Debra Gray King, DDS


January 04, 2011

Clinical Presentation: A Middle Aged Man With Occlusion Problems

Many middle-aged men desire both better function of their teeth and an enhanced appearance to their smile. These objectives often go together and this challenging case is no exception. The patient, a 48 year-old man, was born with congenitally missing upper lateral incisors, #7 and #10. As an adult, a motorcycle accident with trauma to the face caused the loss of tooth #8; subsequently, the patient had porcelain fused to metal (PFM) pontic for tooth #8, with PFM restorations placed on teeth #6, #9, and #11 (4 anterior teeth) (Figure 1a). The patient wanted his previous dental work removed and his smile redesigned to obtain an improved and natural-looking smile. He wanted his new smile to have longer anterior teeth, so that his front teeth would appear more natural and show when he smiled and talked. In previous dental consultations, the patient was told that he would need oral surgery on his jaws to correct his overjet. He did not want surgery and several weeks of dental immobilization of his jaws (Figure 1b).

Figure 1a. Preoperative full face view. 1b. Preoperative view of occlusion problems.

Dental Examination

Occlusion and facial aesthetics were not optimal. Wear facets and micro-enamel fractures were present on the lower anterior teeth. Numerous old amalgam restorations were present on the mandibular posterior teeth. Noticeable inflammation was present around the gingiva for the existing PFMs on the upper anteriors. When the patient closed his teeth together to chew, his lower anterior teeth fit on the outside of the upper teeth, producing a negative overjet (Class III), resulting in a bulldog-like appearance. Upon observation, the lower third of the patient's face was foreshortened, giving his face the appearance that he was strained and tense most of the time.

The Diagnosis

Diagnosis was as follows: Mild, class III occlusion; gingivitis and chronic inflammation maxillary anterior teeth with prior PFM bridge; missing lateral incisors and #8; lateral excursions restricted due to third molar interference (Figures 2a and 2b).

Figure 2a. Preoperative occlusion, retracted and while biting (upper anterior view). 2b. Preoperative occlusion, retracted and while biting (lower anterior view).


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