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

224 THE JOURNAL OF PROSTHETIC DENTISTRY VOLUME 92 NUMBER 3

SAKAR, BEYLI, AND MARSAN
Fig. 1. Frontal view A, without ORPDs, and B, with ORPDs.
maxillary right lateral incisor was narrow, the amount of
the negative horizontal overlap was 11 mm, and the ver-
tical overlap was 15 mm (Fig. 3). The upper lip appeared
posterior to the lower lip (Fig. 2, A). The patient’s rela-
tive mandibular prognathism was due to excessive verti-
cal overlap with a reduced lower anterior facial height,
but the patient could rotate the mandible with help,
and the lower facial height could be returned to normal.
Functional examination demonstrated an edge-to-edge
incisor relationship. In this position a bilateral posterior
open occlusal relationship was observed.
Periodontal therapy included scaling and root planing
all quadrants. The patient was given oral hygiene in-
structions. After the healing period, irreversible hydro-
colloid impressions (Alginoplast; Bayer, Leverkusen,
Germany) were made and diagnostic casts were fabri-
cated.
A face-bow record and an interocclusal record in
maximum intercuspation were made and casts were
mounted in a semiadjustable articulator (Dentatus,
Stockholm, Sweden). The patient and the mounted
diagnostic casts were evaluated by a prosthodontist, an
orthodontist, and a surgeon.
Five treatment plan options were discussed for restor-
ing the OVD and the missing teeth: (1) definitive max-
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THE JOURNAL OF PROSTHETIC DENTISTRY
illary and mandibular ORPDs fabricated at the newly
established OVD; (2) interim maxillary and mandibular
ORPDs with the newly established OVD, OT, and de-
finitive maxillary and mandibular ORPDs; (3) interim
maxillary and mandibular ORPDs fabricated at the
newly established OVD, lengthening of the clinical
crowns of the maxillary incisors, a maxillary fixed partial
denture with cantilevered right second premolar, and
a mandibular fixed partial denture (FPD) and metal ce-
ramic crowns; (4) interim maxillary and mandibular
ORPDs at the newly established OVD, OT, a maxillary
precision attachment removable partial denture, and
a mandibular FPD and metal ceramic crowns; and (5) in-
terim maxillary and mandibular ORPDs at the newly
established OVD, OT, and maxillary and mandibular
implant-supported prostheses.
The advantages and disadvantages of all treatment
options were presented to the patient. Restoring the
OVD appeared to be the first priority to improve
esthetics and function regardless of the definitive treat-
ment.13,20 An occlusal splint was not a satisfactory
choice for the patient’s functional and esthetic re-
quirements during the adaptation period. The use of
definitive maxillary and mandibular ORPDs with or
without OT was eliminated because of the poor esthetics
225
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Fig. 2. Profile view A, without ORPDs, and B, with ORPDs.
of extracoronal direct retainers, while implant prosthe-
ses were eliminated because of the increase in cost and
proximity of the sinus. The use of maxillary and mandib-
ular fixed partial dentures without OT was eliminated
because of the possible effects on emergence profile
which may have resulted in unfavorable forces acting
on the FPDs. Furthermore, the need for endodontic
treatment and possible food retention were dis-
advantages of this treatment option. The use of a maxil-
lary precision-attachment RPD and a mandibular FPD
and metal ceramic crowns was selected to improve the
esthetics of the upper lip, obtain Angle Class I relation-
ship, and satisfy functional requirements of the patient.
Definitive casts of Type III dental stone (Moldano;
Bayer, Leverkusen, Germany) and a face-bow record
were made. Maxillary and mandibular record bases and
wax occlusion rims were fabricated. The OVD was
established using facial measurements and the technique
described by Niswonger.9-12 The mandibular cast was
mounted with a wax (Cavex; Cavex Holland, Haarlem,
Netherlands) centric relation record reinforced with
zinc oxide eugenol (SS White Group, Gloucester,
England) obtained by bilateral manipulation.21
Definitive casts were duplicated in refractory material
(Biosint Extra; Degussa Dental, Hanau, Germany), and
226
SAKAR, BEYLI, AND MARSAN
ORPD patterns were waxed (Multiwax; BDP Industry,
Istanbul, Turkey) on the refractory casts. The prosthesis
was extended to the facial surfaces to obtain a more
esthetic result. Retention beads were placed for the
veneering material on the occlusal and facial surfaces.
The frameworks were cast in a Co-Cr alloy (Magnum
H50; MESA, Brescia, Italy). After intraoral evaluation
of the framework, veneering material (Biodent K1B
Plus; Dentsply, Dreieich, Germany) was placed and arti-
ficial teeth were arranged. OVD, esthetics, and
maxillomandibular relations were verified. The dentures
were processed with heat-polymerized acrylic resin
(Dentimex; Vertex Dental, Zeist, Holland).22 The pa-
tient wore the ORPDs for 6 months (Figs. 1 and 2, B).
During this period the patient was regularly evaluated
for signs of wear on the prostheses (Fig. 4), symptoms
of temporomandibular dysfunction, and muscle tender-
ness. Muscle tenderness was observed in the first week,
but disappeared by the end of the week. The in-
terocclusal rest space was determined to be approxi-
mately 2 mm at the end of 6 months.
Orthodontic treatment was then initiated. The man-
dibular right first premolar was extracted to correct
the negative horizontal overlap. After completion of
the leveling and alignment phase, by using a standard
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SAKAR, BEYLI, AND MARSAN
Fig. 3. Preoperative maximum intercuspation.
Fig. 5. Anterior view of new maxillary ORPD and mandib-
ular retention appliance during retention period.
edgewise technique,23 0.017 3 0.022 rectangular arch
wires (3M Unitek, Monrovia, Calif) were placed in the
maxillary and mandibular dental arches, and 100g of
force was applied on both sides with Class III elastics.
This method was used to retrude the mandibular ante-
rior teeth and protrude the maxillary anterior teeth.
The uprighting and derotating of the maxillary and the
mandibular third molars resulted in an acceptable rela-
tionship in preparation of the prosthetic phase. At the
completion of the orthodontic treatment, an Angle
Class I relationship and correction of the anterior reverse
articulation were observed. During the retention period,
a new maxillary ORPD and mandibular retention appli-
ance were made in the same manner to prevent tooth
mobility and excessive loading (Fig. 5).
As part of the definitive prosthodontic phase of treat-
ment, the mandibular premolars and molars were re-
stored with metal-ceramic (metal—Wiron 99, Vmk
68; Bego, Bremen, Germany; ceramic—IPS d.SIGN,
Ivoclar Vivadent, Schaan, Liechtenstein) crowns and
an FPD to correct the occlusal plane. The maxillary right
canine and first premolar were restored with splinted
metal-ceramic crowns and the lateral incisor was
SEPTEMBER 2004
THE JOURNAL OF PROSTHETIC DENTISTRY
Fig. 4. Interim maxillary and mandibular ORPDs.
Fig. 6. Postoperative frontal view.
cantilevered. The matrix portion of the attachment
(Ceka; Alphadent, Antwerpen, Belgium) was incorpo-
rated in the maxillary right first premolar crown. A lab-
oratory-fabricated bar (Pattern Resin; GC Corp,
Tokyo, Japan) was made to splint the maxillary left first
premolar and the third molar. The matrix portion of the
attachment was incorporated in the bar pattern and the
bar was milled in a milling machine (Cruise 440;
Silfradent, Santa Sofia, Italy). Porcelain was added to
the restorations. The maxillary precision attachment,
RPD, was then fabricated (Fig. 6). The temporoman-
dibular joints and muscles did not show any dysfunction
after an additional period of 6 months.
DISCUSSION
In this treatment, the negative horizontal overlap and
reduced vertical facial height were corrected, and maxil-
lary and mandibular dental arches prepared for pros-
thetic restoration. An ORPD is a prosthesis that rests
on 1 or more natural teeth, the roots of the natural teeth,
and/or implant.7 It is a reversible, conservative, and
effective solution to obtain an esthetic and functional
result.20 The procedure may also be of diagnostic value,
227
THE JOURNAL OF PROSTHETIC DENTISTRY
and it provided useful information to the orthodontic
and oral and maxillofacial surgical team.22 Adaptation
to altered OVD was evaluated by the use of an interim
ORPD. However, several disadvantages are associated
with ORPDs. Abutment teeth are susceptible to caries
if patients cannot be motivated to maintain a level of
good oral hygiene.5 Wear between the denture base
and the supporting teeth increases the possibility of
breakage as the denture base is often thin in the region
of the supporting natural teeth, thus, increasing the pos-
sibility of fracture.5 Esthetics may be compromised
when the prosthesis is removed and, even when the den-
ture is not removed, the presence of extracoronal clasp
direct retainers may negatively effect the esthetics.5,16
Because of these disadvantages, the ORPD was not the
definitive prosthesis for this patient.
An increased occlusal vertical dimension may cause
postoperative problems, including clenching of teeth,
muscle fatigue, soreness of teeth, muscles, and joints,
headache, intrusion of teeth, occlusal instability, and
continued wear. Therefore, it is recommended that
changes to the OVD should be conservative and a trial
period with an interim prosthesis is desirable.13,15
However, some studies demonstrated that jaw muscle
tonus adapts to extreme changes in OVD and a new in-
terocclusal rest space occurs.14,18 Hellsing14 stated that
jaw muscle motor behavior is more dynamic and adapt-
able to environmental changes than previously believed.
In the light of these suggestions, it was determined that
the OVD of the patient be increased approximately 8
mm using interim ORPDs for 6 months. Although re-
storing the OVD to this level may be viewed as extreme,
the patient readily adapted to the new OVD.
SUMMARY
This clinical report described the prosthetic rehabili-
tation in conjunction with orthodontic treatment of
a 38-year-old patient with a skeletal Angle Class III mal-
occlusion. The occlusal vertical dimension was restored,
and an interim overlay removable partial denture was
made. After the trial period and orthodontic treatment,
prosthetic rehabilitation was completed with a maxillary
precision attachment removable partial denture, a man-
dibular fixed partial denture, and metal-ceramic crowns.
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Reprint requests to:
DR OLCAY SAKAR
DEPARTMENT OF REMOVABLE DENTURES
ISTANBUL UNIVERSITY FACULTY OF DENTISTRY
CAPA 34390 ISTANBUL
TURKEY
FAX: 90212525-3585
E-MAIL: olcaysakar@yahoo.com
0022-3913/$30.00
Copyright Ó 2004 by The Editorial Council of The Journal of Prosthetic
Dentistry
doi:10.1016/j.prosdent.2004.06.002
VOLUME 92 NUMBER 3