|Year : 2019 | Volume
| Issue : 3 | Page : 303-307
Cu-sil dentures: A novel approach of Papillon–Lefèvre syndrome management
Shreya Tyagi1, Abi M Thomas1, Vinod Balla2, Ruchika Kundra1
1 Department of Pedodontics and Preventive Dentistry, Christian Dental College, Ludhiana, Punjab, India
2 Department of Dentistry, Rajiv Gandhi Institute of Medical Sciences, Adilabad, Telangana, India
|Date of Web Publication||30-Sep-2019|
Dr. Shreya Tyagi
Department of Pedodontics and Preventive Dentistry, Christian Dental College, Brown Road, Ludhiana - 141 008, Punjab
Source of Support: None, Conflict of Interest: None
| Abstract|| |
Papillon–Lefèvre syndrome (PLS) is a rare genetic disorder characterized by palmoplantar keratosis and premature loss of primary and permanent dentition. Its onset can be as early as 1–4 years of age. The genetic disorder is mutation in the cathepsin C gene. Hereby, we discuss the fabrication of Cu-sil dentures for the prosthetic rehabilitation of a 14-year-old girl with PLS. The case report describes the procedure and associated relevant information regarding the management protocols.
Keywords: Cu-sil dentures, palmoplantar keratosis, Papillon–Lefèvre syndrome
|How to cite this article:|
Tyagi S, Thomas AM, Balla V, Kundra R. Cu-sil dentures: A novel approach of Papillon–Lefèvre syndrome management. J Indian Soc Pedod Prev Dent 2019;37:303-7
|How to cite this URL:|
Tyagi S, Thomas AM, Balla V, Kundra R. Cu-sil dentures: A novel approach of Papillon–Lefèvre syndrome management. J Indian Soc Pedod Prev Dent [serial online] 2019 [cited 2020 Apr 1];37:303-7. Available from: http://www.jisppd.com/text.asp?2019/37/3/303/268177
| Introduction|| |
Papillon–Lefèvre syndrome (PLS) is an autosomal recessive disorder characterized by palmoplantar hyperkeratosis and aggressive periodontitis leading to premature loss of primary and permanent teeth. PLS was first described by two French physicians, Papillon and Lefèvre in 1924. The prevalence is approximately one case in 1–4 million people. The most frequent cause of its expression is consanguineous marriages.
It is a rare genetic disorder caused by loss-of-function mutations in the cathepsin C gene – the encoder for cysteine lysosomal protease, an enzyme highly expressed in the cells of the immune system, lungs, kidneys, and epithelial tissues, thereby deactivating it.
Palmoplantar keratosis usually begins from 1 to 4 years of age, and juvenile periodontitis can be seen as early as 2 years of age. Dural calcification was added as another component of diagnosis by Gorlin et al. By the age of 4 or 5 years, all the primary teeth may have exfoliated. Gingiva becomes normal following the exfoliation of primary teeth. However, this state relapses after the eruption of permanent teeth. Consequently, partial or complete edentulous stage appears by the age of 14–16 years.
In about 20% of patients, infections other than periodontitis can also be seen. Increased incidence of infections led to the hypothesis that an underlying immune disorder is an important primary or secondary etiological factor in predisposing Papillon–Lefèvre patients to periodontitis.
There is increased percentage of Gram-negative microorganisms in these patients. Actinobacillus actinomycetemcomitans is a common pathogenic organism responsible for periodontal destruction. Organisms such as Porphyromonas gingivalis, Prevotella intermedia, Prevotella loescheii, Bacteroides gracilis, and Fusobacterium nucleatum are also involved in periodontitis.
Many treatment options have been described by the authors for the prosthetic rehabilitation of PLS patients, but Cu-sil dentures have been fabricated for these patients for the first time. It is a transitional denture with holes to accommodate the existing natural teeth. A resilient liner is used to fill the gap between the denture base and the tooth so that it seals and does not allow food and fluids to enter below the denture base and also gives cushioning and splinting effect. A Cu-sil denture provides a good retention and stability. In accordance with future needs, relining is possible. The case report is necessary to bring to the notice that for PLS patients in whom the remaining alveolar bone does not allow the placement of dental implant and the conventional complete dentures are not retentive owing to resorbed ridges, Cu-sil dentures can serve as a better treatment option. The remaining teeth have been utilized for the retention of the dentures for the first time in PLS patients. Till date, no case report has mentioned about the Cu-sil denture as one of the treatment modalities in these patients.
| Case Report|| |
A 14-year-old girl reported to the Department of Pedodontics with a chief complaint of loss of multiple teeth and difficulty in chewing food. The family history revealed consanguineous marriage of the parents. The patient was lean and thin. She had a senile facial appearance due to multiple exfoliated teeth. There was slight dystrophy of nails, but the hair was normal. Well-demarcated white keratotic lesions were present on the dorsal surface of hands [Figure 1] and feet [Figure 2]. On the plantar surface of feet, fissuring was present [Figure 3]. The skin was dry and rough on palpation. Only five teeth were present in the oral cavity, i.e., 17, 27, 37, 43, and 47 [Figure 4]. There was Grade 3 mobility in 43, so it was extracted. Orthopantomogram revealed severe alveolar bone resorption giving the teeth a “floating in air” appearance [Figure 5]. Intracranial calcifications were absent on lateral cephalogram [Figure 6].
|Figure 1: Well-demarcated keratotic lesions on the dorsal surface on hands|
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|Figure 5: Orthopantomogram showing “floating in air appearance of teeth” and atrophied jaws|
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For the fabrication of Cu-sil dentures, preliminary impressions were made with alginate (Zelgan, Dentsply) [Figure 7], and final impressions were made with putty and light body polyvinyl siloxane elastomeric impression material (Dentsply). Casts were poured with Type III dental stone (Gypstone, Prevest Denpro Ltd.,) [Figure 8]. Occlusal rims were prepared on temporary denture bases which were fabricated using autopolymerizing acrylic resins (DPI RR Cold Cure). After the bite registration was recorded [Figure 9], the setup was mounted on a three-point articulator. Teeth arrangement was done followed by wax trial. The wax-up of the dentures was done leaving holes corresponding to the remaining natural teeth 17, 27, 37, and 47. The dentures were cured with heat-cure acrylic resin (DPI Heat Cure, DPI) [Figure 10]. Finishing and polishing of the dentures were done. The space in maxillary and mandibular partial dentures around the remaining teeth was widened to give a clearance of 4–5 mm around the teeth. Acrylic-based soft liner (Coe-Soft, GC Soft Liner) was applied to denture and placed into oral cavity to occupy space between denture and natural teeth [Figure 11]. The dentures were inserted in patient's mouth and held in position. After setting of the material, dentures were removed. The excess liner material was trimmed, and dentures were finally inserted in the patient's mouth. Occlusion was checked, and postinsertion instructions were given [Figure 12].
| Discussion|| |
For the treatment of PLS patients, a multidisciplinary approach involving a team of dermatologist, pediatrician, and dental team is required for the overall care. Retinoids including etretinate, acitretin, and isotretinoin are beneficial in the treatment of both hyperkeratosis and periodontitis. Different treatment modalities such as conventional periodontal treatment in the form of scaling and root planning; oral hygiene instructions, 0.2% chlorhexidine gluconate mouth rinses; and a course of antibiotic therapy have been suggested to control the active periodontitis. For the successful management of PLS cases, following guidelines have been proposed: it includes extraction of the deciduous dentition and construction of complete dentures 3 months after the removal of primary teeth. It also includes a prophylactic dose of antibiotic for 10 days immediately after the denture insertion, and the denture bases are adjusted during the emergence of the permanent dentition followed by another dose of antibiotic.
For the rehabilitation of edentulous PLS patient, conventional complete dentures, implant-supported complete dentures, overdentures, or a combination of these can be utilized. As proposed by Ullbro et al., Woo et al., and Etoz et al., the use of implants could considerably enhance future therapeutic options. According to Senel et al., the treatment of these patients is complicated because the patients become edentulous at a young age, and alveolar ridges are severely atrophic because of early-onset periodontitis.
In the present case, the patient underwent treatment for the cutaneous lesions but was not relieved and thus discontinued the treatment. For the prosthetic rehabilitation, the treatment plan was planned by the multidisciplinary team. The remaining alveolar bone was not sufficient enough for the implant, so removable prosthesis was chosen as the treatment option. The fabrication of Cu-sil denture was planned, and the remaining teeth 17, 27, 37, and 47 were retained to record the centric relation and vertical dimension. The Cu-sil dentures thus fabricated maintained the proprioception by remaining natural teeth and provided the psychological benefit of avoiding extraction. No antibiotic was prescribed to the patient during the treatment, but the patient was instructed to maintain strict oral hygiene regimen. The patient was kept on regular follow-up visits.
The limitation of Cu-sil dentures is the short functional duration of soft liner. It can deteriorate over a period of time which includes changes in the physical properties (hardening, cracking, or tearing), and thus, the prosthesis needs to be monitored at regular follow-up appointments.
| Conclusion|| |
Prosthodontic rehabilitation of PLS patients can improve their oral functioning, appearance, self-confidence, and minimize the onset of emotional and psychological problems. In conclusion, the fabrication of Cu-sil denture was preferred to provide the psychological benefit of preserving the remaining teeth. Successful periodontal management of PLS patients is challenging, and it is imperative to maintain the oral hygiene status to achieve the long-term success of the treatment.
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
Conflicts of interest
There are no conflicts of interest.
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[Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5], [Figure 6], [Figure 7], [Figure 8], [Figure 9], [Figure 10], [Figure 11], [Figure 12]