Correction of prognathism with fixed and removable partial dentures John B. Boyd, Jr., D.D.S., M.S.D.* Howard Lrniversity, College of Dentistry, Washington,
D. C.
S
ince prognathism is a serious social and functional impediment, its correction is essential to restore function and esthetics in the oral and behavioral rehabilitation of a prognathous patient. Even though many advances have been made in its early diagnosis and orthodontic, prosthodontic, and surgical management of it, there are many patients who require treatment in adult life. When orthodontic treatment or surgical intervention is not feasible, these patients should be treated by the prosthodontist. ETIOLOGY Etiologically, there are three types of prognathism: (1) true prognathism, (2) false prognathism, and (3) acromegaly. The first two types develop during early childhood, whereas the third type is a result of endocrine dysfunction that occurs in adulthood. TREATMENT The treatment modality is determined by the type of prognathism. Any treatment, however, should establish adequate function and esthetics. They are complementary because it is not possible to achieve normal facial contours unless the teeth and mandible are in relatively normal occlusion. Furthermore, unless the teeth, tongue, and lips are able to function properly, phonetics is impaired. Surgical-orthodontic procedures such as maxillary and mandibular osteotomy for repositioning the mandible and maxillae for the correction of true prognathism have been described by Thoma,’
Read before the American Prosthodontic Society, Miami Beach, Fla. l Profeaeor, Department of Community and Restorative Dcnristry; Director of General DentistT and Dental Auxiliary Utilization Programs.
COZ-3913/78/110509
+ 04$00.40/O 0 19iR The C. V. Mosby Co
Trauner and Obwegeser,’ and others.:‘. 4 However, Moo& has pointed out that surgical procedures are often unnecessary in patients with an anterior crossbite from pseudo-Class III malocclusion. He reported on a patient treated conservatively by prosthodontic means. Ginder” reported treatment of three patients to illustrate the use of orthodontics in conjunction with prosthodohtic treatment in the correction of prognathism. Moore’ reported prosthodontic treatment of a patient using a superimposed prosthesis to correct pseudoprognathism caused by a cleft palate defect. CHANGES
IN VERTICAL
DIMENSION
A thorough understanding of vertical dimension and its relation to rest position and interocclusal (free way) space is important before an attempt is made to increase the vertical dimension of occlusion. Prostheses that increase the vertical dimension of occlusion (bite planes) can be used to relieve the symptoms of pain and trismus in patients who have suffered loss of vertical dimension due to loss of teeth, bruxism, poor restorations, and inadequate occlusal adjustments. Increases in vertical dimension which encroach on the interocclusal space and alter rest position must be accomplished over a long period of time. A prosthesis that encroaches on the existing interocclusal space increases the disturbing input to the neuromuscular mechanism because of occlusal interferences and predisposes the patient to traumatic temporomandibular joint (TMJ) arthritis or muscle pain. On the other hand, a loss of vertical dimension and “anterior displacement” of the mandible can produce muscle and TMJ pain.“. ” understand the It is necessary to thoroughly hazards and consequences of increasing the occlusal vertical dimension, since an opening prosthesis is needed to treat most patients with prognathism. It is
THE JOURNAL OF PROSTHETIC DFNTISTRY
509
BOYI?
Fig. I. The left side of the preoperative
Fig. 2. The right side of the preoperative used first to increase the occlusal vertical dimension to relieve the acute symptoms of trismus and pain of the muscles and the TMJ, and then to sustain the level of increase and thereby restore function and esthetics.
REPORT OF A PATIENT History. A woman patient, presented for treatment
510
42 years of age, complaining of ill-fitting
radiograph.
radiograph.
dentures and pain in the teeth and TMJ. A panorex radiograph was taken (Figs. 1 and 2), and diagnostic casts were made and mounted on an articulator. Examination revealed mandibular prognathism with a deep anterior crossbite (Fig. 3). The patient was wearing inadequately designed and -poorly fitting removable partial dentures. The restorative procedures had been done within the prognathic occlusion. As a result there was
NOVEMBER
197%
VOLUME
40
NUMBER
5
CORRECTION
OF PROCNATHISM
Fig. 3. The patient’s untreated deep anterior crossbite. excessive wear of the acrylic resin labial surfaces of the upper anterior restorations and pain in the teeth and TMJ. The patient also stated dissatisfaction with her appearance and an inability to chew food properly which was leading to digestive problems. Treatment. The upper and lower right third molars were extracted, and the extraction sites were allowed to heal for 3 months. The lower removable partial denture was rebased, and an acrylic resin occlusal splint was built up on the occlusal surfaces of the artificial teeth to increase the vertical dimension approximately 10 mm. This produced an edgeto-edge relationship (Fig. 4). The patient was then monitored on a weekly basis. After 8 weeks of observation, during which time the patient reported no TMJ discomfort and exhibited no difficulties functioning at this opening, the crowns on the upper left canine and first premolar were removed. The teeth were reprepared and covered with acrylic resin temporary crowns. This was done to help maintain the occlusion at the established level and to aid in recording the vertical dimension for mounting purposes when the crowns on the other teeth were removed. Two weeks later the crowns were removed from the upper right canine, lateral and central incisors, and the upper left central and lateral incisors. These teeth were reprepared and the vertical dimension recorded. This record was made with zinc oxideeugenol bite registration paste in a Kerr’s bite frame* while the temporary acrylic resin crowns on the upper left canine and first premolar maintained the newly established vertical dimension of occlu*Kerr
Mfg. Co., Romulus, Mich.
THE JOURNAL
OF PROSTHETIC
DENTISTRY
Fig. 4. The edge-to-edge relationship produced with a trial occlusal splint prosthesis. Note the excessive wear of existing anterior crowns.
Fig. 5. The
finished
porcelain-fused-to-gold
restora-
tions. sion. Temporary acrylic resin crowns for the upper right canine, central and lateral incisors, and upper left central and lateral incisor were constructed to the vertical opening maintained by the temporary acrylic resin crowns on the upper left canine and first premolar. The temporary crowns on the upper left first premolar and canine were then removed and a vertical dimension record was obtained for this side, as previously described with the acrylic resin temporary crowns on the other teeth, maintaining the newly established vertical dimension. All the temporary acrylic resin crowns were then removed and a master impression of the prepared teeth was made. An impression of the lower jaw was made with the occlusal splint in place to provide an opposing cast. A face-bow record was taken for mounting the working casts on a Hanau articulatol~ with the vertical dimension records.
511
successfully treated by the use of fixed and removable partial denture prosthodontics. Careful neuromuscular evaluation of the patient is necessary for the successof the treatment rendered. The nonsurgical treatment of prognathism by this method was described. REFERENCES I. 2.
Fig. 6. The completed treatment, with new upper and lower removable partial dentures in place.
3.
Porcelain on metal crowns were fabricated for the upper teeth. Rest seats, guiding planes, and proper for new removable partial clasping contours
4.
dentures were incorporated in the restorations and on the remaining natural teeth (Fig. 5). Upper and lower removable partial dentures were then fabricated at the increased vertical dimension of occlusion. The removable partial dentures were placed (Fig. 6) and the functional occlusion for the newly established vertical dimension was checked., The patient was checked after 6 months. The functional occlusion was still satisfactory, and the patient reported no discomfort and complete satisfaction with function and esthetics.
5.
6.
Thoma, K. H.: Oblique osteotomy of the mandibular ramus. Oral Surg 14:23, 1961. (Suppl I) Trauncr, R., and Obwegeser, H. L.: The surgical correction of mandibular prognathism and rutorgnathia with consideration ofgenioplasty. Oral Surg l&677,1957; 10:787, 1957; I&899, 1957. Hinds, E. C., and Ken, J. M.: Surgical Treatment of Developmental Jaw Deformities. St. Louis, 1972, The C. V. Mosby Co. Nathanson, N. R., and Moynihan, F. M.: Prognathism: One stage intra oral osteotomy. Oral Surg 24~410, 1966. Moore, D. S.: Temporomandibular joint pain dysfunction and pseudo Class III malocclusion. J Can Dent Asscx 41:407, 1975. Ginder, 0.: Pmsthodontic management of problems in prognathism. NY J Dent 35:148, 1969. Moore, D. J.: The continuing role of the prosthodontists in the treatment of patients with cleft lip and paiate. J PROSTHET DENT 36:186, 1976. Lammie, A. G., Perry, H. T., Jr., and Crumm, B. D.: Certain observations on complete denture patients: Part 1. Method and results. J Paosmrr DENT 8:786, 1958. Brill, N., Schiibeler, S., and Tryde, C.: Influence of occlusal patterns on movements of the mandible. J PROSTHET DENT 121255, 1962.
Rrprrnt reqursts to: DR. JCIHZ~ B. B~YD, JK.
HOWARD UNIVERSITY
SUMMARY
COLLEGE
Prognathism
orthodontic
512
in those patients
for whom
procedures are contraindicated
surgical
WASHIWWN,
OF
DENTISTRY
D. C. 20059
can be
NOVEMBER
1978
VOLUME
40
NUMBER
5
D. C.
S
ince prognathism is a serious social and functional impediment, its correction is essential to restore function and esthetics in the oral and behavioral rehabilitation of a prognathous patient. Even though many advances have been made in its early diagnosis and orthodontic, prosthodontic, and surgical management of it, there are many patients who require treatment in adult life. When orthodontic treatment or surgical intervention is not feasible, these patients should be treated by the prosthodontist. ETIOLOGY Etiologically, there are three types of prognathism: (1) true prognathism, (2) false prognathism, and (3) acromegaly. The first two types develop during early childhood, whereas the third type is a result of endocrine dysfunction that occurs in adulthood. TREATMENT The treatment modality is determined by the type of prognathism. Any treatment, however, should establish adequate function and esthetics. They are complementary because it is not possible to achieve normal facial contours unless the teeth and mandible are in relatively normal occlusion. Furthermore, unless the teeth, tongue, and lips are able to function properly, phonetics is impaired. Surgical-orthodontic procedures such as maxillary and mandibular osteotomy for repositioning the mandible and maxillae for the correction of true prognathism have been described by Thoma,’
Read before the American Prosthodontic Society, Miami Beach, Fla. l Profeaeor, Department of Community and Restorative Dcnristry; Director of General DentistT and Dental Auxiliary Utilization Programs.
COZ-3913/78/110509
+ 04$00.40/O 0 19iR The C. V. Mosby Co
Trauner and Obwegeser,’ and others.:‘. 4 However, Moo& has pointed out that surgical procedures are often unnecessary in patients with an anterior crossbite from pseudo-Class III malocclusion. He reported on a patient treated conservatively by prosthodontic means. Ginder” reported treatment of three patients to illustrate the use of orthodontics in conjunction with prosthodohtic treatment in the correction of prognathism. Moore’ reported prosthodontic treatment of a patient using a superimposed prosthesis to correct pseudoprognathism caused by a cleft palate defect. CHANGES
IN VERTICAL
DIMENSION
A thorough understanding of vertical dimension and its relation to rest position and interocclusal (free way) space is important before an attempt is made to increase the vertical dimension of occlusion. Prostheses that increase the vertical dimension of occlusion (bite planes) can be used to relieve the symptoms of pain and trismus in patients who have suffered loss of vertical dimension due to loss of teeth, bruxism, poor restorations, and inadequate occlusal adjustments. Increases in vertical dimension which encroach on the interocclusal space and alter rest position must be accomplished over a long period of time. A prosthesis that encroaches on the existing interocclusal space increases the disturbing input to the neuromuscular mechanism because of occlusal interferences and predisposes the patient to traumatic temporomandibular joint (TMJ) arthritis or muscle pain. On the other hand, a loss of vertical dimension and “anterior displacement” of the mandible can produce muscle and TMJ pain.“. ” understand the It is necessary to thoroughly hazards and consequences of increasing the occlusal vertical dimension, since an opening prosthesis is needed to treat most patients with prognathism. It is
THE JOURNAL OF PROSTHETIC DFNTISTRY
509
BOYI?
Fig. I. The left side of the preoperative
Fig. 2. The right side of the preoperative used first to increase the occlusal vertical dimension to relieve the acute symptoms of trismus and pain of the muscles and the TMJ, and then to sustain the level of increase and thereby restore function and esthetics.
REPORT OF A PATIENT History. A woman patient, presented for treatment
510
42 years of age, complaining of ill-fitting
radiograph.
radiograph.
dentures and pain in the teeth and TMJ. A panorex radiograph was taken (Figs. 1 and 2), and diagnostic casts were made and mounted on an articulator. Examination revealed mandibular prognathism with a deep anterior crossbite (Fig. 3). The patient was wearing inadequately designed and -poorly fitting removable partial dentures. The restorative procedures had been done within the prognathic occlusion. As a result there was
NOVEMBER
197%
VOLUME
40
NUMBER
5
CORRECTION
OF PROCNATHISM
Fig. 3. The patient’s untreated deep anterior crossbite. excessive wear of the acrylic resin labial surfaces of the upper anterior restorations and pain in the teeth and TMJ. The patient also stated dissatisfaction with her appearance and an inability to chew food properly which was leading to digestive problems. Treatment. The upper and lower right third molars were extracted, and the extraction sites were allowed to heal for 3 months. The lower removable partial denture was rebased, and an acrylic resin occlusal splint was built up on the occlusal surfaces of the artificial teeth to increase the vertical dimension approximately 10 mm. This produced an edgeto-edge relationship (Fig. 4). The patient was then monitored on a weekly basis. After 8 weeks of observation, during which time the patient reported no TMJ discomfort and exhibited no difficulties functioning at this opening, the crowns on the upper left canine and first premolar were removed. The teeth were reprepared and covered with acrylic resin temporary crowns. This was done to help maintain the occlusion at the established level and to aid in recording the vertical dimension for mounting purposes when the crowns on the other teeth were removed. Two weeks later the crowns were removed from the upper right canine, lateral and central incisors, and the upper left central and lateral incisors. These teeth were reprepared and the vertical dimension recorded. This record was made with zinc oxideeugenol bite registration paste in a Kerr’s bite frame* while the temporary acrylic resin crowns on the upper left canine and first premolar maintained the newly established vertical dimension of occlu*Kerr
Mfg. Co., Romulus, Mich.
THE JOURNAL
OF PROSTHETIC
DENTISTRY
Fig. 4. The edge-to-edge relationship produced with a trial occlusal splint prosthesis. Note the excessive wear of existing anterior crowns.
Fig. 5. The
finished
porcelain-fused-to-gold
restora-
tions. sion. Temporary acrylic resin crowns for the upper right canine, central and lateral incisors, and upper left central and lateral incisor were constructed to the vertical opening maintained by the temporary acrylic resin crowns on the upper left canine and first premolar. The temporary crowns on the upper left first premolar and canine were then removed and a vertical dimension record was obtained for this side, as previously described with the acrylic resin temporary crowns on the other teeth, maintaining the newly established vertical dimension. All the temporary acrylic resin crowns were then removed and a master impression of the prepared teeth was made. An impression of the lower jaw was made with the occlusal splint in place to provide an opposing cast. A face-bow record was taken for mounting the working casts on a Hanau articulatol~ with the vertical dimension records.
511
successfully treated by the use of fixed and removable partial denture prosthodontics. Careful neuromuscular evaluation of the patient is necessary for the successof the treatment rendered. The nonsurgical treatment of prognathism by this method was described. REFERENCES I. 2.
Fig. 6. The completed treatment, with new upper and lower removable partial dentures in place.
3.
Porcelain on metal crowns were fabricated for the upper teeth. Rest seats, guiding planes, and proper for new removable partial clasping contours
4.
dentures were incorporated in the restorations and on the remaining natural teeth (Fig. 5). Upper and lower removable partial dentures were then fabricated at the increased vertical dimension of occlusion. The removable partial dentures were placed (Fig. 6) and the functional occlusion for the newly established vertical dimension was checked., The patient was checked after 6 months. The functional occlusion was still satisfactory, and the patient reported no discomfort and complete satisfaction with function and esthetics.
5.
6.
Thoma, K. H.: Oblique osteotomy of the mandibular ramus. Oral Surg 14:23, 1961. (Suppl I) Trauncr, R., and Obwegeser, H. L.: The surgical correction of mandibular prognathism and rutorgnathia with consideration ofgenioplasty. Oral Surg l&677,1957; 10:787, 1957; I&899, 1957. Hinds, E. C., and Ken, J. M.: Surgical Treatment of Developmental Jaw Deformities. St. Louis, 1972, The C. V. Mosby Co. Nathanson, N. R., and Moynihan, F. M.: Prognathism: One stage intra oral osteotomy. Oral Surg 24~410, 1966. Moore, D. S.: Temporomandibular joint pain dysfunction and pseudo Class III malocclusion. J Can Dent Asscx 41:407, 1975. Ginder, 0.: Pmsthodontic management of problems in prognathism. NY J Dent 35:148, 1969. Moore, D. J.: The continuing role of the prosthodontists in the treatment of patients with cleft lip and paiate. J PROSTHET DENT 36:186, 1976. Lammie, A. G., Perry, H. T., Jr., and Crumm, B. D.: Certain observations on complete denture patients: Part 1. Method and results. J Paosmrr DENT 8:786, 1958. Brill, N., Schiibeler, S., and Tryde, C.: Influence of occlusal patterns on movements of the mandible. J PROSTHET DENT 121255, 1962.
Rrprrnt reqursts to: DR. JCIHZ~ B. B~YD, JK.
HOWARD UNIVERSITY
SUMMARY
COLLEGE
Prognathism
orthodontic
512
in those patients
for whom
procedures are contraindicated
surgical
WASHIWWN,
OF
DENTISTRY
D. C. 20059
can be
NOVEMBER
1978
VOLUME
40
NUMBER
5
