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Treatment of Severe Malocclusion: report of case
G holam Abbas M ortazavi,* D .D .S ., Tehran, Iran
Treatment of Severe Malocclusion: report of case
A 29 year old Negro woman was treated for a severe hereditary malocclusion. Since
sion. H er chief complaints were appear ance and lack o f proper mastication.
the patient lacked mandibular posterior teeth, orthodontic treatment to correct maxillary
protrusion
was
P H Y S IC A L C O N D IT IO N
impossible.
Therefore, therapy was planned to elimi nate maxillary protrusion by surgery and to rehabilitate the maxillary arch with a fixed bridge. Periodontal therapy also was included in the planned treatment. Good esthetics and adequate mastication were
T h e patient was thin, weighing 93 pounds and measuring 5 feet 4 inches. She ap peared undernourished. T his condition m ight have been due to inadequate masti catory function. Aside from a hysterec tomy, the patient had no history o f any serious illness.
achieved. E X T R A O R A L A N D IN T R A O R A L E X A M IN A T IO N
A 29 year old N egro wom an cam e to the dental department at M ichael Reese H os pital, Chicago, with a severe m alocclu
T h e patient had a thin, tapered face and a pronounced labial sulcus, characteristic
Fig. I • A : Lateral view of face before treatment. B: Roentgenogram of skull. N o te degrée of maxillary protrusion. C : Lateral view of face after treatment
M O R T A Z A V I . . . V O L U M E 67, D E C E M B E R 1963 • 113/873
Fig. 2 • A : Lower arch. N o te linguoversion of lower teeth, recession of labial gin g iva in left bicuspid region, and im pression of upper teeth in lower ridge as result of extrusion of maxillary teeth. B: U p p e r and lower teeth in centric relation. A ll lower teeth are lingual to the upper teeth except m andibular right third m olar which has occlusal contact with upper right second molar. N ote also that about 5 mm. o f gin g iva of lower teeth is covered by u pp e r teeth. C : Rehabilitation o f maxilla by six unit fixed b ridge after plastic surgery. D: Lower arch after periodontal therapy and rem odeling of teeth
o f a deep overbite (Fig. 1 ,A ). Intraoral examination revealed the follow ing: In the lower jaw , all molars except the right third m olar were extracted because o f caries. A ll the low er bicuspids, espe cially the right second bicuspid, were in linguoversion. T h e first bicuspid on the right side was labial to the second bicus pid and about 3 mm. below the occlusal plane. T h e low er arch was extremely nar row with a congenitally missing central incisor (Fig. 2,A ) . In the maxillary arch, all the teeth ex cept the right third m olar were present. T h e maxillary central and lateral incisors had a severe overjet with a 1 to 2 mm. diastema (F ig .l,A ; 1,B; 2,B; 3,A ) . T here was no actual occlusal contact except be tween the maxillary right second molar and the m andibular right third molar. All the m andibular teeth, except the latter, were lingual to the maxillary teeth in cen tric relation (Fig. 2 ,B ). All maxillary pos terior teeth, except the one in occlusal contact, were extruded. Extrusion was more severe in the left side. T h e maxillary left molars were pushing against the lower arch in centric relation, and the impres sion m ade by them could be seen in the m andibular ridge. T h e maxillary left b i cuspids were rubbing against the labial mucosa o f the mandibular bicuspids (Fig. 2,A ; 2 ,B ). W hen the teeth were in centric
occlusion, the maxillary anterior teeth ex tended over the gingiva o f the mandibular anterior teeth com pletely hiding them from front view (Fig. 2 ,B ). T h e m an dibular anterior teeth were touching the palate, causing a cleft in the lingual sur face o f the maxillary left lateral incisor and partial resorption o f its root only slightly short o f the apex. All the teeth had m oderate periodontal disease caused by p oor oral hygiene, traumatic occlu sion, and fo o d im paction. T h e depth o f the pockets ranged from 3 to 8 mm. T h e anterior section o f the low er arch showed a severe undercut labially and was co v ered by a thin mucosa. F A M IL Y H IS T O R Y
T h e patient was single; her m other and sister were alive. She and her sister were interlocked twins. H er twin had a similar type o f malocclusion. T h e patient stated that her maternal aunt, great-aunt, and cousin had a maxillary protrusion similar to her own. N obody on her father’ s side had a similar condition. E TIO L O G Y
From what was noted in the familial his tory, it was concluded that the cause of m alocclusion in this patient was heredi-
114/874 • THE J O U R N A L O F T H E A M E R IC A N DEN T A L A S S O C IA T IO N
Fig. 3 • A : D iagn o stic m odels show ing relation of ¡aws and protrusion of premaxilla. B: Lower den ture made over and anterior to lower dentition. C : D iagnostic m odels after treatment
tary and that it possibly was aggravated by thumbsucking. TREATM ENT
T h e first step in treatment planning was orthodontic consultation. T h e orthodon tist stated that nothing could be done be cause o f lack o f m andibular posterior teeth. A plan fo r therapy was devised to eliminate the maxillary protrusion by sur gery and rehabilitate the maxillary arch with a fixed bridge follow ed by treating the periodontal condition and com pleting all necessary operative procedures. T hen the m andibular arch was to be restored by making a com plete lower denture over and anterior to the m andibular dentition. T o eliminate the maxillary deformity, the upper central and lateral teeth with the excess alveolar projection were re m oved. As a guide fo r this procedure, a template o f self-curing clear acrylic resin was made. In order to restore the m axil lary anterior section immediately, a tem porary six unit bridge was made before surgery o f self-curing acrylic resin on the stone cast. Before surgery, the two m axil lary cuspids were prepared for jacket crowns. T h e fou r maxillary incisors were extracted under local anesthesia. T hen osteoplasty was perform ed to a previously planned and desired degree. Imm ediately after sutures were placed, the temporary bridge was adjusted and cemented. A p ro nounced difference in appearance was seen at once. A deform ity which the pa tient had suffered for years was eliminated in one visit. A fter uneventful com plete healing, a permanent restoration consist ing o f a six unit bridge, using two cuspids as abutments, was constructed and ce mented into place (Fig. 2 ,C ) . T h e next step was periodontal therapy. T h e depth o f the pockets was 3 to 5 m m .,
M O R T A Z A V I . . . V O L U M E 67, D EC EM B ER 1963 • 115/875
except mesial of the maxillary right first bicuspid. This tooth, which had an 8 mm. pocket, was extracted not only be cause of a deep pocket and mobility, but also because its malposititon and infra occlusion was a possible source of inter ference in the plan for the completed restoration. The remaining teeth were treated by scaling and curettage, and the patient was instructed in proper toothbrushing and home care. In the lower jaw, in addition to linguoversion and supraclusion of the anterior teeth, the alveolar ridge protruded labially and was covered by a thin mucosa and had an unesthetic appearance. Hav ing planned construction of a lower den ture covering the dentition, it was de cided to eliminate the undercut and to gain a more esthetic appearance. Perio dontal surgery was performed under local anesthesia; it consisted of a gingivectomy for elimination of pockets, osteoplasty for elimination of the undercut and improve ment in appearance and a vestibular ex tension (push back) with frenectomy to obtain more attached gingiva. Then a periodontal pack was placed and neces sary home care instruction with medica tion was given to the patient. The pack was changed one week postoperatively (Fig. 2,D ). While healing was progress ing, the operative procedures were com pleted. After the periodontal condition had been alleviated and had healed suffi ciently, construction of a denture over the mandibular dentition was started. The mouth, as well as study models, again were examined carefully. At this point, the problem of severe undercuts of the teeth was encountered. In the lower arch all bicuspids, especially the second right one, were tilted lingually (Fig. 2,A ). These undercuts would pre sent difficulty in setting the denture in the mouth. In addition, they would re strict the space for the tongue which would make it inconvenient for the pa tient and would also greatly impair her speech. The distance between the lingual
cuspid of the second bicuspids was only 19 mm. For these reasons, the lower right second bicuspid which had a severe un dercut was extracted, the lingual surface of the left bicuspids was reduced, and the undercuts were eliminated. The final im pression was taken with rubber base ma terial in an acrylic tray. Then registration of centric relation and vertical dimension was attempted. The registration of the former was easily made because lack of any excursion made the centric relation a definite position. Determination of vertical dimension was problematic. The freeway space reg istered 4.75 mm. anteriorly. Naturally the posterior opening was less (about one third). This presented a problem in setting the teeth, since the upper teeth touched the lower ridge in centric occlu sion. For this reason, and because it was felt that vertical dimension had been somewhat closed as the result of extrac tion of the posterior teeth, it was decided to open the bite about an additional 3 mm. From centric relation the bite was opened about 8 mm. The teeth were set and tried several times until the satisfac tory setup was obtained. Acrylic resin teeth were used in order to set the anterior teeth as close to the ridge as possible. Speech and esthetics were tested and after a satisfactory setup was established, the denture was processed (Fig. 3,B) and seated after several attempts to relieve the undercuts. After occlusal adjustments, the vertical opening was reduced from 3 mm. to 2 mm. The procedure fulfilled two goals: good esthetics and adequate mastication (Fig. 1,C; 3,C ). The result was satisfactory to both patient and den tist. The patient has been under obser vation for the past few months and is getting along well. A ve. Shah, Charah Eskandari Koutcheh Khoshkhouy, N o. 7
The author expresses his gratitude to Saul Levy and Arthur Elfenbaum for their assistance in this case pres entation. *Formerly, dental department, Michael Reese Hospital and Medical Center, C hicago; department of stomatol ogy, Boston University, School of Medicine.
Treatment of Severe Malocclusion: report of case
A 29 year old Negro woman was treated for a severe hereditary malocclusion. Since
sion. H er chief complaints were appear ance and lack o f proper mastication.
the patient lacked mandibular posterior teeth, orthodontic treatment to correct maxillary
protrusion
was
P H Y S IC A L C O N D IT IO N
impossible.
Therefore, therapy was planned to elimi nate maxillary protrusion by surgery and to rehabilitate the maxillary arch with a fixed bridge. Periodontal therapy also was included in the planned treatment. Good esthetics and adequate mastication were
T h e patient was thin, weighing 93 pounds and measuring 5 feet 4 inches. She ap peared undernourished. T his condition m ight have been due to inadequate masti catory function. Aside from a hysterec tomy, the patient had no history o f any serious illness.
achieved. E X T R A O R A L A N D IN T R A O R A L E X A M IN A T IO N
A 29 year old N egro wom an cam e to the dental department at M ichael Reese H os pital, Chicago, with a severe m alocclu
T h e patient had a thin, tapered face and a pronounced labial sulcus, characteristic
Fig. I • A : Lateral view of face before treatment. B: Roentgenogram of skull. N o te degrée of maxillary protrusion. C : Lateral view of face after treatment
M O R T A Z A V I . . . V O L U M E 67, D E C E M B E R 1963 • 113/873
Fig. 2 • A : Lower arch. N o te linguoversion of lower teeth, recession of labial gin g iva in left bicuspid region, and im pression of upper teeth in lower ridge as result of extrusion of maxillary teeth. B: U p p e r and lower teeth in centric relation. A ll lower teeth are lingual to the upper teeth except m andibular right third m olar which has occlusal contact with upper right second molar. N ote also that about 5 mm. o f gin g iva of lower teeth is covered by u pp e r teeth. C : Rehabilitation o f maxilla by six unit fixed b ridge after plastic surgery. D: Lower arch after periodontal therapy and rem odeling of teeth
o f a deep overbite (Fig. 1 ,A ). Intraoral examination revealed the follow ing: In the lower jaw , all molars except the right third m olar were extracted because o f caries. A ll the low er bicuspids, espe cially the right second bicuspid, were in linguoversion. T h e first bicuspid on the right side was labial to the second bicus pid and about 3 mm. below the occlusal plane. T h e low er arch was extremely nar row with a congenitally missing central incisor (Fig. 2,A ) . In the maxillary arch, all the teeth ex cept the right third m olar were present. T h e maxillary central and lateral incisors had a severe overjet with a 1 to 2 mm. diastema (F ig .l,A ; 1,B; 2,B; 3,A ) . T here was no actual occlusal contact except be tween the maxillary right second molar and the m andibular right third molar. All the m andibular teeth, except the latter, were lingual to the maxillary teeth in cen tric relation (Fig. 2 ,B ). All maxillary pos terior teeth, except the one in occlusal contact, were extruded. Extrusion was more severe in the left side. T h e maxillary left molars were pushing against the lower arch in centric relation, and the impres sion m ade by them could be seen in the m andibular ridge. T h e maxillary left b i cuspids were rubbing against the labial mucosa o f the mandibular bicuspids (Fig. 2,A ; 2 ,B ). W hen the teeth were in centric
occlusion, the maxillary anterior teeth ex tended over the gingiva o f the mandibular anterior teeth com pletely hiding them from front view (Fig. 2 ,B ). T h e m an dibular anterior teeth were touching the palate, causing a cleft in the lingual sur face o f the maxillary left lateral incisor and partial resorption o f its root only slightly short o f the apex. All the teeth had m oderate periodontal disease caused by p oor oral hygiene, traumatic occlu sion, and fo o d im paction. T h e depth o f the pockets ranged from 3 to 8 mm. T h e anterior section o f the low er arch showed a severe undercut labially and was co v ered by a thin mucosa. F A M IL Y H IS T O R Y
T h e patient was single; her m other and sister were alive. She and her sister were interlocked twins. H er twin had a similar type o f malocclusion. T h e patient stated that her maternal aunt, great-aunt, and cousin had a maxillary protrusion similar to her own. N obody on her father’ s side had a similar condition. E TIO L O G Y
From what was noted in the familial his tory, it was concluded that the cause of m alocclusion in this patient was heredi-
114/874 • THE J O U R N A L O F T H E A M E R IC A N DEN T A L A S S O C IA T IO N
Fig. 3 • A : D iagn o stic m odels show ing relation of ¡aws and protrusion of premaxilla. B: Lower den ture made over and anterior to lower dentition. C : D iagnostic m odels after treatment
tary and that it possibly was aggravated by thumbsucking. TREATM ENT
T h e first step in treatment planning was orthodontic consultation. T h e orthodon tist stated that nothing could be done be cause o f lack o f m andibular posterior teeth. A plan fo r therapy was devised to eliminate the maxillary protrusion by sur gery and rehabilitate the maxillary arch with a fixed bridge follow ed by treating the periodontal condition and com pleting all necessary operative procedures. T hen the m andibular arch was to be restored by making a com plete lower denture over and anterior to the m andibular dentition. T o eliminate the maxillary deformity, the upper central and lateral teeth with the excess alveolar projection were re m oved. As a guide fo r this procedure, a template o f self-curing clear acrylic resin was made. In order to restore the m axil lary anterior section immediately, a tem porary six unit bridge was made before surgery o f self-curing acrylic resin on the stone cast. Before surgery, the two m axil lary cuspids were prepared for jacket crowns. T h e fou r maxillary incisors were extracted under local anesthesia. T hen osteoplasty was perform ed to a previously planned and desired degree. Imm ediately after sutures were placed, the temporary bridge was adjusted and cemented. A p ro nounced difference in appearance was seen at once. A deform ity which the pa tient had suffered for years was eliminated in one visit. A fter uneventful com plete healing, a permanent restoration consist ing o f a six unit bridge, using two cuspids as abutments, was constructed and ce mented into place (Fig. 2 ,C ) . T h e next step was periodontal therapy. T h e depth o f the pockets was 3 to 5 m m .,
M O R T A Z A V I . . . V O L U M E 67, D EC EM B ER 1963 • 115/875
except mesial of the maxillary right first bicuspid. This tooth, which had an 8 mm. pocket, was extracted not only be cause of a deep pocket and mobility, but also because its malposititon and infra occlusion was a possible source of inter ference in the plan for the completed restoration. The remaining teeth were treated by scaling and curettage, and the patient was instructed in proper toothbrushing and home care. In the lower jaw, in addition to linguoversion and supraclusion of the anterior teeth, the alveolar ridge protruded labially and was covered by a thin mucosa and had an unesthetic appearance. Hav ing planned construction of a lower den ture covering the dentition, it was de cided to eliminate the undercut and to gain a more esthetic appearance. Perio dontal surgery was performed under local anesthesia; it consisted of a gingivectomy for elimination of pockets, osteoplasty for elimination of the undercut and improve ment in appearance and a vestibular ex tension (push back) with frenectomy to obtain more attached gingiva. Then a periodontal pack was placed and neces sary home care instruction with medica tion was given to the patient. The pack was changed one week postoperatively (Fig. 2,D ). While healing was progress ing, the operative procedures were com pleted. After the periodontal condition had been alleviated and had healed suffi ciently, construction of a denture over the mandibular dentition was started. The mouth, as well as study models, again were examined carefully. At this point, the problem of severe undercuts of the teeth was encountered. In the lower arch all bicuspids, especially the second right one, were tilted lingually (Fig. 2,A ). These undercuts would pre sent difficulty in setting the denture in the mouth. In addition, they would re strict the space for the tongue which would make it inconvenient for the pa tient and would also greatly impair her speech. The distance between the lingual
cuspid of the second bicuspids was only 19 mm. For these reasons, the lower right second bicuspid which had a severe un dercut was extracted, the lingual surface of the left bicuspids was reduced, and the undercuts were eliminated. The final im pression was taken with rubber base ma terial in an acrylic tray. Then registration of centric relation and vertical dimension was attempted. The registration of the former was easily made because lack of any excursion made the centric relation a definite position. Determination of vertical dimension was problematic. The freeway space reg istered 4.75 mm. anteriorly. Naturally the posterior opening was less (about one third). This presented a problem in setting the teeth, since the upper teeth touched the lower ridge in centric occlu sion. For this reason, and because it was felt that vertical dimension had been somewhat closed as the result of extrac tion of the posterior teeth, it was decided to open the bite about an additional 3 mm. From centric relation the bite was opened about 8 mm. The teeth were set and tried several times until the satisfac tory setup was obtained. Acrylic resin teeth were used in order to set the anterior teeth as close to the ridge as possible. Speech and esthetics were tested and after a satisfactory setup was established, the denture was processed (Fig. 3,B) and seated after several attempts to relieve the undercuts. After occlusal adjustments, the vertical opening was reduced from 3 mm. to 2 mm. The procedure fulfilled two goals: good esthetics and adequate mastication (Fig. 1,C; 3,C ). The result was satisfactory to both patient and den tist. The patient has been under obser vation for the past few months and is getting along well. A ve. Shah, Charah Eskandari Koutcheh Khoshkhouy, N o. 7
The author expresses his gratitude to Saul Levy and Arthur Elfenbaum for their assistance in this case pres entation. *Formerly, dental department, Michael Reese Hospital and Medical Center, C hicago; department of stomatol ogy, Boston University, School of Medicine.