lit>e) were
compared to normal values for Japa-
nese women (solid line) (reported by
lizuka and IshJkawa"'). Mandibular
incisor (L-1]; maxiiiary ncisor (U-1);
(A-P), Frankfort horizontal (FH]; sella-
nasion (S-Nl, seiia-nasion-point A
(SNA!; seiia-nasion-poinf B (SNB);
nasion-pogonjon N-P].
* Interincisai angle.
t L-1 I0 occiusal plane,
+ L-1 lo mandJbuiar plane.
Table I Facial height and esthetic plane
Patient Norm*
N-ANS/N-Gn{%)
ANS-Gn/N-Gn i%)
Esthetic plane to lower lip (mm)
Esthetic plane to upper lip (mm)
45.9 44.4 2.0
54.2 55.6 2. 0
9.0 2.3 2. 5
4. S 0.6 2.4
* Normal value for Japanese women, as reported by Matsumolo.'
N = nasiorii ANS = anlerior nasal spine- Cn - ynalhiun.
registration (Ramitec. ESPE). Occlusal contact was
made between opposing premolars (Eig 5).
As a guide for gingivectomy and alveolectomy. a
template was prepared on the maxillary cast, on which
all teeth were removed, and the area of the alveolar
ridge was modified to form a smooth surface.
Anterior teeth were arranged according to the line
previously marked on the cast, and then the immediate
denture was made conventionally.
After extraction of all the remaining maxiUary teeth,
from left first premolar to right first premolar, the
gingivectomy and alveolectomy were performed ac-
cording to the template. The immediate demure was
inserted after the template was shown to fit over the
denture-bearing area without causing tissue blanching
(Fig 6).
Two weeks after insertion of the maxillary denture,
all the mandibular anterior teeth were extracted, and a
gingivectomy was performed. After the wounds had
healed, an impression was taken in the same way as for
the maxilla and the occlusal relationships were
238
Quintessence International Volume 27, Number 4/1995
Havakawa et al
Fig 4 The positions of the maxillary incisors (dotted line)
were determined on the cephalomelric iracing so that Ihe
value of the maxillary incisor to the nasion-pogonion
N-Pog) plane was brought near to the mean ot Japanese
women.
Fig 5 The maxillomandibular relationship was recorded
wilh occlusion between the opposing premolars.
Fig 6 A template has boen prepared as a guide fcr
gingivectomy and alveolectomy.
recorded, using the contacts in the premolar regions as
a guide.
The immediate denture was made on the mandibular
cast, on which the premolars were removed. The
immediate denture was inserted after all the mandib-
ular remaining teeth were extracted.
Three months after insertion of the immediate
dentures, cephalometric analysis revealed that the
vertical dimension had decreased a little. To restore it
to the preoperative situation, the posterior teeth were
built up with an autopolymerizating acrylic resin.
Subsequently, new complete dentures were con-
structed with conventional methods. To check the
vertical dimension of occlusion and the position of the
anterior teeth, cephalograms were prepared each time
the occlusai rims and the trial dentures were inserted in
the mouth. Furthermore, when the triai dentures were
inserted, the position of the anterior teeth was
evaiuated by assessing the patient's appearance.
On the cephalogram taken with the new dentures in
situ, the anterior teeth and lips were greatiy retruded
compared with their positions on the preoperative
cephalogram. The value of the maxillary incisor to the
nasion-pogonion plane was brought nearly to the
mean value for Japanese women, and the esthetic plane
was improved. It was also obvious from the patient's
appearance that esthetics was greatly improved (Figs 7
to 9).
The dentures fit weli, and the patient's chief
complaint was solved to her satisfaction.
Quintessence Intemational Volume 27, Number 4/1996
239
Hayakawa et al
Fig 7 New complete dentures are intended to maintain the
vertical dimension of occlusion and restore lip compe-
tence.
Fig 8 (Right) Superimposition of the preoperative ceph-
alometric tracing (solid lines)\ and the tracing with new
dentures (dotted lines). Esthetic plane (E-pi).
\
Figs 9a and 9b The new dentures greatly improve esthetics.
Discussion
In this case, the advanced gingival hyperplasia and
significant displacement of remaining teeth caused
severe damage to the patient's appearance. The patient
was eager for esthetic improvement.
The cephalometric analysis was used to determine
the degree to which the teeth had drifted. The analyses
used were Downs' analysis^ and the Northwestern
analysis.^ usually used in orthodontics, and Ricketts'
analysis'' and Mastumoto's analysis,- used in prostho-
dontic treatment. According to the analyses, although
the mandibular plane angle ofthe patient was steeper
than the mean value for Japanese women, it was
clinically acceptable. Labial tipping of the anterior
leeth caused by the alveolar hyperplasia was the
problem that needed to be solved.
240
Quintessence Intemationai Volume 27, Number 4/1996
Hayakawa et al
Because it was thought that a successful result could
not be attained by periodontal treatment, it was
decided that the appearance could be improved by
insertion of complete dentures after extraction of all
Ihe remaining hopeless teeth.
During fabrication of immediate complete dentures,
the cephalometric analysis was very useful in deciding
the position ofthe anterior teeth. To bring the esthetic
plane close to the mean value, the anterior teeth ofthe
immediate dentures were arranged by referring to the
value of maxillary incisor to the nasion-pogonion
plane.
The occlusion ofthe opposing premolars and pre-
operative cephalograms were helpftil in maintaining
the vertical dimension of occlusion.
The lower facial height decreased by 3.5 mm 3
months after insertion ofthe immediate dentures. This
reduction was believed to be caused by a decrease of
the gingival swelling and rsorption of alveolar bone.
The vertical dimension of occlusion was restored by
building up the posterior teeth with an autopoly-
merizing acrylic resin.
Although enough time was allowed for wound
healing before the fabrication of new dentures, it is
necessary to continue assessing the rsorption of
alveolar bone, because of the extraction of all the
remaining teeth and the extensive alveolar plastic
surgery that was peribrmed.
Summary
The mild form of hydantoin-associated gingival hyper-
plasia may be improved by reduction ofthe dosage of
the anticonvulsant drug and thorough plaque control.
In the severe form of drug-induced hyperplasia, it is
not possible to cure the problems completely by
gingivectomy or plaque control. In the present case, it
was decided to extract all the patient's remaining teeth
and restore Ilinction and esthetics early with complete
dentures.
References
1. lizuka T, Ishikawa F. Normal standards for various cephatomelric
analysis in Japanese adults. J Jpn Orthod Soc I957;I6:4-I2.
2. Matsumoto T. A roentgenographic cephalometric study on vertical
dimension. J Jpn Prosthodom Soc 197hl5:209-220.
3. Downs W. Variation in facial relationships: Their significance in
treatment and prognosis. Am J Orthod 1948:34:812-840.
4. Graber TM. A critical review of clinical cephalometric radiography.
Am J Orthod 1954:40:1-26.
5. Rickeits [IM. A foundation for cephalometric communication. Am J
Orthod 1960:46:330-357. D
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