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A teamwork approach to correct a severe prosthodontic problem
T h e p atien t had a severe Class II m alo cclusio n , w ith m axillary a n terio r p ro tru sion , o vererup tion of th e left m axillary p o s terio r teeth, and an u n d es irab le p la n e of occlu sion . A co m b ined ap p ro ach involving su rg ical, p erio d o n tal, and p ro sth o d o n tic p ro ced u re s w as used in th e successful tre a tm e n t plan th at did not re q u ire th e e x tra ctio n of all m axillary p o s terio r teeth.
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L o u is S. B e lin fa n te , DDS J a m e s M. A b n e y , Jr., DDS, Sm yrna, G a ■ ■ ■ ■ ■ ■
N ot infrequently dentists are faced with a mul titude o f problems regarding the proper replace ment o f one or several missing teeth. A partic ular situation that frequently poses a challenge in treatment planning is the overeruption of the maxillary posterior quadrant. If this quadrant opposes an edentulous area, prosthodontic treat ment becom es very difficult since adequate in termaxillary space must be obtained to satisfy prosthodontic requirements. A different con cept for the successful correction of this prob lem is presented through utilization of a modern surgical technique.
R e p o rt o f ca se
A 28-year-old patient came for evaluation of her oral and facial condition. A maxillofacial phys ical examination was performed. These records were obtained: plaster diagnostic casts; intraand extraoral photographs; and periapical, pan oramic, and cephalometric radiographs. The results of the examination and evalua tion of the records indicated slight periodontal disease, malalignment of several teeth, multiple edentulous spaces, a maxillary protrusion (8 mm), impingement of the mandibular anterior teeth on the palatal gingiva, lack of proper inter maxillary space on the left side because o f maxil lary bicuspid and molar overeruption (Fig 1, 2),
Fig 1 ■ Top, in itial Class II m alocclusion. B ottom , overerup tio n o f left m axillary po sterior teeth.
JADA, Vol. 91, August 1975 ■ 357
Fig 2 ■ P anoram ic radiograph indicates lack o f proper interm axillary space (arrows).
and lack o f a proper plane o f occlusion on the left posterior side. It was felt that this situation could be allevi ated by surgical, periodontal, and prosthodontic therapy. The treatment plan included gingival curettage, orthodontic consultation (which was refused by the patient), surgical intervention to simultaneously reduce the 8-mm overjet and raise the left maxillary posterior segment (Fig 3), improvement of the plane of occlusion, and re storative treatment including a removable lower partial denture, a full coverage restoration, and inlays on indicated teeth. The patient was hos pitalized and the surgical procedure performed (Fig 4).
■ Surgical and restorative treatm ent: After local infiltration with lidocaine (Xylocaine) hy drochloride with 1:100,000 epinephrine, incis ions were made in the maxillary alveolar mucosa so that vertical and horizontal bone could be re moved through the tunneling technique. A pre formed mandibular acrylic splint was ligated to the mandible with three circum-mandibular wires. The splint, designed by the general den tist, contained negative impressions of the re positioned maxillary posterior cusps; therefore, it acted as a surgical guide. After all bony cuts were made and the maxilla positioned posterior ly and superiorly, soft tissue closure was done with 3-0 chromic sutures. The patient tolerated
Fig 3 ■ Left, m axillary osteotom y allow ing tooth-bearing segm ent to be respositioned po steriorly and su pe riorly (arrow). Right, com pleted osteotom y show ing im proved interm axillary space and reduction of overjet. 358
■ JADA, Vol. 91, August 1975
Fig 4 ■ P anoram ic radiograph indicates restoration of proper interm axillary space (arrows).
the procedure quite well. About eight weeks after surgery, the restor ative phase began. All operative procedures were oriented toward the completion of a Ken nedy Class II, modification type 1 removable partial denture. A crown was placed on the man dibular left cuspid and an inlay in the mandibu lar right second molar. After a partial denture framework was insert ed, the free-end saddle area was cast corrected to facilitate tissue adaptation of the edentulous area. The casts were mounted, and the partial denture was finished and delivered. The surgically repositioned segments show no evidence of relapse after 13 months (Fig 5). The patient’s masticatory mechanism has been im proved functionally and esthetically.
D is c u s s io n
Generally* several conventional options are available to increase intermaxillary space: cor onal reduction for crown placement (which often necessitates concomitant endodontic therapy); alveolectomy of the edentulous ridge if bone, or tissue, or both permit; or extraction of offending teeth (obviously the most odious choice). The purpose of each option is to create a space that will properly accept both a maxillary and mandibular dentition that is sufficient to satisfy
Fig 5 ■ Completed treatm ent w ith partial denture in place.
the patient’s dental, functional, and esthetic needs. The method presented gives the dentist an additional option.
S u m m a ry
Treatment for a patient with a severe Class II malocclusion, maxillary anterior protrusion, left maxillary posterior overeruption with resultant loss o f intermaxillary space, and an undesirable plane of occlusion has been presented. Through the combined approaches of oral surgery and restorative dentistry, the patient was success fully treated without the loss of multiple pos terior teeth.
Dr. B elinfante is an oral and maxillofacial surgeon, and Dr. Abney is in general practice. Dr. B elinfante's address is 3001 S C obb Dr, Smyrna, Ga 30080.
Belinfante— Abney: TEAMWORK APPROACH TO PROSTHODONTIC PROBLEM ■ 359
A
t e a m
a
s e
v e
w
r e
o r k
a p
p r o s t h
p
r o
a c h
o d o n
t i c
t o
c o r r e c t
p r o b l e m
L o u is S. B e lin fa n te , DDS J a m e s M. A b n e y , Jr., DDS, Sm yrna, G a ■ ■ ■ ■ ■ ■
N ot infrequently dentists are faced with a mul titude o f problems regarding the proper replace ment o f one or several missing teeth. A partic ular situation that frequently poses a challenge in treatment planning is the overeruption of the maxillary posterior quadrant. If this quadrant opposes an edentulous area, prosthodontic treat ment becom es very difficult since adequate in termaxillary space must be obtained to satisfy prosthodontic requirements. A different con cept for the successful correction of this prob lem is presented through utilization of a modern surgical technique.
R e p o rt o f ca se
A 28-year-old patient came for evaluation of her oral and facial condition. A maxillofacial phys ical examination was performed. These records were obtained: plaster diagnostic casts; intraand extraoral photographs; and periapical, pan oramic, and cephalometric radiographs. The results of the examination and evalua tion of the records indicated slight periodontal disease, malalignment of several teeth, multiple edentulous spaces, a maxillary protrusion (8 mm), impingement of the mandibular anterior teeth on the palatal gingiva, lack of proper inter maxillary space on the left side because o f maxil lary bicuspid and molar overeruption (Fig 1, 2),
Fig 1 ■ Top, in itial Class II m alocclusion. B ottom , overerup tio n o f left m axillary po sterior teeth.
JADA, Vol. 91, August 1975 ■ 357
Fig 2 ■ P anoram ic radiograph indicates lack o f proper interm axillary space (arrows).
and lack o f a proper plane o f occlusion on the left posterior side. It was felt that this situation could be allevi ated by surgical, periodontal, and prosthodontic therapy. The treatment plan included gingival curettage, orthodontic consultation (which was refused by the patient), surgical intervention to simultaneously reduce the 8-mm overjet and raise the left maxillary posterior segment (Fig 3), improvement of the plane of occlusion, and re storative treatment including a removable lower partial denture, a full coverage restoration, and inlays on indicated teeth. The patient was hos pitalized and the surgical procedure performed (Fig 4).
■ Surgical and restorative treatm ent: After local infiltration with lidocaine (Xylocaine) hy drochloride with 1:100,000 epinephrine, incis ions were made in the maxillary alveolar mucosa so that vertical and horizontal bone could be re moved through the tunneling technique. A pre formed mandibular acrylic splint was ligated to the mandible with three circum-mandibular wires. The splint, designed by the general den tist, contained negative impressions of the re positioned maxillary posterior cusps; therefore, it acted as a surgical guide. After all bony cuts were made and the maxilla positioned posterior ly and superiorly, soft tissue closure was done with 3-0 chromic sutures. The patient tolerated
Fig 3 ■ Left, m axillary osteotom y allow ing tooth-bearing segm ent to be respositioned po steriorly and su pe riorly (arrow). Right, com pleted osteotom y show ing im proved interm axillary space and reduction of overjet. 358
■ JADA, Vol. 91, August 1975
Fig 4 ■ P anoram ic radiograph indicates restoration of proper interm axillary space (arrows).
the procedure quite well. About eight weeks after surgery, the restor ative phase began. All operative procedures were oriented toward the completion of a Ken nedy Class II, modification type 1 removable partial denture. A crown was placed on the man dibular left cuspid and an inlay in the mandibu lar right second molar. After a partial denture framework was insert ed, the free-end saddle area was cast corrected to facilitate tissue adaptation of the edentulous area. The casts were mounted, and the partial denture was finished and delivered. The surgically repositioned segments show no evidence of relapse after 13 months (Fig 5). The patient’s masticatory mechanism has been im proved functionally and esthetically.
D is c u s s io n
Generally* several conventional options are available to increase intermaxillary space: cor onal reduction for crown placement (which often necessitates concomitant endodontic therapy); alveolectomy of the edentulous ridge if bone, or tissue, or both permit; or extraction of offending teeth (obviously the most odious choice). The purpose of each option is to create a space that will properly accept both a maxillary and mandibular dentition that is sufficient to satisfy
Fig 5 ■ Completed treatm ent w ith partial denture in place.
the patient’s dental, functional, and esthetic needs. The method presented gives the dentist an additional option.
S u m m a ry
Treatment for a patient with a severe Class II malocclusion, maxillary anterior protrusion, left maxillary posterior overeruption with resultant loss o f intermaxillary space, and an undesirable plane of occlusion has been presented. Through the combined approaches of oral surgery and restorative dentistry, the patient was success fully treated without the loss of multiple pos terior teeth.
Dr. B elinfante is an oral and maxillofacial surgeon, and Dr. Abney is in general practice. Dr. B elinfante's address is 3001 S C obb Dr, Smyrna, Ga 30080.
Belinfante— Abney: TEAMWORK APPROACH TO PROSTHODONTIC PROBLEM ■ 359