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Year : 2015  |  Volume : 4  |  Issue : 1  |  Page : 56-59

Esthetic rehabilitation of prosthodontically compromised orthodontic patient: An interdisciplinary approach

Department of Orthodontics, Dr. Sudha and Nageswara Rao Siddhartha Institute of Dental Sciences, Chinnaoutpalli, Gannavaram Mandal, Krishna, Andhra Pradesh, India

Date of Web Publication16-Mar-2015

Correspondence Address:
Dr. Dodda Kiran Kumar
Department of Orthodontics, Dr. Sudha and Nageswara Rao Siddhartha Institute of Dental Sciences, Chinnaoutpalli, Gannavaram Mandal, Krishna, Andhra Pradesh
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/2277-8632.153331

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A 28-year-old male patient came with the chief complaint of missing front teeth. On examination, the anterior bite is collapsed with no space for the replacement of fixed prosthesis. The patient was started by means of a conventional fixed orthodontic therapy, in which bite opening mechanics were used like the leveling of curve of spee in the lower arch and removable prosthesis with anterior bite plate incorporated, in the upper arch. After 15 months of orthodontic treatment, adequate bite opening was achieved for the replacement of the prosthesis. The interdisciplinary approach gave the patient not only the best possible esthetics but also functional outcome.

Keywords: Collapsed bite, curve of spee, esthetic rehabilitation, interdisciplinary approach, missing anterior teeth

How to cite this article:
Kumar DK, Singamsetty EP, Meka BP, Suryadevara S. Esthetic rehabilitation of prosthodontically compromised orthodontic patient: An interdisciplinary approach. J NTR Univ Health Sci 2015;4:56-9

How to cite this URL:
Kumar DK, Singamsetty EP, Meka BP, Suryadevara S. Esthetic rehabilitation of prosthodontically compromised orthodontic patient: An interdisciplinary approach. J NTR Univ Health Sci [serial online] 2015 [cited 2023 Mar 30];4:56-9. Available from: https://www.jdrntruhs.org/text.asp?2015/4/1/56/153331

  Introduction Top

A good smile is necessary to establish positive social relationships. Missing anterior teeth in young individuals is a big concern as it affects the esthetics and also affects the psychosocial relationships of the individual. [1],[2],[3],[4] Apart, from the esthetic point of view, the missing teeth also create functional problems in which the functions like speech, deglutition and to a certain extent mastication can be hampered. Here, we present a case report of 28-year-old male patient with missing anterior and anteriorly collapsed bite.

  Case Report Top

A 28-year-old male patient presented with the chief complaint of missing upper front teeth. Patient reported history of road traffic accident 8 months back, following which he had lost the upper front teeth. On clinical examination, patient has straight profile, orthognathic facial divergence with competent lips [Figure 1]. On intraoral examination, the patient has Angle's class II molar relation and class II canine relation with missing upper right central and left central and lateral incisors and periodontally compromised lower right central incisor along with lower anterior crowding [Figure 2]. There was scissor bite in relation to premolars of the right and left sides. Anteriorly, the bite was collapsed, lower anterior teeth were almost touching the upper anterior palate, and there was no adequate space for the replacement of missing teeth with prosthesis.
Figure 1: Pretreatment extraoral photographs

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Figure 2: Pretreatment intraoral photographs

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On examination of orthopantamogram [Figure 3], the upper right central incisor, left central and upper left lateral incisor were missing, and all the remaining permanent teeth have erupted into the oral cavity. On examination of the lateral cephalogram [Figure 4], patient had a straight profile with mild lower anterior proclination and average growth pattern.
Figure 3: Pretreatment orthopantomogram

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Figure 4: Pretreatment lateral cephalogram

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The treatment objective was to unravel lower anterior crowding, correction of scissor bite, and to level the curve of spee in the lower arch and to open the bite anteriorly to provide adequate vertical clearance for replacing the lost teeth with prosthesis. [1],[2],[3],[4],[5]

Treatment procedure

Orthodontic therapy: The recommended treatment plan was to level and align the upper and lower arches using 0.022 MBT prescription. The lower right central incisor was extracted as it is periodontally compromised. An anterior bite plate [Figure 5] is used with anterior acrylic teeth incorporated. The anterior bite plate helped in creating a posterior dis-occlusion of 2 mm into which the posterior teeth supraerupted and contributed to anterior bite opening. [6] The anterior bite opening was further enhanced by the customization of the bracket positioning. The bracket position was customized in such a way that lower anterior brackets were positioned 0.5 mm incisally, and the posterior brackets were positioned 0.5 mm gingivally than the ideal bracket positions. [7] This helped in leveling of the exaggerated curve of spee in the lower arch, which helped in further opening of the bite anteriorly [Figure 6].

The treatment took approximately 15 months of duration. Debonding was done in the upper and lower arches. Anterior bite plate was given as a retainer in the upper arch, and a permanent lingual bonded retainer was given in the lower arch. After the adequate bite opening had been accomplished, the case was referred back to the Department of Prosthodontics for prosthetic rehabilitation.
Figure 5: Removable prosthesis with anterior bite plate

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Figure 6

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The patient informed about the placement of implants supported prosthesis and teeth supported prosthesis, and he opted for tooth supported prosthesis. The orthopantamogram examination revealed healthy periodontal status of the existing upper anterior. The right lateral incisor and canine and the left canine were used as abutments. Crown preparation was done for all-ceramic prosthesis with a shoulder finish line, impressions were taken, and cementation of fixed partial prosthesis was done. The patient left the department with a happy and confident smile [Figure 7] and [Figure 8].
Figure 7: Posttreatment extraoral photographs

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Figure 8

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  Discussion Top

Treatment of partial edentulism with an interdisciplinary approach has evolved into a predictable procedure for the majority of patients and is expected to play a significant role in oral rehabilitation. However, adult patients have many preexisting conditions that are not seen in the adolescent population including tooth loss, severe skeletal dysplasias, periodontal disease, and various forms of temporomandibular dysfunctions. Frequently, the preexisting conditions that are present in the adult patients interfere with the achievement of orthodontist general idealized goals. In such adult cases, an attempt to achieve ideal tooth positions that are feasible only in dentitions with class I skeletal relationship may be considered over treatment. This is not to say that orthodontic therapy provided is any less precise, rather it suggests a need to customize orthodontic treatment for the individual patient so that the achievement of any one goal does not undermine a less obvious but equally important functionally.

Problem-oriented synthesis of the dental need of each case helps determine specific treatment objectives that one must establish before determining the orthodontic treatment plan. Beginning treatment without knowing the specific goals for the individual patient or with unrealistic goals can lead to treatment failures.

In general, the treatment plan for missing teeth is to replace using removable partial denture or a fixed prosthesis or using implants. [8],[9],[10] The objective of the prosthesis is to not only replace the missing teeth but also to maintain the function and integrity of the surrounding dentofacial structures. The partially edentulous case discussed in this article required orthodontic correction of tilted teeth adjacent to missing teeth site and realignment of lower anterior teeth for creation of the ideal pontic space and sufficient over jet, respectively.

Extrusion of posterior teeth is one of the most common methods to correct deep overbite [6] this can be an effective method of bite opening. 1 mm of upper or lower molar extrusion effectively reduces the incisor overlap by 1.5-2.5 mm. A very common method to extrude posterior teeth in patients with a deep curve of spee is to level the arches with the sequential use of straight continuous archwires. [7]

A close variation of this technique is to use mandibular reverse curve of spee or maxillary exaggerated curve of spee wires. Progressively increasing step bends in the arch wire also reduces overbite. Other common treatment options include the use of a bite plate, which allows the posterior teeth to erupt, thereby reducing the overbite.

The orthodontic therapy prior to the prosthetic therapy, in this case, helped in achieving the ideal pontic space and later the prosthetic therapy not only improved the esthetics but also provided an adequate over jet and overbite, restoring the function.

  Conclusion Top

Today, orthodontics is not just for children and adolescents. For the past two decades, increasing the number of adults has been referred to orthodontists to correct their malocclusions. Adults are usually wonderful patients, because they are cooperative, clean their teeth, and show up for appointments and are appreciative of the clinicians' efforts. Adults may have problems other than malposed teeth and jaws that make their orthodontic treatment more challenging. However, adults may have old failing restorations, edentulous spaces, periodontal defects, gingival discrepancies, hopeless teeth, and a variety of other restorative and periodontal problems that could compromise the orthodontic result. However, in the compromised adult malocclusion, a team of orthodontists, oral surgeon, periodontist and endodontist must interact to make a prudent decision for the benefit of the patient.

With the patient co-operation and the timely follow-up and expertise, conventional techniques, we could achieve the best possible results.

  References Top

Chan MD. An adult malocclusion requiring a combination of orthodontic and prosthodontic treatment. Am J Orthod Dentofacial Orthop 1997;111:100-5.  Back to cited text no. 1
Fleming PS, Seehra J, Dibiase AT. Combined orthodontic-restorative management of maxillary central incisors lost following traumatic injury: A case report. Orthodontics (Chic.) 2011;12:242-51.  Back to cited text no. 2
Kawakami M, Okamoto K, Fujii R, Kirita T. Orthodontic rehabilitation for anterior teeth lost due to trauma with crowding malocclusion. Dent Traumatol 2010;26:357-9.  Back to cited text no. 3
Savadi RC, Savadi AR, Anand Kumar V, Bharath Shetty V. Modification of esthetics using a combined orthodontic and a prosthodontic approach: A case report. J Indian Prosthodont Soc 2010;10:128-31.  Back to cited text no. 4
Nazirkar G, Saikhedkar R, Gupta A. Conventional implant with orthodontic treatment for anterior missing tooth management. Int J Dent Clin 2011;3:85-6.  Back to cited text no. 5
Otto RL, Anholm JM, Engel GA. A comparative analysis of intrusion of incisor teeth achieved in adults and children according to facial type. Am J Orthod 1980;77:437-46.  Back to cited text no. 6
Weiland FJ, Bantleon HP, Droschl H. Evaluation of continuous arch and segmented arch leveling techniques in adult patients - a clinical study. Am J Orthod Dentofacial Orthop 1996;110:647-52.  Back to cited text no. 7
Albrektsson T, Zarb G, Worthington P, Eriksson AR. The long-term efficacy of currently used dental implants: A review and proposed criteria of success. Int J Oral Maxillofac Implants 1986;1:11-25.  Back to cited text no. 8
Mishra P, Chandrasekaran S, Mohamed JB. Implants in periodontally compromised sites. Int J Dent Clin 2011;3:100-1.  Back to cited text no. 9
Kumar P, Puranik SN. Anterior spring cantilever fixed partial denture: A simple solution to a complex prosthodontic dilemma. Int J Dent Clin 2010;2:41-3.  Back to cited text no. 10


  [Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5], [Figure 6], [Figure 7], [Figure 8]


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