Oral Rehabilitation Therapies in A Patient with Facial Dysmorphia and Psychiatric Profile-Clinical Case Report

1 Department of Odontology, Periodontology and Fixed Prosthesis, Faculty of Dental Medicine, Grigore T. Popa University of Medicine and Pharmacy, 16 Universităţii Street, 700115, Iasi, Romania 2 Public Health and Management Department, Faculty of Dental Medicine, Grigore T. Popa University of Medicine and Pharmacy, 16 Universităţii Street, 700115, Iasi, Romania; e-mail: lucianburlea@yahoo.com * Corresponding author 3 Department of Odontology, Periodontology and Fixed Prosthesis, Faculty of Dental Medicine, Grigore T. Popa University of Medicine and Pharmacy, 16 Universităţii Street, 700115, Iasi, Romania 4 Department of Oral-Implantology, Dental Prostheses Technology, Removable Dentures, Faculty of Dental Medicine, Grigore T. Popa University of Medicine and Pharmacy, 16 Universităţii Street, 700115, Iasi, Romania. 5 Department of Oral-Implantology, Dental Prostheses Technology, Abstract: This article describes rehabilitation of one case, complex psychiatric treatment, facial asimetry, with mandibular and maxilla missing teeth and dental disharmony, with a fixed and also removable hybrid prosthesis. Rehabilitation with fixed or removable prosthesis is even more challenging when the edentulous span is long and the ridge is irregular deformities and unfavorable biomechanics encountered at the prosthetic field for complex rehabilitation. In such situation, a fixed-removable prosthesis allows favorable biomechanical stress distribution along with restoration of esthetics, phonetics, comfort, hygiene, and better postoperative care and maintenance.


Introduction
Facial dysmorphisms are a complex clinical entity with profound facial implications the picture of this is even more complex given the facial echo of dental imbalances caused by edentation and their complications and also general disease influences (Agarwal et al., 2011;Chronopoulos et al., 2008;Munot et al., 2017;Roumanas, 2009).
In general, the facial asymmetry of adult patients are candidates for surgical correction therefore, patient assessment and selection remain major issues in diagnosis and treatment planning. It depends very much on the degree of asymmetry so mild to moderate facial asymmetry can be managed by orthodontic treatment. Severe skeletal asymmetry most often requires a management protocol surgery (Chan, 2008;Itoh et al., 2008;Ishizaki et al., 2010;Oh & Basho, 2010).
Minor facial asymmetry is common and can be observed in every individual there is a normallity in the aesthetic norms, facial asymmetry affects the lower half of the face more than the upper face.
Facial asymmetry is the condition in which one half side of the face does not resemble to the other in shape and dimensions and can be from dental origin or be caused by a different type of occlusal imbalances, general affectation that can induced the idee of assimetry or some kind ofocclusal conditions such as unilateral cross-bite, forced lateroocclusion, discrepancy of the midlines of the upper and lower dental arch present extraoraly with facial asymmetry.
Prosthetic dentistry train the restoration and maintenance of oral functions, comfort, stability, appearance, and health of the patient by the substitution of missing teeth and contiguous tissues with artificial substitutes (Brown et al., 2016;Nur et al., 2016;Gharechahi et al., 2008;Jackson et al., 2013).
History of the disease: -Chronology and etiology of tooth loss-tooth loss began 37 years ago and has continued until today, due to the complication of tooth decay.
-The patient does not received previous prosthetic treatment, and the dental treatments performed were in an emergency.
General and dental hereditary-collateral antecedents: -His mother: hypertension; multiple cariouslesions and periodontal disease.
General and dental personal history: depression, hypertension, hypertyroidism and at dental level: multiple carious lesions, periodontal disease, radicular chist.
Living and working conditions: hightlevel of stress, physicalwork also accentuated family misunderstandings.
At TMJ also muscular subjective clinical examination: absence of pain but a TMJ disorder (Fig 2. a, b, c, d, e). ObjectiveTMJ exam: Static inspection: left latero-deviation 2mm; dynamic inspection: lateral deviation of the chin to the left at the maximum opening of the mouth; in profile the step movement of the chin. Palpation: asymmetrical, asynergic movements, of increased amplitude on the right side. Listening: right joint crack.
Oral Rehabilitation Therapies in A Patient with Facial Dysmorphia … Laura Elisabeta CHECHERIŢĂ, et al.
The examination of the maxillary and mandibular dental arches as well as the examination of the static and dynamic occlusion we notice important imbalances and the presence of the potential prosthetic divides but also the functional irregularity of the ridges and the existing disharmonies ( Fig. 3. a, b, c). In order to obtain a complete and solid diagnosis, we are accompanied by the presence of paraclinical examinations oropantomography and the study model that objectifies us and offers us important suggestions in the subsequent therapeutic approach (Fig. 3, 4).

Diagnosis
I. General health status diagnosis-General status allows the dental treatment.
3. Pulpal lesions: Simple pulpalgangrene, located at the level of tooth 48, of microbial etiology, with impaired masticatory, physiognomic and phonetic function with slow evolution, without local complications, favorable prognosis, untreated.
Chronic periodontitis, located at the level of teeth: 12, 32, 22 bacterial etiology, with impaired masticatory and physiognomic function, with slow evolution, without local complications, favorable prognosis, untreated.

Periodontal integrity diagnosis:
Generalized chronic marginal periodontitis, maxilla and mandibular, medium, of microbial etiology, with chewing and physiognomic disorders, with slow evolution in time, with local complications (dental migration) and loco-regional (TMJ dysfunction), with favorable prognosis by treatment, untreated.

Arch integrity diagnosis:
Oral Rehabilitation Therapies in A Patient with Facial Dysmorphia … Laura Elisabeta CHECHERIŢĂ, et al.
-TMJ diagnosis: Articular dysfunction, TMJ impairment through asymmetric, asynergic and left lateral deviation of the 3 mm chin in the opening movement, the etiology given by malocclusion, with masticatory functional disorders, swallowing with slow evolution, with local and locoregional complications, prognosis, untreated.
8. Mucosa, tongue, salivary gland integrity diagnosis-normal. 9. Surgical diagnosis: Irrecoverable root residues, at the level of teeth: 14, 24, 25, 26, 34, 45, 47, of  214 In order to complete the treatment plan, we organize ourselves in management for the complex oral rehabilitation of the patient with the restoration of the occlusion plan, the cranio-mandibular repositioning with the help of temporary acrylic partial dentures as well as therapeutic situation.
Treatment Plan: 1. Health education: • patient awareness on its oral health; • explanation of sanitation methods for oral hygiene (a correct brushing technique, encouraging the use of dental floss and mouthwash); • convincing the patient about the utility of the treatment; • proposing and establishing the optimal treatment plan and treatment stages.
2. General preparation of the body: • physical: correct diet; • psychological: creating a good psychological tonus with a fair, serious and understanding attitude of the dental team. 3. Pre-Prosthetic Treatment Plan: -Cariestreatment at 28, 44, (class 1 Black), 35, 22, 32 (class 4 Black) and for abrasion of frontal area group.
Oral Rehabilitation Therapies in A Patient with Facial Dysmorphia … Laura Elisabeta CHECHERIŢĂ, et al.

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The intermediate stages of the fixed prosthetic treatment of the extraoral and intraoral skeletal sample as well as the temporary prosthesis and the occlusal adaptation of the fixed prosthesis part in the context of the unveiled palate of the occlusion but recovered with the temporary prosthesis ( Fig. 6. a, b, c). Maxillatherapeutical solution: -6 metallo-ceramic elements,fixed prosthesis ( Fig. 7. a, b, c ) and -flexible therapeutical solution.  Class 1 Kennedy extended with 1 modifications;  Flexible palatal denture composed of: -a flexible main connector palatine plate in contact with remaining teeth; -2 acrylic saddle bearing 8 artificial acrylic anatomorphic medium height cusp teeth with EMSS,at 1.3, 2.3.
Mandibletherapeutical solution • Physiognomic metallo-ceramic bridge 3.5 to 4.4 composed of: Crowns-3.5, 3.3, 4.1, 4.4Pontics-3.4, 3.2 and 3.1; • Flexible denture. Fig. 7. a, b,  216 Some aspects regarding the treatment with partially adjuvant prostheses and the use of the articulator in achieving an occlusion ( Fig. 8. a,  b,c) as close as possible to our desideratum as well as their adaptation in the hybrid context of the articulated joint prosthesis with the adjuvant for optimal occlusal and temporary stage prosthesis ( Fig. 9.a,b,c).

Discussions
Management of cases with facial asymmetry psyhiatric disease, depends on the severity of the discrepancy, the treatment needs of acase, and the esthetic awareness of the patient. Facial asymmetry involves a combination of dental, skeletal, and soft tissue factors.
A comprehensive diagnosis is important in patients with facial asymmetry so as to formulate a treatment plan suited for each patient.
A clinician has to keep in consideration thetreatment needs and desire of the patient before deriving the treatment plan for a case.
Paraclinical examination, OPG, provides three-dimensional details of the craniofacial skeleton and has been used for evaluating disarmony of arches asymmetry also model study and clinical examination inspection.
The facial asymmetry is a major aesthetic deficiency, but thanks to modern dentistry it can be successfully resolved through a contemporary prosthetic approach (Cristache et al., 2019;Zegan et al., Oral Rehabilitation Therapies in A Patient with Facial Dysmorphia … Laura Elisabeta CHECHERIŢĂ, et al. 217 2017) in our case not from all points of view (Loue & Sattar, 2020;Popa & Dobrescu, 2017) but trying to draw attention to other aspects and thus improving the general appearance in correlation with the treatment of existing general pathologies (Jeyavalan et al., 2012;Maroulakos et al., 2017).

Conclusions
In our case the treatment with a hybrid denture is an affordable choice to fulfill the patient's esthetic demands together with providing a good prognosis for the prosthesis and preservation the compromise situation.
In the context of the complex oral rehabilitation of the solved clinical case we can observe a way forward and motivations of the well-being of the physiognomic masticatory comfort marking an increase of the patient's quality of life.