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Combined prosthodontic and orthodontic treatment of a patient with a Class III

skeletal malocclusion: A clinical report


Olcay Sakar, DMD,a Mehmet Beyli, DMD, PhD, MsC,by and Gulnaz Marsan, DMDc
Istanbul University Faculty of Dentistry, Istanbul, Turkey

This clinical report describes a multidisciplinary approach for the treatment of a patient with Angle Class
III skeletal malocclusion and decreased occlusal vertical dimension. An overlay removable partial denture
(ORPD) was used to reestablish the occlusal vertical dimension (OVD). After the trial and adjustment
period, the reduced lower anterior dentofacial height was orthodontically increased and the negative
horizontal overlap was corrected. A maxillary precision attachment RPD and a mandibular fixed partial
denture and metal ceramic crowns were fabricated to satisfy esthetic and functional
requirements. (J Prosthet Dent 2004;92:224-8.)

A maxillary skeletal deficiency either alone or in com-


bination with mandibular prognathism can be an etio-
CLINICAL REPORT
A 38-year-old man was self-referred to the Faculty of
logical factor in Angle Class III development.1 Dentistry at Istanbul University. The chief complaints
Dentoalveolar malrelation also may result in an Angle were loss of teeth, masticatory difficulty, and poor
Class III malocclusion.2 Generally, a significant decrease esthetics. The patient was in good general health and
is found in the angular relationship between the maxilla the medical and dental histories were noncontributory.
and mandible for individuals with an Angle Class III An extensive clinical examination was performed.
malocclusion.3,4 Prosthetic rehabilitation may be indi- Initial frontal and profile extraoral examination revealed
cated to establish an acceptable occlusal vertical dimen- an apparent difference between upper and lower facial
sion (OVD).5,6 OVD is defined as the vertical height and an Angle Class III malocclusion. The patient
measurement of the face between 2 selected points when had deep folds and angular cheilitis in the commissures
the occluding members are in contact.7 The measure- of the mouth (Fig. 1, A).
ment of the closest speaking space8 and interocclusal rest Facial measurements were used to assess the rest
position9 are common methods used to establish OVD. vertical dimension (RVD). Next, the patient closed to
Proportional face measurements may also be used.10-12 maximum intercuspation and the OVD was deter-
Reestablishing an acceptable vertical dimension mined. A difference of 7 mm between the patient’s
should be based on the ability of the oral cra- OVD and RVD was measured. Because of tipping and
niomandibular system to tolerate change. Verification rotation of maxillary and mandibular third molars, the
of the patient’s ability to withstand any alteration in posterior vertical dentoalveolar height was significantly
OVD should be diagnostically determined before a de- decreased. The patient was diagnosed as having reduced
finitive prosthesis is fabricated.13-16 Transitional remov- OVD.9-13
able partial dentures (RPD), occlusal splints, and The patient was partially edentulous. The maxillary
provisional restorations have been advocated in the right lateral incisor, second premolars, all molars except
treatment and reestablishment of the OVD.17 for the maxillary left third molar, and the mandibular left
Increasing OVD beyond the original rest vertical dimen- second premolar, first molars, and left second molar
sion results in the establishment of a new postural posi- were missing. An occlusal plane discrepancy was noted.
tion of the mandible and a new interocclusal rest The maxillary left third molar, mandibular left first
space.18 This article describes the treatment for a patient premolar, and mandibular right premolars and second
with Angle Class III malocclusion and reduced OVD, molar were not at the same level as the occlusal plane.
using overlay RPD (ORPD) as an interim prosthesis, The patient had no dental caries, excessive wear, or
followed by orthodontic treatment (OT), and remov- restorations. The periodontal examination revealed the
able maxillary and fixed mandibular partial dentures as presence of minimal plaque and gingival inflammation.
definitive prostheses. Clinical examination of the temporomandibular joints
did not demonstrate any dysfunction.
Cephalometric panoramic radiographs were made
a and a Steiner cephalometric analysis19 was completed.
Associate Professor, Department of Removable Dentures.
b
Professor, Former Chairman of Department of Removable Dentures.
The patient presented with an Angle Class III malocclu-
c
Research Assistant, Department of Orthodontics. sion owing to both maxillary anterior deficiency and
y
Deceased. mandibular prognathism. The extraction site of the

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Fig. 1. Frontal view A, without ORPDs, and B, with ORPDs.

maxillary right lateral incisor was narrow, the amount of illary and mandibular ORPDs fabricated at the newly
the negative horizontal overlap was 11 mm, and the ver- established OVD; (2) interim maxillary and mandibular
tical overlap was 15 mm (Fig. 3). The upper lip appeared ORPDs with the newly established OVD, OT, and de-
posterior to the lower lip (Fig. 2, A). The patient’s rela- finitive maxillary and mandibular ORPDs; (3) interim
tive mandibular prognathism was due to excessive verti- maxillary and mandibular ORPDs fabricated at the
cal overlap with a reduced lower anterior facial height, newly established OVD, lengthening of the clinical
but the patient could rotate the mandible with help, crowns of the maxillary incisors, a maxillary fixed partial
and the lower facial height could be returned to normal. denture with cantilevered right second premolar, and
Functional examination demonstrated an edge-to-edge a mandibular fixed partial denture (FPD) and metal ce-
incisor relationship. In this position a bilateral posterior ramic crowns; (4) interim maxillary and mandibular
open occlusal relationship was observed. ORPDs at the newly established OVD, OT, a maxillary
Periodontal therapy included scaling and root planing precision attachment removable partial denture, and
all quadrants. The patient was given oral hygiene in- a mandibular FPD and metal ceramic crowns; and (5) in-
structions. After the healing period, irreversible hydro- terim maxillary and mandibular ORPDs at the newly
colloid impressions (Alginoplast; Bayer, Leverkusen, established OVD, OT, and maxillary and mandibular
Germany) were made and diagnostic casts were fabri- implant-supported prostheses.
cated. The advantages and disadvantages of all treatment
A face-bow record and an interocclusal record in options were presented to the patient. Restoring the
maximum intercuspation were made and casts were OVD appeared to be the first priority to improve
mounted in a semiadjustable articulator (Dentatus, esthetics and function regardless of the definitive treat-
Stockholm, Sweden). The patient and the mounted ment.13,20 An occlusal splint was not a satisfactory
diagnostic casts were evaluated by a prosthodontist, an choice for the patient’s functional and esthetic re-
orthodontist, and a surgeon. quirements during the adaptation period. The use of
Five treatment plan options were discussed for restor- definitive maxillary and mandibular ORPDs with or
ing the OVD and the missing teeth: (1) definitive max- without OT was eliminated because of the poor esthetics

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THE JOURNAL OF PROSTHETIC DENTISTRY SAKAR, BEYLI, AND MARSAN

Fig. 2. Profile view A, without ORPDs, and B, with ORPDs.

of extracoronal direct retainers, while implant prosthe- ORPD patterns were waxed (Multiwax; BDP Industry,
ses were eliminated because of the increase in cost and Istanbul, Turkey) on the refractory casts. The prosthesis
proximity of the sinus. The use of maxillary and mandib- was extended to the facial surfaces to obtain a more
ular fixed partial dentures without OT was eliminated esthetic result. Retention beads were placed for the
because of the possible effects on emergence profile veneering material on the occlusal and facial surfaces.
which may have resulted in unfavorable forces acting The frameworks were cast in a Co-Cr alloy (Magnum
on the FPDs. Furthermore, the need for endodontic H50; MESA, Brescia, Italy). After intraoral evaluation
treatment and possible food retention were dis- of the framework, veneering material (Biodent K1B
advantages of this treatment option. The use of a maxil- Plus; Dentsply, Dreieich, Germany) was placed and arti-
lary precision-attachment RPD and a mandibular FPD ficial teeth were arranged. OVD, esthetics, and
and metal ceramic crowns was selected to improve the maxillomandibular relations were verified. The dentures
esthetics of the upper lip, obtain Angle Class I relation- were processed with heat-polymerized acrylic resin
ship, and satisfy functional requirements of the patient. (Dentimex; Vertex Dental, Zeist, Holland).22 The pa-
Definitive casts of Type III dental stone (Moldano; tient wore the ORPDs for 6 months (Figs. 1 and 2, B).
Bayer, Leverkusen, Germany) and a face-bow record During this period the patient was regularly evaluated
were made. Maxillary and mandibular record bases and for signs of wear on the prostheses (Fig. 4), symptoms
wax occlusion rims were fabricated. The OVD was of temporomandibular dysfunction, and muscle tender-
established using facial measurements and the technique ness. Muscle tenderness was observed in the first week,
described by Niswonger.9-12 The mandibular cast was but disappeared by the end of the week. The in-
mounted with a wax (Cavex; Cavex Holland, Haarlem, terocclusal rest space was determined to be approxi-
Netherlands) centric relation record reinforced with mately 2 mm at the end of 6 months.
zinc oxide eugenol (SS White Group, Gloucester, Orthodontic treatment was then initiated. The man-
England) obtained by bilateral manipulation.21 dibular right first premolar was extracted to correct
Definitive casts were duplicated in refractory material the negative horizontal overlap. After completion of
(Biosint Extra; Degussa Dental, Hanau, Germany), and the leveling and alignment phase, by using a standard

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Fig. 3. Preoperative maximum intercuspation. Fig. 4. Interim maxillary and mandibular ORPDs.

Fig. 5. Anterior view of new maxillary ORPD and mandib- Fig. 6. Postoperative frontal view.
ular retention appliance during retention period.

cantilevered. The matrix portion of the attachment


edgewise technique,23 0.017 3 0.022 rectangular arch (Ceka; Alphadent, Antwerpen, Belgium) was incorpo-
wires (3M Unitek, Monrovia, Calif) were placed in the rated in the maxillary right first premolar crown. A lab-
maxillary and mandibular dental arches, and 100g of oratory-fabricated bar (Pattern Resin; GC Corp,
force was applied on both sides with Class III elastics. Tokyo, Japan) was made to splint the maxillary left first
This method was used to retrude the mandibular ante- premolar and the third molar. The matrix portion of the
rior teeth and protrude the maxillary anterior teeth. attachment was incorporated in the bar pattern and the
The uprighting and derotating of the maxillary and the bar was milled in a milling machine (Cruise 440;
mandibular third molars resulted in an acceptable rela- Silfradent, Santa Sofia, Italy). Porcelain was added to
tionship in preparation of the prosthetic phase. At the the restorations. The maxillary precision attachment,
completion of the orthodontic treatment, an Angle RPD, was then fabricated (Fig. 6). The temporoman-
Class I relationship and correction of the anterior reverse dibular joints and muscles did not show any dysfunction
articulation were observed. During the retention period, after an additional period of 6 months.
a new maxillary ORPD and mandibular retention appli-
ance were made in the same manner to prevent tooth
DISCUSSION
mobility and excessive loading (Fig. 5).
As part of the definitive prosthodontic phase of treat- In this treatment, the negative horizontal overlap and
ment, the mandibular premolars and molars were re- reduced vertical facial height were corrected, and maxil-
stored with metal-ceramic (metal—Wiron 99, Vmk lary and mandibular dental arches prepared for pros-
68; Bego, Bremen, Germany; ceramic—IPS d.SIGN, thetic restoration. An ORPD is a prosthesis that rests
Ivoclar Vivadent, Schaan, Liechtenstein) crowns and on 1 or more natural teeth, the roots of the natural teeth,
an FPD to correct the occlusal plane. The maxillary right and/or implant.7 It is a reversible, conservative, and
canine and first premolar were restored with splinted effective solution to obtain an esthetic and functional
metal-ceramic crowns and the lateral incisor was result.20 The procedure may also be of diagnostic value,

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THE JOURNAL OF PROSTHETIC DENTISTRY SAKAR, BEYLI, AND MARSAN

and it provided useful information to the orthodontic 2. Ucuncu N, Ucem TT, Yuksel S. A comparison of chincap and maxillary
protraction appliances in the treatment of skeletal Class III malocclusions.
and oral and maxillofacial surgical team.22 Adaptation Eur J Orthod 2000;22:43-51.
to altered OVD was evaluated by the use of an interim 3. Chang HP, Kinoshita Z, Kawamoto T. Craniofacial pattern of Class III de-
ORPD. However, several disadvantages are associated ciduous dentition. Angle Orthod 1992;62:139-44.
4. Tollaro I, Baccetti T, Bassarelli V, Franchi L. Class III malocclusion in the
with ORPDs. Abutment teeth are susceptible to caries deciduous dentition: a morphological and correlation study. Eur J Orthod
if patients cannot be motivated to maintain a level of 1994;16:401-8.
good oral hygiene.5 Wear between the denture base 5. Windchy A, Khan Z, Fields H. Overdentures with metal occlusion to
maintain occlusal vertical dimension and prevent denture fracture. J Pros-
and the supporting teeth increases the possibility of thet Dent 1988;60:11-4.
breakage as the denture base is often thin in the region 6. Pound E. Utilizing speech to simplify a personalized denture service. J
of the supporting natural teeth, thus, increasing the pos- Prosthet Dent 1970;24:586-600.
7. The glossary of prosthodontics terms. J Prosthet Dent 1999;81:39-110.
sibility of fracture.5 Esthetics may be compromised 8. Silverman MM. Speaking method in measuring vertical dimension. J Pros-
when the prosthesis is removed and, even when the den- thet Dent 1953;3:193-9.
ture is not removed, the presence of extracoronal clasp 9. Niswonger ME. The rest position of the mandible and the centric relation.
Am Dent Assoc 1934;21:1572-82.
direct retainers may negatively effect the esthetics.5,16 10. Willis FM. Features of the face involved in full denture prosthesis. Dent
Because of these disadvantages, the ORPD was not the Cosmos 1955;77:851-4.
definitive prosthesis for this patient. 11. McGee GF. Use of facial measurements in determining vertical dimen-
sion. Am Dent Assoc 1947;35:342-50.
An increased occlusal vertical dimension may cause 12. Fayz F, Eslami A. Determination of occlusal vertical dimension: a literature
postoperative problems, including clenching of teeth, review. J Prosthet Dent 1988;59:321-3.
muscle fatigue, soreness of teeth, muscles, and joints, 13. Turner KA, Missirlian DM. Restoration of the extremely worn dentition. J
Prosthet Dent 1984;52:467-74.
headache, intrusion of teeth, occlusal instability, and 14. Hellsing G. Functional adaptation to changes in vertical dimension. J
continued wear. Therefore, it is recommended that Prosthet Dent 1984;52:867-70.
changes to the OVD should be conservative and a trial 15. Dawson P. Evaluation, diagnosis, and treatment of occlusal problems. 2nd
ed. St. Louis: Elsevier; 1989. p. 56-71, 500-10.
period with an interim prosthesis is desirable.13,15 16. Windchy AM, Morris JC. An alternative treatment with the overlay remov-
However, some studies demonstrated that jaw muscle able partial denture: a clinical report. J Prosthet Dent 1998;79:249-53.
tonus adapts to extreme changes in OVD and a new in- 17. Jahangiri L, Jang S. Onlay partial denture technique for assessment of ad-
equate occlusal vertical dimension: a clinical report. J Prosthet Dent
terocclusal rest space occurs.14,18 Hellsing14 stated that 2002;87:1-4.
jaw muscle motor behavior is more dynamic and adapt- 18. Carlsson GE, Ingerwall B, Kocak G. Effect of increasing vertical dimension
able to environmental changes than previously believed. on masticatory system in subjects with natural teeth. J Prosthet Dent 1979;
41:284.
In the light of these suggestions, it was determined that 19. Steiner CC. Cephalometrics for you and me. Am J Orthodont 1953;39:
the OVD of the patient be increased approximately 8 729-55.
mm using interim ORPDs for 6 months. Although re- 20. Graser GN, Rogoff GS. Removable partial overdentures for special pa-
tients. Dent Clin North Am 1990;34:741-58.
storing the OVD to this level may be viewed as extreme, 21. Hobo S, Iwata T. Reproducibility of mandibular centricity in three dimen-
the patient readily adapted to the new OVD. sions. J Prosthet Dent 1985;53:649-54.
22. Farmer JB, Connelly ME. Treatment of open occlusions with onlay and
overlay removable partial dentures. J Prosthet Dent 1984;51:300-3.
SUMMARY 23. Graber TM, Vanarsdall RL Jr. Orthodontics: current principles and techni-
ques. 3rd ed. St Louis: Mosby; 2000. p. 276.
This clinical report described the prosthetic rehabili-
tation in conjunction with orthodontic treatment of Reprint requests to:
a 38-year-old patient with a skeletal Angle Class III mal- DR OLCAY SAKAR
DEPARTMENT OF REMOVABLE DENTURES
occlusion. The occlusal vertical dimension was restored,
ISTANBUL UNIVERSITY FACULTY OF DENTISTRY
and an interim overlay removable partial denture was CAPA 34390 ISTANBUL
made. After the trial period and orthodontic treatment, TURKEY
FAX: 90212525-3585
prosthetic rehabilitation was completed with a maxillary E-MAIL: olcaysakar@yahoo.com
precision attachment removable partial denture, a man-
dibular fixed partial denture, and metal-ceramic crowns. 0022-3913/$30.00
Copyright Ó 2004 by The Editorial Council of The Journal of Prosthetic
Dentistry
REFERENCES
1. Proffit WR, White RP Jr, Sarver DM. Contemporary treatment of dentofa-
cial deformity. St.Louis: Elsevier; 2003. p. 507. doi:10.1016/j.prosdent.2004.06.002

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