A 44-year-old female presented with severe vestibulo-bullous lesions as a result of oral pemphigus vulgaris (PV). The patient had been under the care of a periodontist, an ear, nose and throat specialist and had been taking systemic steroids in order to help minimize the effects of PV. The patient has experienced several painful erosive lesions as a result of bullae formation, rupture and subsequent sloughing of the oral tissues.Nikolsky's sign (gentle horizontal pressure on the oral mucosa similar to what a denture would accomplish repeatedly) is used as an initial diagnostic test for mucocutaneous bullous diseases. PV is identified through direct immunofluorescent staining of Immunoglobulin G in the intercellular regions of the epidermis and is potentially life-threatening. Patients with PV have developed autoantibodies directed against desmosomes, which serve as the primary attachment between keratinocytes. The first signs of PV, typically in the fourth to sixth decade of life, are oral lesions and are typically the last to be resolved with therapy.
Treatment of PV primarily involves the use of systemic corticosteroids often in combination with immunosuppressive drugs. The side effects of long-term corticosteroid use include osteoporosis and an increased susceptibility to a wide-range of infections. The most common approach is to use the lowest dose of corticosteroid necessary to control the condition. It is especially critical to look for a history of taking medications related to osteoporosis such as Fosamax, Activa or Boniva.
This patient had suffered from advanced periodontal disease – particularly evident in the lower arch resulting in a hopeless prognosis. Minor trauma as a result of wearing a denture would certainly result in epithelial separation, acantholysis or bullae (fluid-filled elevation greater than 1cm in diameter) formation.
The restorative treatment plan includes a mandibular fixed hybrid (fixed-detachable), however, the challenge in restoring this patient with PV is compounded by a limited ability to open her mouth.
Traditionally, an open-tray final impression involves placing the implant specific impression abutments and connecting with a rigid material, such as GC Pattern Resin LS (low shrinkage). The goal is to maintain a precise record of the 3-dimensional position of the dental implants while minimizing the effect of the dimensional change related to the impression material – particularly when recording a full arch. The impression abutments remain embedded within the impression for use in creating a master cast, as shown in the main photo of the article.
Typically, an impression tray loaded with impression material, is inserted by going up and over the impression abutments placed in the mouth. This can be painful or simply impossible in a scenario where the patient simply can not open wide enough to accommodate, particularly with a time-sensitive material.
The final impression for the definitive restoration in this patient was completed through the use of a 2-piece custom tray. (Fig. 1-3)The first component was made to capture the edentulous areas in the posterior segments of the mandibular arch as well as the lingual aspect of the impression abutments. A visual evaluation can be completed to assure the appropriate capture of information prior to proceeding.
The second component was made to capture the facial aspect of the impression abutments and to connect to the first component of the custom tray. The modified open-tray technique allowed for primarily an anterior path of removal after releasing impression abutments.
Douglas G. Benting, DDS, MS, FACP, Spear Visiting Faculty and Contributing Author. [ www.drbenting.com ]
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