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Clinical Section |
Orthodontic Departments, Liverpool University Dental Hospital, Liverpool, UK and Countess of Chester Hospital, Chester, UK
Orthodontic Departments, Leighton Hospital, Crewe, UK and Countess of Chester Hospital, Chester, UK
Address for correspondence: Ms Mhairi Walker, Orthodontic Department, Liverpool University Dental Hospital, Pembroke Place, Liverpool, L3 5PS, UK. Email: mhairiwalker{at}mac.com
Received 1 September 2006; accepted 30 July 2007
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Abstract |
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Key words: Orthodontics, transplants, gingival overgrowth, enamel hypoplasia
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Introduction |
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This has been brought about by advances in tissue typing, improved immunosuppressant drugs, control of opportunistic infections and advances in surgical techniques.2 A 95% survival rate following transplant procedures is reported with graft survival rates in excess of 85%.2
A significant risk associated with these procedures is organ transplant rejection. Immunosuppressant therapy is required to minimize host rejection and commonly involves the use of a combination of prednisolone, azathioprine, ciclosporin and more recently, tacrolimus.3
Ciclosporin in particular has had a major impact on graft survival in organ transplant surgery, but its use is associated with a number of unwanted side effects.4 These include nephrotoxicity, hypertension, hepatotoxicity, diabetes mellitus and gingival overgrowth.2,3 Gingival enlargement secondary to drug therapy is widespread and reports suggest 8–100% of patients taking ciclosporin have this overgrowth, with children and adolescents being more susceptible than adults.1,3 The wide range of prevalence reported in the literature is due to variation in assessment of the overgrowth.
Nifedipine is used for these patients to control hypertension and reduce ciclosporin-induced nephrotoxicity.5 When used concomitantly however, these drugs accentuate gingival hyperplasia6 and the number of patients with clinically significant overgrowth is reported to be more than double.7
This case report describes a case in which a 15-year old girl presented with significant gingival overgrowth following a renal transplant. She was being maintained on a long-term regimen of ciclosporin and nifedipine. Her malocclusion was successfully managed with orthodontic treatment, improved oral hygiene and a concurrent change of medication.
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Case report |
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History
Her medical history indicated congenital nephrotic syndrome for which she had undergone a renal transplant at age eight. This condition was stable and managed with ciclosporin, nifedipine, azathioprine and prednisolone. She suffered from drug-induced gingival hyperplasia but had no other side effects from her medication. Under the guidance of a consultant in paediatric dentistry, she had undergone a gingivectomy procedure, by a specialist in surgical dentistry, one year previously, to reduce her gingival enlargement.
Extra-oral assessment
On frontal examination the patient presented with acceptable facial symmetry and balance and acceptable tooth show on smiling. Her dental centrelines were coincident with the mid-facial axis. On three-quarter and profile views, she had average vertical proportions, an average naso-labial angle and her lips were competent at rest (Figure 1a–d).
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Treatment aims
These were as follows:
Treatment plan
The orthodontic treatment plan involved use of upper and lower fixed appliances on a non-extraction basis. The plan was therefore as follows:
Treatment progress
Oral hygiene was already of a good standard but given the degree of hyperplasia, oral hygiene instruction and dietary advice was reinforced on a dedicated dental health education clinic. Her plaque index score was reduced from 13 to 1.8%. Informed consent was gained including additional warnings of the possible need to abandon treatment if the hyperplasia worsened significantly; the possibility of a residual overjet post-treatment and the requirement for long-term retention as the lower labial segment was planned to be advanced during treatment.
The upper and lower arches were bonded with MBT Victory Series pre-adjusted edgewise brackets (3M Unitek, Monrovia CA, USA). UR2 was not bracketed initially. Laceback mechanics were placed in the upper right and left quadrants, and 0.016-inch heat-activated nickel titanium (NiTi) wires were used to begin levelling and aligning the arches. The lower arch was progressed to a customized and co-ordinated 0.019 x 0.025-inch stainless steel archwire. In the upper arch, a 0.018-inch stainless steel archwire was placed and space opened between UR1 and UR3 with a NiTi open coil spring to allow the UR2 to be bracketed. An auxiliary 0.014-inch NiTi archwire could then be placed to allow alignment of UR2.
The oral hygiene remained at an excellent standard, but the gingival hyperplasia was steadily worsening. This was especially evident in the labial segments and on removing the archwire, indentations were noted in these areas. On replacing the archwire, blanching of the gingivae was apparent as the archwire pressed on the gingivae between UR1 and UL1 (Figure 4a–e). The increased risk of decalcification and the need for further surgical intervention were discussed with the patient. She indicated that she wished to continue with treatment but this decision would need to be reviewed periodically.
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In light of the worsening hyperplasia, it was felt that although her medical condition was stable, it would be appropriate to consult her general medical practitioner to review her current medication. Her anti-hypertensive medication was changed from nifedipine and substituted with enalapril. Following this her gingival hyperplasia started to resolve.
As the gingivae were improving, LR7 and LL7 were aligned into a 0.019 x 0.025-inch stainless steel wire and the upper arch seated to the lower with braided 0.019 x 0.025-inch stainless steel archwires and box elastics. The arches were debonded and upper and lower Essix retainers (Raintree Essix Inc., Metairie LA, USA) were provided to be worn only at night. Instructions were given on the requirement for this to be continued indefinitely. Treatment was completed over 20 months and a good aesthetic result was achieved (Figures 5a–d, 6a–e). It was arranged for composite restorations to restore the hypoplastic lesions in the anterior segments (Figure 7a–e). As the gingival hyper-plasia had almost fully resolved and the patient was very happy with the outcome, it was not necessary to consider further gingival surgery.
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Discussion |
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,8 This may account for the notching seen on this patient’s incisor and canine teeth and the hypomineralized first permanent molars. Non-carious tooth loss can also be seen in this group of patients and may be attributed to nausea, anorexia nervosa or oesophageal regurgitation.3
Treatment was aimed at preventing worsening of the gingival hyperplasia as well as minimizing the effect of expression. It is worth noting however that while stringent oral hygiene measures may reduce the degree of overgrowth,2 they do not inhibit its development.2,10
A non-extraction treatment plan was used for this patient even though she presented with occlusal features that under normal circumstances would have necessitated extractions. She had a tenuous overbite, moderate crowding, several hypoplastic teeth and the lower incisors were already ahead of A-Po. It was decided not to extract in case treatment needed to be curtailed due to the medical problems or worsening gingival overgrowth preventing the closure of residual extraction space. Avoidance of space closing mechanics would mean gingival hyperplasia was less likely to counteract orthodontic therapy. This is problematic due to space closing springs impinging upon the bulbous interdental tissue rather than the intended tooth. Furthermore, archwire loops can be displaced buccally thereby altering the direction of intended force. In addition, at various stages in treatment, gingival hyperplasia may engulf and occlude buccal tubes, delay the eruption of teeth and open anterior diastemata.11
With regard to retention, retention clasps of removable appliances may encroach on the hyperplastic gingivae in embrasures so preventing full seating.11
Further measures used in this case included utilizing MBT Victory Series brackets. These brackets are both small and low profile and were therefore intended to aid oral hygiene. Bonded tubes rather than bands on the molar teeth were used, and all excess composite was removed at the time of bond-up to further simplify oral hygiene.
The treatment plan aimed for a mild advancement of the lower labial segment in order to relieve crowding and this was achieved during treatment. This dictated that a regime of long-term indefinite retention be used. Essix type retainers were used as they impact only minimally upon the gingival tissues. A lingual bonded retainer was not employed due to hygiene concerns in light of any recurrence of the gingival overgrowth.
An important factor in the management of this patient was having a well-organized treatment protocol with liaison between specialties. Prior to referral to the Orthodontic Department, this patient underwent a full mouth gingivectomy. This is however, generally only of temporary benefit2 and indeed the overgrowth recurred by the time the patient was initially assessed (see Figure 2a–e
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Assistance was also provided by the patient’s physician, changing her medication from nifedipine to enalapril. This eliminated the combined effect of ciclosporin and nifedipine on the gingival overgrowth while adequately controlling hypertension.6 Substitution of ciclosporin with tacrolimus (FK506) can also be considered as this reduces the risk of developing gingival overgrowth as well as minimizing its severity in existing cases.2,12 Following completion of orthodontic treatment, input was also received from restorative colleagues in addressing the hypoplasia affecting the incisor and canine teeth.
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Conclusion |
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The authors recommend early consultation with these patients’ physicians to explore whether medication can be adjusted to aid control of the gingival overgrowth. Further assistance may be sought from oral surgery and/or periodontology colleagues to perform gingival recontouring procedures.
This case report highlights that even though patients with drug-induced gingival overgrowth present difficult challenges for orthodontic treatment, their management can be successful if the practitioner is aware of the causes of the overgrowth, its control and its implications on treatment mechanics. Techniques suggested within this report can aid orthodontic management (Table 1).
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References |
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2 Chabria D, Weintraub RG, Kilpatrick NM. Mechanisms and management of gingival overgrowth in paediatric transplant recipients: a review. Int J Paediatr Dent 2003; 13: 220–29.[CrossRef][Medline]
3 Proctor R, Kumar N, Stein A, Moles D, Porter S. Oral and dental aspects of chronic renal failure. J Dent Res 2005; 84: 199–208.
4 Seymour RA, Jacobs DJ. Cyclosporin and the gingival tissues. J Clin Periodontol 1992; 19: 1–11.[CrossRef][Medline]
5 Thomason JM, Seymour RA, Rice N. The prevalence and severity of cyclosporin and nifedipine-induced gingival overgrowth. J Clin Periodontol 1993; 20: 37–40.[CrossRef][Medline]
6 Bökenkamp A, Bohnhorst B, Beier C, Albers N, Offner G, Brodehl J. Nifedipine aggravates cyclosporine A-induced gingival hyperplasia. Pediatr Nephrol 1994; 8: 181–85.[CrossRef][Medline]
7 Thomason JM, Seymour RA, Ellis JS. Risk factors for gingival overgrowth in patients medicated with ciclosporin in the absence of calcium channel blockers. J Clin Periodontol 2005; 32: 273–79.[CrossRef][Medline]
8 Soames JV, Southam JC. Oral Pathology, 3rd edn. New York: Oxford University Press, 1998, 3–17.
9 Kantarci A, Cebeci I, Tuncer O, Carin M, Firatli E. Clinical effects of periodontal therapy on the severity of cyclosporin A-induced gingival hyperplasia. J Periodontol 1999; 70: 587–593[CrossRef][Medline]
10 Seymour RA, Smith DG. The effect of a plaque control programme on the incidence and severity of cyclosporin-induced gingival changes. J Clin Periodontol 1991; 18: 107–10.[CrossRef][Medline]
11 Daley TD, Wysocki GP, Mamandras AH. Orthodontic therapy in the patient treated with cyclosporine. Am J Orthod Dentofacial Orthop 1991; 100: 537–41.[Medline]
12 Webster AC, Woodroffe RC, Taylor RS, Chapman JR, Craig JC. Tacrolimus versus ciclosporin as primary immunosuppression for kidney transplant recipients: meta-analysis and meta-regression of randomised trial data. BMJ 2005; 331: 810.
This article has been cited by other articles:
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  A. Patel, D. J Burden, and J. Sandler Medical disorders and orthodontics J. Orthod., December 1, 2009; 36(Suppl): 1 - 21. [Abstract] [Full Text] [PDF]
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