Use of implant anchorage to correct an anterior cross bite in a patient with a class III malocclusion. A Case Report
A 62-year old male patient was referred by their long-time restorative dentist with a chief complaint, “I want to restore my entire mouth. Everything is breaking, my bite is off, and I can’t seem to chew properly”. He has a history of sleep apnea, a strong gag reflex, and an inability to keep his throat closed during dental treatment. His past dental history included extensive restorative treatment with porcelain fused to metal crowns and resin restorations.
Extraorally, there is a limited range of maximal opening, however, TMJs were asymptomatic. No lymph node swellings were noticed around the neck and chin area. Facial skin, nose, and lips were all healthy.
Intraorally, there is a skeletal/dental class III malocclusion with an anteroposterior crossbite, multiple missing posterior teeth, ill-fitting restorations, generalized dental caries, occlusal interferences in protrusive and lateral excursive movements. In addition, we noticed extensive occlusal wear, a reverse occlusal plane, diastemata in lower anteriors, multiple resin restorations, and generalized 1-2mm mobility with reduced periodontal support.
The challenge, in this case, was to reset the occlusion and restore the entire mouth, given the very few posterior dentitions and compromised periodontal support.
Evaluation & Diagnosis
Initial situation showing a class 3 malocclusion, anterior cross bite and uneven occlusal planes.
A 62-year-old male patient was referred by their long-time restorative dentist with a chief complaint, “I want to restore my entire mouth. Everything is breaking, my bite is off, and I can’t seem to chew properly”. He has a history of sleep apnea, a strong gag reflex, and an inability to keep his throat closed during dental treatment. His past dental history included extensive restorative treatment with porcelain fused to metal crowns and resin restorations.
A digital set up was done demonstrating that lower premolars needed to be retracted 3.5mm per side. Space for #4/5 was enlarged to 14mm and space was created between #10/11 to advance the upper incisors. Conventional edgewise orthodontic mechanics were used with .022” slot MBT twin brackets. Brackets were bonded to implant provisionals. Treatment time was 22 months in braces.
Progress & Completion
Radiograph with implant #19 and #30 placed July 29, 2019. Nobel Active implants to be used as orthodontic anchorage.
Post-ortho teeth alignment, anterior cross bite correction, and teeth positioning for future restorative work.
Vertical dimension was not changed due to patients difficulty of maximal opening established during the diagnostic exam.
Allows patient to visualize final prosthodontic treatment before it begins.
Vertical dimension of occlusion remained unchanged.
Set-up preparation guides to help visualize depth reduction.
Interocclusal records following preps and impressions of both arches simultaneously.
Preparing both arches in these types of cases is imperative to facilitate a better control of the occlusion.
Shade matching different substrates/abutments was challange for the clinician and lab to control the esthetic outcome.
Double cord technique using a double zero (00) and zero (0) for tissue displacement.
A combination of screw retained implant crowns and Lithium disilicate veneers.
Restorations tried-in for fit before cementation. Cemented simultaneously, one arch at a time.
Meticulous excess cement removal, hence slight tissue irritation. It is key to maintaining long term tissue health.
Post COVID, Nobel active implants placed in positions 4, 5, & 20. A trans-crestal sinus augmentation and simultaneous implant placement #4 (4.3X11.5mm). #5 (3.5X11.5mm), #20 (3.5X11.5mm) placed in April 05, 2021.
Post ortho teeth alignment, anterior cross bite correction, and teeth positioning for future restorative work. Implants #19 and #30 used for orthodontic anchorage. Conventional edgewise orthodontic mechanics were used with .022” slot MBT twin brackets. Brackets were bonded to implant provisionals. Treatment time was 22 months in braces.
Follow-up & Outcome
Six months post insertion showing stable healthy tissues.
Periapical radiolucencies are mineralizing, implant bone levels remain stable.
Anterior guidance showing contact on the centrals and slightly lateral incisor.
Close-up smile six months post restorative treatment.
Mandibular occlusal view showing final restorations in-situ.
Maxillary occlusal view showing final restorations in-situ. The Zr copings helped to block-up the dark build-ups.
A comprehensive interdisciplinary treatment plan, prior to any extensive prosthodontic full mouth rehabilitation is highly recommended. In cases with complex orthodontic problems, endosseous dental implants placed in pre planned positions based on an orthodontic set-up, is key for optimum success. The difficulty in this case was the accurate placement of implants and the ortodontic correction of a skeletal class III using only a dental approach.
Was the patient deprogrammed first to access whether his maxilla-mand relationship was anteriorly displaced. How did you
If the vd was opened how much retrusion of the mandible could be attained. Lastly how did you monitor or evaluate sir volume changes as related to retraction of lowers and bicuspids. Thank you
In reply to Was the patient deprogrammed first to access whether his maxilla-mand relationship was anteriorly displaced. How did you by Anonymous
In reply to Was the patient deprogrammed first to access whether his maxilla-mand relationship was anteriorly displaced. How did you by Anonymous
In reply to Was the patient deprogrammed first to access whether his maxilla-mand relationship was anteriorly displaced. How did you by Anonymous