J Interdiscip Dentistry
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Table of Contents
CASE REPORT
Year : 2014  |  Volume : 4  |  Issue : 2  |  Page : 93-96

Complete anterior open bite of an adult treated with prosthetic rehabilitation


1 Department of Conservative and Endodontics, SVS Institute of Dental Sciences, Mahabubnagar, Andhra Pradesh, India
2 Department of Orthodontics, AME Dental College, Raichur, Karnataka, India

Date of Web Publication15-Oct-2014

Correspondence Address:
Shilpa Reddy Admala
Department of Conservative and Endodontics, SVS Institute of Dental Sciences, Mahabubnagar, Andhra Pradesh
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/2229-5194.142947

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   Abstract 

Smile makeover is one of the most common reasons for patients seeking dental treatment. When such treatment is planned, the clinician should integrate an interdisciplinary approach to achieve acceptable dentofacial aesthetics and functional occlusion without compromising periodontal health. Every dental practitioner must have thorough understanding of the roles of the various disciplines in producing an aesthetic makeover, with the most conservative and biologically sound interdisciplinary treatment plan possible. The treatment objectives for this patient were to correct the appearance, keeping in mind that the patient wanted dentofacial improvement in a short span of time. Hence, it was planned to correct the smile by prosthetic camouflage, that is, by placing ceramic crowns. This treatment option was considered to be the best suitable for the patient because of time constraints and also the stability for orthodontic open bite correction being low and having a high tendency to relapse.
Clinical Relevance To Interdisciplinary Dentistry

  • When a smile makeover is planned, the clinician should integrate an interdisciplinary approach to achieve acceptable dentofacial aesthetics and functional occlusion without compromising periodontal health.
  • The dentist should skillfully integrate various disciplines to intervene with the tissues as minimally as possible and keep them biologically sound.
  • In the following case, orthodontic open bite correction was the best suitable option. However as the patient wanted a significant dentofacial improvement in a short span of time, his dental health was improved with periodontal and endodontic therapy and smile correction done by a prosthodontic camouflage, that is, by decreasing the posterior teeth crown height and bringing anterior teeth into occlusion and rehabilitating it to functional occlusion.

Keywords: Anterior open bite, dentofacial aesthetics, prosthetic camouflage


How to cite this article:
Admala SR, Admala NR, Surender L R, Aravelli S. Complete anterior open bite of an adult treated with prosthetic rehabilitation. J Interdiscip Dentistry 2014;4:93-6

How to cite this URL:
Admala SR, Admala NR, Surender L R, Aravelli S. Complete anterior open bite of an adult treated with prosthetic rehabilitation. J Interdiscip Dentistry [serial online] 2014 [cited 2019 Jun 20];4:93-6. Available from: http://www.jidonline.com/text.asp?2014/4/2/93/142947


   Introduction Top


Anterior open bite in adults is known as one of the most challenging and aesthetic problem in orthodontics. [1],[2] Open bite is a malocclusion that occurs in the vertical plane, characterized by lack of vertical overlap between the maxillary and mandibular dentition. Open bites can occur in the anterior and the posterior region and are called anterior open bite and posterior open bite respectively. [3],[4] An anterior open bite can be caused by skeletal vertical disharmony, muscular imbalance, habits, or local alveolar growth deficiency. Posterior cross bites can also have several etiologies, including transverse skeletal imbalance between the maxilla and the mandible, and altered tooth positioning in a bucco-palatal or lingual direction.

Sheets states that, "An impaired self-image may be more disabling developmentally than the pertinent physical defect". [5] An attractive smile can easily be spoiled due to persistent nonnutritive sucking habit which may result in long-term problems like anterior or posterior open bite, interference of normal tooth eruption and position or alteration of bone growth. If the habit stops before the eruption of permanent incisors most of the changes resolve spontaneously but if the habit persists it may result in long-term problems. Professional evaluation has been recommended for children before the age of 3 years with subsequent intervention to cease the initiated habit. [6]

The treatments for open bite and cross bite are determined by their etiology and diagnosis. Large skeletal imbalances must be corrected surgically, while tooth and alveolar disharmonies can be corrected by dentoalveolar movement. [7] Hence, management of open bite in an adult can be corrected by orthodontic or surgical intervention depending on the etiology. The aim of this article is to highlight a new approach of prosthetic camouflage in adult open bite cases where in the patient is limited by options due to time constraint.


   Case report Top


A 46-year-old male reported to the clinic, expressing a wish to improve the appearance of his anterior teeth in a short span of time due to personal reasons. There were no significant findings in his medical history, but dental history revealed that the patient had a habit of digit sucking since childhood. On external examination, patient presented with symmetrical face [Figure 1]. Frontal view showed that the anterior teeth were in the reverse curve, and space was seen between the maxillary and mandibular anterior teeth, giving an unpleasing appearance, due to which patient was conscious during conversation and smiling [Figure 1].
Figure 1: Preoperative extraoral and intraoral view

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Patient also complained of pain in left posterior region since few days and gave a history of root canal therapy done in lower posterior teeth few years back.

Intraoral examination revealed  [Figure 1]:

  • Anterior open bite
  • Proclined anterior teeth
  • Macroglossia
  • Class II molar relationship on both sides
  • Decayed #17, #27, #28, #38
  • Missing #22
  • Generalized hypoplastic defects in enamel.
  • Endo perio lesions in #18, #17, #16, #15, #26, #27, #28, #38, #36, #46, #47, #48 (posterior teeth of all the four quadrants)
  • Irreversible pulpitis in #28, #38, and #37.


After confirming the above with clinical and radiographic examination [Figure 2] treatment was divided into the following phases:
Figure 2: Preoperative and postoperative radiograph

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1. Emergency phase: #18, #27, #28, #38, and #48 were extracted as they had poor prognosis and root canal therapy was initiated in #17, #16, #15, #26, and #36

2. Peroidontal phase: Flap surgery was done in all the four quadrants

3. Restorative phase: Re-root canal therapy was initiated in #37 as the patient complained of pain and root canal therapy of posterior teeth were completed [Figure 2].

The treatment objectives for this patient were to correct the appearance, keeping in mind that the patient wanted the dentofacial improvement in a short span of time. So it was planned to correct the smile by prosthodontic camouflage, that is, by reducing posterior crown height thus bringing the anterior teeth into occlusion and changing axial inclination of anterior teeth to reduce overjet. This treatment option was considered to be the best suitable for the patient because of his disinterest towards orthodontic therapy and acceptable crown root ratio in posterior teeth.

Hence, full mouth rehabilitation with ceramic crowns was planned, and diagnostic wax-up was done. However, as crown preparation was done for #21 and #23 for fixed partial dentures and tooth preparation done on anterior teeth for changing the axial inclination, patient complained of severe sensitivity and pain despite preparing teeth with acceptable clinical protocol. As the pain persisted for few weeks, intentional root canal therapy was done in these teeth, and crown preparation done for the above [Figure 3]. Upper and lower casts were mounted on a semi-adjustable articulator (Hanau Modular Articulator; Whip Mix Corp., Louisville, USA) using a face bow record [Figure 3]. The new vertical dimension of occlusion (VDO) was set by 4 mm decrease in the incisal guidance pin of the articulator. Teeth were temporized with the new VDO and during the 2-month trial period, patient was evaluated for muscle tenderness, discomfort of temporomandibular joint, speech, and facial esthetics. This adjusted occlusion was transferred to customized anterior guide table made with acrylic resin, and final crown preparation was done giving a radial shoulder finish line as the patient insisted for metal free ceramic crowns. Definitive impressions were made with additional silicone impression material (Aquasil Dentsply, Germany). The obtained zirconia copings (Procera, Nobel Biocare) were checked for the fit and marginal accuracy [Figure 3] and sent to the laboratory for ceramic layering. The final prostheses were designed for mutually protected occlusion. Postoperatively we achieved class 1 molar and canine relationship bilaterally with a stable bite of the patient avoiding any fulcrum in the posterior intraoral area. Since the open bite was 8 mm, complete correction of the open bite would lead to, long central incisors in wax-up model. So it was planned to correct an open bite partially, giving 12 mm of clinical crown length of central incisors and lateral incisors were made in harmony with central incisors. [8] Overjet and overbite of the patient were maintained to edge to edge bite to camouflage the open bite and to maintain the anterior aesthetics [Figure 4].
Figure 3: Teeth preparation, articulation and try in

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Figure 4: Extraoral and intraoral postoperative view

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   Discussion Top


Open bite can be either skeletal or dental in origin. Open bite, only of dental origin, can be corrected by a prosthetic approach. In the present case, open bite resulted due to interference with normal eruption of incisors because of persistent digit sucking habit, that is, the open bite was purely of dental origin.

The present case can be managed either orthodontically or by giving prosthesis. For the orthodontic approach of correcting an open bite, the patient had to undergo fixed orthodontic treatment which the patient considered it to be time consuming. Furthermore, there are chances of relapse if the patient compliance is poor for retention appliance. [9] Patient's desire was to correct his aesthetics in a short span of time. Therefore, despite good prognosis, orthodontic treatment was declined by the patient, and prosthodontic rehabilitation was the only treatment option left.

While planning the present case it was kept in mind that the most important teeth for appearance are the central incisors, as they are generally the teeth most exposed during conversation and usually the focus of attention when an individual smiles or laughs. [10] The un-aesthetic appearance of the patient was mainly due to the large open bite and proclined incisors. The open bite was not limited to the incisors, but the extent of open bite was up to first molar, so full mouth prosthesis was planned. Endodontic therapy was planned for the molar teeth as they were affected by endo-perio lesions. [11] Change in axial inclination of teeth to bring them to acceptable esthetics and functional occlusion involved removal of significant enamel and dentine of these teeth. Patient was explained that intentional endodontic therapy would be performed if required and persistence of severe sensitivity and pain in these teeth led to endodontic therapy subsequently.

In the tooth measurement tables recorded by G.V. Black, the average height of a maxillary central incisor was noted as 10 mm with the greatest being 12 mm and the least being 8 mm. [11] Complete correction of the open bite would lead to long central incisors, so it was planned to correct an open bite partially, giving 12 mm of clinical crown length of central incisors. The incisal level of #21, #11, and #12 was decided by the incisal edge of #22 and by doing so the reverse curve was corrected, the dark space between the maxillary and mandibular anterior teeth was reduced and a pleasing appearance was achieved as per the patient satisfaction.


   Conclusion Top


Treatment plan was based on patient's chief complaint. Despite orthodontic treatment being the best treatment modality for such a case, prosthodontic rehabilitation with endodontic and periodontal intervention was planned to keep the patient's demand in mind that he wanted results within a short span of time.

 
   References Top

1.Huang GJ, Justus R, Kennedy DB, Kokich VG. Stability of anterior openbite treated with crib therapy. Angle Orthod 1990;60:17-24.  Back to cited text no. 1
    
2.Espeland L, Dowling PA, Mobarak KA, Stenvik A. Three-year stability of open-bite correction by 1-piece maxillary osteotomy. Am J Orthod Dentofacial Orthop 2008;134:60-6.  Back to cited text no. 2
    
3.Almeida RR, Henriques JF, Almeida MR, Vasconcelos MH. Early treatment of anterior open bite-prevention of orthognathic surgery. In: Davidovitch Z, Mah J, editors. Biological Mechanisms of Tooth Eruption, Resorption and Replacement by Implants. Boston: Harvard Society for the Advancement of Orthodontics; 1998. p. 585-8.  Back to cited text no. 3
    
4.Rodrigues de Almeida R, Ursi WJ. Anterior open bite. Etiology and treatment. Oral Health 1990;80:27-31.  Back to cited text no. 4
    
5.Sheets CG. Modern dentistry and the esthetically aware patient. J Am Dent Assoc 1987;Spec No: 103E-5.  Back to cited text no. 5
    
6.Nowak AJ, Warren JJ. Infant oral health and oral habits. Pediatr Clin North Am 2000;47:1043-66, vi.  Back to cited text no. 6
    
7.Spear FM, Kokich VG. A multidisciplinary approach to esthetic dentistry. Dent Clin North Am 2007;51:487-505, x.  Back to cited text no. 7
    
8.Wheeler RC. A Text Book of Dental Anatomy and Physiology. Philadelphia, PA: W.B. Saunders; 1965. p. 102, 103, 126, 131, 427.  Back to cited text no. 8
    
9.Greenlee GM, Huang GJ, Chen SS, Chen J, Koepsell T, Hujoel P. Stability of treatment for anterior open-bite malocclusion: A meta-analysis. Am J Orthod Dentofacial Orthop 2011;139:154-69.  Back to cited text no. 9
    
10.Frush JP, Fisher RD. Introduction to dentogenic restorations. J Prosthet Dent 1955;5:586-95.  Back to cited text no. 10
    
11.Parolia A, Gait TC, Porto IC, Mala K. Endo-perio lesion: A dilemma from 19 th until 21 st century. J Interdiscip Dent 2013;3:2-11.  Back to cited text no. 11
    


    Figures

  [Figure 1], [Figure 2], [Figure 3], [Figure 4]



 

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