Prosthodontic Rehabilitation with a Telescopic Prosthesis of a Nonsyndromic Oligodontia Patient Anil Kumar Sethuram, BDS, MDS,1 Vimal Arora, BDS, MDS,2 Arup Kumar Pal, BDS, MDS,3 Harbir Singh Sandhu, BDS, MDS,2 Nand Kishore Sahoo, BDS, MDS,4 & B.S. Guruprasada, BDS, MDS5 1
Department of Prosthodontics, Command Military Dental Centre Lucknow, Lucknow, India Department of Prosthodontics, O/o DGDS, Integrated AHQ, Delhi, India 3 Department of Oral and Maxillofacial Surgery, Command Military Dental Centre Lucknow, Lucknow, India 4 Department of Oral and Maxillofacial Surgery, AFMC Pune, Pune, India 5 Department of Prosthodontics, Command Military Dental Centre Chandigarh, Chandigarh, India 2
Keywords Oligodontia; telescopic prosthesis; developmental disorder. Correspondence Anil Kumar Sethuram, Department of Prosthodontics, Command Military Dental Centre Lucknow, C/o CMDC (CC), Post Office Dilkusha, Lucknow 226002, India. E-mail: [email protected] Supported by the Indian Army Dental Corps. Presented at the 42nd Indian Prosthodontic Society Conference, November 6 to 9, 2014, Chandigarh, Lucknow, India. The authors declare that they have no conflict of interests.
Abstract Oligodontia is the congenital absence of six or more permanent teeth, excluding the third molars. Oligodontia of permanent dentition is a rare occurrence. Preservation of the remaining deciduous dentition in such situations is important for both functional and esthetic rehabilitation of the patient. This clinical report describes the rehabilitation of a 16-year-old male with oligodontia of permanent teeth treated by an interdisciplinary team of prosthodontist, pedodontist, and orthodontist. The remaining deciduous dentition was endodontically treated. Occlusal vertical dimension (OVD) of the deciduous dentition was assessed. A full-mouth single piece porcelain-fusedto-metal telescopic prosthesis for the maxillary and mandibular arches was planned with a minimal increase in OVD. The telescopic prosthesis provided excellent retention, stability, esthetics, and stress equalization on the remaining deciduous dentition. Maintenance of oral hygiene procedures was simplified for the adolescent with the telescopic prosthesis. Preservation of remaining deciduous dentition and fabrication of a telescopic prosthesis in this patient provided an effective esthetic and functional rehabilitation.
Accepted December 3, 2014 doi: 10.1111/jopr.12297
Oligodontia is a rare entity that can be associated with a genetic syndrome or can occur as a nonsyndromic isolated familial trait.1 Congenital absence of permanent dentition is attributed to environmental factors such as trauma, malignancy, irradiation, hormonal influences, hereditary genetic dominant factors, and thalidomide therapy.2 Odontogenesis is mainly controlled by the MSX1 and PAX9 genes. Any mutation of the PAX9 gene leads to a nonsyndromic form of tooth agenesis.3 Early diagnosis and prompt treatment of a patient with oligodontia is essential to reduce disabilities. Dental conditions like malocclusion and altered facial appearance can lead to psychological disturbances and difficulty in mastication and speech. Rehabilitation depends on the extent of oligodontia and other underlying syndromes associated with it.4 Management of nonsyndromic oligodontia is much simpler than a case associated with underlying syndromes. The ultimate goal of rehabilitation should be to achieve prosthetic and
esthetic functionality of the remaining oral structures. Treatment planning should focus on the “perpetual preservation of what remains than the meticulous restoration of the missing tooth structures.”5 The deciduous dentition in patients with oligodontia has to be preserved to prevent the long-term effects of edentulism caused by congenital absence of permanent teeth. Telescopic crowns as retainers for removable prostheses were introduced at the beginning of 20th century. The term coined was crown and sleeve coping, or Konuskrone,6 a German term that describes a cone-shaped design. These crowns exhibit retention by friction when completely seated using a wedging effect. The smaller the convergence angles of the telescopic copings, the greater the retentive force. The retention is further enhanced by supplementary attachments and the functionally molded denture borders.7 The proprioception from the periodontal ligament prevents occlusal overload, resorption of roots, and alveolar ridge due to excessive forces.8
C 2015 by the American College of Prosthodontists Journal of Prosthodontics 25 (2016) 247–251
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Figure 1 Preoperative intraoral view. Figure 2 Mandibular telescopic coping cementation.
This clinical report presents a unique feature of nonsyndromic oligodontia of permanent dentition and describes rehabilitation of a patient with a telescopic crown retained porcelain-fusedto-metal (PFM) removable dental prosthesis (RDP) using deciduous teeth as retainers for an enhanced functional and esthetic outcome.
Clinical report A 16-year-old male patient with nonsyndromic oligodontia of permanent dentition reported with a chief complaint of unesthetic appearance, difficulty in mastication, and impaired quality of life. Clinical examination revealed the presence of multiple retained deciduous teeth and eruption of a few permanent teeth (Fig 1). A routine exam of the blood, including serum calcium, alkaline phosphatise, TSH, T3, and T4 was conducted. The physical examination showed that the hairs were not thin and sparse, nails were not brittle, and no difficulty in perspiration was seen, ruling out ectodermal dysplasia. On ocular examination, no signs of glaucoma were seen, ruling out Reiger syndrome. A panoramic radiograph showed multiple missing permanent teeth. The deciduous teeth present were #s 52, 53, 55, 61 to 63, and 65 in the maxillary arch and #s 71 to 75 and 81 to 85 in the mandibular arch (FDI two-digit notation for primary dentition). The erupted permanent teeth were #s 11 and 26 (partially erupted) in the maxillary arch and #s 36 and 46 in the mandibular arch (FDI two-digit notation for permanent dentition). Tooth #81 had poor prognosis because of decreased crown to root ratio and hence was taken up for extraction. Diagnostic impressions of both arches were made with irreversible hydrocolloid impression material (Septodont Plastalgin dust-free alginate, 3M ESPE, St. Paul, MN). Facebow transfer (UTS 3D Transfer Bow, Stratos 200; Ivoclar Vivadent, Schaan, Liechteinstein) and occlusal vertical dimension (OVD) was recorded at centric relation. The maxillary and mandibular models were articulated on the semi-adjustable articulator (Stratos 200) at the existing OVD. A diagnostic wax-up was done to plan the fabrication of the permanent prosthesis for esthetic and functional rehabilitation with minimal increase of 3 mm in the anterior region to obtain a 1 mm disclusion in the posterior region to compensate for the telescopic prosthesis from the existing OVD without jeopardizing temporomandibular joint function. 248
A custom-made Broadrick occlusal plane analyzer9 was used for analyzing the Curve of Spee and developing an acceptable occlusion in the diagnostic wax-up. Endodontic treatment of the remaining deciduous dentition (using Metapex root canal filling material; Metabiomed, Chungbuk, Korea) and permanent right central incisor (using gutta percha) was completed. Tooth preparation of the remaining deciduous mandibular molars was performed with a shoulder margin, and the mandibular anterior teeth were prepared with a knife-edge margin because of the limited amount of clinical crown available. The maxillary dentition was untouched at this stage for reproducing the existing occlusion at increased OVD. A wax-up was done taking into consideration the philosophy of telescopic crowns. All the deciduous mandibular teeth received telescopic copings (Fig 2). The permanent mandibular and erupting maxillary left first molar were not involved, considering the age of the patient and unpredictable prognosis of the retained deciduous dentition. The fabricated telescopic copings (Wirobond C; Bego USA, Lincoln, RI) were placed intraorally on the teeth, and copings were picked up by alginate impression (Septodont Plastalgin). Type V stone was poured into the pickup impression to incorporate the telescopic copings over the master cast. Surveying and milling of the telescopic copings were performed using a milling machine. After achieving the ideal parallelism, a wax-up was done over the telescopic copings, incorporating a mesh on the lingual flange area for fabrication of a hybrid single-unit removable PFM restoration with a lingual flange denture base. The Broadrick plane measurements recorded during the diagnostic wax-up procedure were used as a guide during the porcelain build-up procedure to reproduce the occlusion on mandibular right and left quadrants. The telescopic copings were cemented intraorally, and the prosthesis was checked for retention, stability, and esthetics. The mandibular prosthesis was removed, and an impression of the lower arch with telescopic copings was made. The prosthesis was seated on the prepared cast and articulated with the maxillary counterpart on the semiadjustable articulator. Tooth preparation of the maxillary deciduous teeth was performed. Telescopic copings (Wirobond C) were fabricated for maxillary deciduous teeth (Figs 2–4). The copings were placed intraorally over the maxillary teeth, and the pickup impression procedure as discussed above was
C 2015 by the American College of Prosthodontists Journal of Prosthodontics 25 (2016) 247–251
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Telescopic Prosthesis Rehabilitation of Nonsyndromic Oligodontia
Figure 3 Maxillary telescopic coping cementation.
Figure 6 Mandibular prosthesis insertion.
Figure 4 Panoramic radiograph showing cemented telescopic copings.
Figure 7 Prosthesis in occlusion.
Figure 5 Maxillary prosthesis insertion. Figure 8 Postoperative extraoral view.
followed for the maxillary arch. The wax-up was done over the telescopic copings, incorporating a palatal mesh for fabrication of hybrid single-unit removable PFM restorations with the palatal denture base (Wirobond C nickel & beryllium free; Figs 5–8). The patient was educated on oral hygiene and prosthesis maintenance. A postoperative evaluation was done. In the evaluation process it was noticed that the patient had minimal discomfort during the first few days of prosthesis insertion. He experienced chewing difficulties, which gradually returned to normalcy over a period of time. The prosthesis markedly improved his functionality, esthetics, and quality of life.
Discussion Treatment planning for nonsyndromic oligodontia of permanent teeth is a great challenge to the interdisciplinary team.10 The consequences of missing teeth are speech and masticatory disorders and esthetic problems caused by disturbed growth and development of the orofacial region, which can impair quality of life.11,12 Accurate diagnosis and careful treatment planning with a preconception of the final outcome should be the priority. The patient presented in this article is unique. He had
C 2015 by the American College of Prosthodontists Journal of Prosthodontics 25 (2016) 247–251
249
Telescopic Prosthesis Rehabilitation of Nonsyndromic Oligodontia
multiple missing permanent tooth buds with overretained deciduous teeth. In this patient, preservation of the deciduous dentition was of prime importance because of the absence of multiple permanent teeth. Because of decreased clinical crown lengths and fragility of the existing dentition for prosthesis load, the deciduous teeth had to be endodontically treated followed by augmentation with telescopic metal copings to preserve the structural integrity of the remaining tooth structure. Metapex was used as the root canal filling material for deciduous dentition and gutta-percha for the permanent teeth.13 Prosthetic rehabilitation in children must be adapted to growth and development. It is a general rule that the final prosthetic solution should be avoided until the end of growth and development.14 In this situation, the patient was a borderline case with an age of 16 years. The permanent mandibular first molars and erupting permanent maxillary left first molar were not a part of the planned definitive prosthesis. Considering the growth of the patient, rehabilitation with a PFM removable telescopic prosthesis was planned.4 The treatment of patients with oligodontia includes RDPs, overdentures, implant-supported prostheses, and fixed dental prostheses.15-17 The removable prosthesis has the option of modification for converting to a fixed PFM prosthesis by removal of the denture bases once patient growth is complete. The other added advantage of a removable telescopic prosthesis is that modifications could be done in case of any deciduous tooth loss. Frequent follow-up of the patient showed that he was able to speak and function better. The facial appearance had improved, leading to a perception of an increased quality of life. The patient’s sociophobia with his surroundings had markedly improved. Delaying the treatment of patients with oligodontia would lead to loss of the deciduous tooth structures, leading to residual ridge resorption, and limited treatment options. Long-term followup was planned to evaluate the physiologic changes occurring in the individual and modifying the prosthesis, accordingly. The root canal filling material used for deciduous teeth was Metapex. If in any case root resorption occurs and the deciduous tooth exfoliates, the prosthesis could be modified, and the crown of the exfoliated tooth could be converted into a pontic and the prosthesis reinserted. Retained primary teeth with no permanent successor are mostly lost due to caries or periodontal breakdown. Root resorption is not the primary cause for loss of these teeth.18 A recent study assessed infraocclusion, root resorption, and restorations in 111 patients with retained primary mandibular molars lacking successors.19 Infraocclusion was estimated to be a more critical factor for the prognosis of retained primary molars than root resorption. Haselden et al20 conducted a study on root resorption in retained deciduous canine and molar teeth without permanent successors in patients with severe hypodontia. The problem was studied using 356 orthopantomogram radiographs from the records of 249 patients who had attended a specialist hypodontia clinic and had retained deciduous teeth with no permanent successors. The study concluded that lower canines had a predictable lifespan that appeared to be good. Upper canines also presented a predictable lifespan, but of lesser duration than lower canines. Molars have a poorer and less predictable lifespan. In this clinical report the primary teeth were protected from caries by cementing telescopic copings. Root resorption was not 250
Sethuram et al
a major concern, as studies have already quoted the long-term prognosis of the retained primary teeth without a permanent successor.19 There was always an alternative option present for replacement of lost deciduous teeth (if any) with an implantsupported restoration. The added advantage in this patient was the removable telescopic prosthesis that could be modified according to the patient’s needs and could increase the longevity of the prosthesis. Even if all the deciduous teeth exfoliated over a period of time, nothing would be lost, and there is always an alternative option of advanced implant therapy in such patients. OVD is an important factor to be considered while treating such patients. In our patient OVD was not increased after the definitive prosthesis insertion. OVD was recorded at the diagnostic stage, and the same was replicated in the definitive prosthesis. The mandibular prosthesis was fabricated first at the determined OVD followed by tooth preparation of the maxillary arch. The upper member was then articulated with the mandibular telescopic prosthesis with a centric bite record. A minimal increase in OVD can be done in such cases as the condylar growth still exists in these patients.
Conclusion This clinical report describes rehabilitation of a nonsyndromic oligodontia patient with a PFM removable telescopic prosthesis. There was a significant improvement in the patient’s quality of life. A coordinated interdisciplinary approach is required for the long-term follow-up of patients with nonsyndromic oligodontia.
Acknowledgments The authors thank all the staff and technicians of CMDC (CC) for being a part of this project.
References 1. Kotsiomiti E, Kassa D, Kapari D: Oligodontia and associated characteristics: assessment in view of prosthodontic rehabilitation. Eur J Prosthodont Restor Dent 2007;15:55-60 2. Mostowska A, Biedziak B, Trzeciak WH: A novel mutation in PAX9 causes familial form of molar oligodontia. Eur J Hum Genet 2006;14:173-179 3. Guruprasad R, Nair PP, Hegde K, et al: Case report: nonsyndromic oligodontia. JIDA 2011;3:450-454 4. Singh AP, Boruah LC: Nonsydromic oligodontia in permanent dentition of three siblings: a case report. JIDA 2009;3:117-119 5. Devan MM: The nature of the partial denture foundation: suggestion for its preservation. J Prosthet Dent 1952;2:210-218 6. Langer Y, Langer A: Tooth supported telescopic prosthesis in compromised dentitions: a clinical report. J Prosthet Dent 2000;84;129-132 7. Wenz HT, Lehmann KM: A telescopic crown concept for the restoration of the partially edentulous arch: the Marburg double crown system. Int J Prosthodont 1998;11:541-550 8. Bergmann B, Ericson A, Molin M: Long term clinical results after treatment with conical crown retained dentures. Int J Prosthodont 1996;9:533-539 9. Chaturvedi S, Verma AK, Ali M, et al: Full mouth rehabilitation using custom-made Broadrick flag: a case report. Int J Case Rep Images 2012;3:41-44
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10. Hobson RS, Carter NE, Gillgrass TJ, et al: The interdisciplinary team and the general dental practitioner. Br Dent J 2003; 194:479-482 11. He X, Shu W, Kang Y, et al: Esthetic and functional rehabilitation of a patient with nonsyndromic oligodontia: a case report from China. J Esthet Restor Dent 2007;19:137142 12. Worsaae N, Jensen BN, Holm B, et al: Treatment of severe hypodontia-oligodontia-an interdisciplinary concept. Int J Oral Maxillofac Surg 2007;36:473-480 13. Goerig AC, Camp JH: Root canal treatment in primary teeth: a review. Pediatr Dent 1982;5:33-37 14. Bural C, Oztas E, Ozturk S, et al: Multidisciplinary treatment of non-syndromic oligodontia. Eur J Dent 2012;6:218-226 15. Becelli R, Morello R, Renzi G, et al: Treatment of oligodontia with endo-osseous fixtures: experience in eight consecutive patients at the end of dental growth. J Craniofac Surg 2007; 18:1327-1330
Telescopic Prosthesis Rehabilitation of Nonsyndromic Oligodontia
16. Thalji GN, Cooper LF: The role of complete overdentures in esthetic rehabilitation of the adolescent oligodontia patient. A case report. J Esthet Restor Dent 2010;22:213-221 17. Gunbay T, Koyuncu BO, Sipahi A, et al: Multidisciplinary approach to a nonsyndromic oligodontia patient using advanced surgical techniques. Int J Periodontics Restorative Dent 2011;31: 297-305 18. Sletten DW, Smith BH, Southard KA, et al: Retained deciduous mandibular molars in adults : a radiographic study of long term changes. Am J Orthod Dentofacial Orthop 2003;124:625-630 19. Hvaring CL, Oqaard B, Stenvik A, et al: The prognosis of retained primary molars without successors: infraocclusion, root resorption and restorations in 111 patients. Eur J Orthod 2014; 36:26-30 20. Haselden K, Hobkirk JA, Goodman JR, et al: Root resorption in deciduous canine and molar teeth without permanent successors in patients with severe hypodontia. Int J Paediatr Dent 2001;11: 171-178
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Department of Prosthodontics, Command Military Dental Centre Lucknow, Lucknow, India Department of Prosthodontics, O/o DGDS, Integrated AHQ, Delhi, India 3 Department of Oral and Maxillofacial Surgery, Command Military Dental Centre Lucknow, Lucknow, India 4 Department of Oral and Maxillofacial Surgery, AFMC Pune, Pune, India 5 Department of Prosthodontics, Command Military Dental Centre Chandigarh, Chandigarh, India 2
Keywords Oligodontia; telescopic prosthesis; developmental disorder. Correspondence Anil Kumar Sethuram, Department of Prosthodontics, Command Military Dental Centre Lucknow, C/o CMDC (CC), Post Office Dilkusha, Lucknow 226002, India. E-mail: [email protected] Supported by the Indian Army Dental Corps. Presented at the 42nd Indian Prosthodontic Society Conference, November 6 to 9, 2014, Chandigarh, Lucknow, India. The authors declare that they have no conflict of interests.
Abstract Oligodontia is the congenital absence of six or more permanent teeth, excluding the third molars. Oligodontia of permanent dentition is a rare occurrence. Preservation of the remaining deciduous dentition in such situations is important for both functional and esthetic rehabilitation of the patient. This clinical report describes the rehabilitation of a 16-year-old male with oligodontia of permanent teeth treated by an interdisciplinary team of prosthodontist, pedodontist, and orthodontist. The remaining deciduous dentition was endodontically treated. Occlusal vertical dimension (OVD) of the deciduous dentition was assessed. A full-mouth single piece porcelain-fusedto-metal telescopic prosthesis for the maxillary and mandibular arches was planned with a minimal increase in OVD. The telescopic prosthesis provided excellent retention, stability, esthetics, and stress equalization on the remaining deciduous dentition. Maintenance of oral hygiene procedures was simplified for the adolescent with the telescopic prosthesis. Preservation of remaining deciduous dentition and fabrication of a telescopic prosthesis in this patient provided an effective esthetic and functional rehabilitation.
Accepted December 3, 2014 doi: 10.1111/jopr.12297
Oligodontia is a rare entity that can be associated with a genetic syndrome or can occur as a nonsyndromic isolated familial trait.1 Congenital absence of permanent dentition is attributed to environmental factors such as trauma, malignancy, irradiation, hormonal influences, hereditary genetic dominant factors, and thalidomide therapy.2 Odontogenesis is mainly controlled by the MSX1 and PAX9 genes. Any mutation of the PAX9 gene leads to a nonsyndromic form of tooth agenesis.3 Early diagnosis and prompt treatment of a patient with oligodontia is essential to reduce disabilities. Dental conditions like malocclusion and altered facial appearance can lead to psychological disturbances and difficulty in mastication and speech. Rehabilitation depends on the extent of oligodontia and other underlying syndromes associated with it.4 Management of nonsyndromic oligodontia is much simpler than a case associated with underlying syndromes. The ultimate goal of rehabilitation should be to achieve prosthetic and
esthetic functionality of the remaining oral structures. Treatment planning should focus on the “perpetual preservation of what remains than the meticulous restoration of the missing tooth structures.”5 The deciduous dentition in patients with oligodontia has to be preserved to prevent the long-term effects of edentulism caused by congenital absence of permanent teeth. Telescopic crowns as retainers for removable prostheses were introduced at the beginning of 20th century. The term coined was crown and sleeve coping, or Konuskrone,6 a German term that describes a cone-shaped design. These crowns exhibit retention by friction when completely seated using a wedging effect. The smaller the convergence angles of the telescopic copings, the greater the retentive force. The retention is further enhanced by supplementary attachments and the functionally molded denture borders.7 The proprioception from the periodontal ligament prevents occlusal overload, resorption of roots, and alveolar ridge due to excessive forces.8
C 2015 by the American College of Prosthodontists Journal of Prosthodontics 25 (2016) 247–251
247
Telescopic Prosthesis Rehabilitation of Nonsyndromic Oligodontia
Sethuram et al
Figure 1 Preoperative intraoral view. Figure 2 Mandibular telescopic coping cementation.
This clinical report presents a unique feature of nonsyndromic oligodontia of permanent dentition and describes rehabilitation of a patient with a telescopic crown retained porcelain-fusedto-metal (PFM) removable dental prosthesis (RDP) using deciduous teeth as retainers for an enhanced functional and esthetic outcome.
Clinical report A 16-year-old male patient with nonsyndromic oligodontia of permanent dentition reported with a chief complaint of unesthetic appearance, difficulty in mastication, and impaired quality of life. Clinical examination revealed the presence of multiple retained deciduous teeth and eruption of a few permanent teeth (Fig 1). A routine exam of the blood, including serum calcium, alkaline phosphatise, TSH, T3, and T4 was conducted. The physical examination showed that the hairs were not thin and sparse, nails were not brittle, and no difficulty in perspiration was seen, ruling out ectodermal dysplasia. On ocular examination, no signs of glaucoma were seen, ruling out Reiger syndrome. A panoramic radiograph showed multiple missing permanent teeth. The deciduous teeth present were #s 52, 53, 55, 61 to 63, and 65 in the maxillary arch and #s 71 to 75 and 81 to 85 in the mandibular arch (FDI two-digit notation for primary dentition). The erupted permanent teeth were #s 11 and 26 (partially erupted) in the maxillary arch and #s 36 and 46 in the mandibular arch (FDI two-digit notation for permanent dentition). Tooth #81 had poor prognosis because of decreased crown to root ratio and hence was taken up for extraction. Diagnostic impressions of both arches were made with irreversible hydrocolloid impression material (Septodont Plastalgin dust-free alginate, 3M ESPE, St. Paul, MN). Facebow transfer (UTS 3D Transfer Bow, Stratos 200; Ivoclar Vivadent, Schaan, Liechteinstein) and occlusal vertical dimension (OVD) was recorded at centric relation. The maxillary and mandibular models were articulated on the semi-adjustable articulator (Stratos 200) at the existing OVD. A diagnostic wax-up was done to plan the fabrication of the permanent prosthesis for esthetic and functional rehabilitation with minimal increase of 3 mm in the anterior region to obtain a 1 mm disclusion in the posterior region to compensate for the telescopic prosthesis from the existing OVD without jeopardizing temporomandibular joint function. 248
A custom-made Broadrick occlusal plane analyzer9 was used for analyzing the Curve of Spee and developing an acceptable occlusion in the diagnostic wax-up. Endodontic treatment of the remaining deciduous dentition (using Metapex root canal filling material; Metabiomed, Chungbuk, Korea) and permanent right central incisor (using gutta percha) was completed. Tooth preparation of the remaining deciduous mandibular molars was performed with a shoulder margin, and the mandibular anterior teeth were prepared with a knife-edge margin because of the limited amount of clinical crown available. The maxillary dentition was untouched at this stage for reproducing the existing occlusion at increased OVD. A wax-up was done taking into consideration the philosophy of telescopic crowns. All the deciduous mandibular teeth received telescopic copings (Fig 2). The permanent mandibular and erupting maxillary left first molar were not involved, considering the age of the patient and unpredictable prognosis of the retained deciduous dentition. The fabricated telescopic copings (Wirobond C; Bego USA, Lincoln, RI) were placed intraorally on the teeth, and copings were picked up by alginate impression (Septodont Plastalgin). Type V stone was poured into the pickup impression to incorporate the telescopic copings over the master cast. Surveying and milling of the telescopic copings were performed using a milling machine. After achieving the ideal parallelism, a wax-up was done over the telescopic copings, incorporating a mesh on the lingual flange area for fabrication of a hybrid single-unit removable PFM restoration with a lingual flange denture base. The Broadrick plane measurements recorded during the diagnostic wax-up procedure were used as a guide during the porcelain build-up procedure to reproduce the occlusion on mandibular right and left quadrants. The telescopic copings were cemented intraorally, and the prosthesis was checked for retention, stability, and esthetics. The mandibular prosthesis was removed, and an impression of the lower arch with telescopic copings was made. The prosthesis was seated on the prepared cast and articulated with the maxillary counterpart on the semiadjustable articulator. Tooth preparation of the maxillary deciduous teeth was performed. Telescopic copings (Wirobond C) were fabricated for maxillary deciduous teeth (Figs 2–4). The copings were placed intraorally over the maxillary teeth, and the pickup impression procedure as discussed above was
C 2015 by the American College of Prosthodontists Journal of Prosthodontics 25 (2016) 247–251
Sethuram et al
Telescopic Prosthesis Rehabilitation of Nonsyndromic Oligodontia
Figure 3 Maxillary telescopic coping cementation.
Figure 6 Mandibular prosthesis insertion.
Figure 4 Panoramic radiograph showing cemented telescopic copings.
Figure 7 Prosthesis in occlusion.
Figure 5 Maxillary prosthesis insertion. Figure 8 Postoperative extraoral view.
followed for the maxillary arch. The wax-up was done over the telescopic copings, incorporating a palatal mesh for fabrication of hybrid single-unit removable PFM restorations with the palatal denture base (Wirobond C nickel & beryllium free; Figs 5–8). The patient was educated on oral hygiene and prosthesis maintenance. A postoperative evaluation was done. In the evaluation process it was noticed that the patient had minimal discomfort during the first few days of prosthesis insertion. He experienced chewing difficulties, which gradually returned to normalcy over a period of time. The prosthesis markedly improved his functionality, esthetics, and quality of life.
Discussion Treatment planning for nonsyndromic oligodontia of permanent teeth is a great challenge to the interdisciplinary team.10 The consequences of missing teeth are speech and masticatory disorders and esthetic problems caused by disturbed growth and development of the orofacial region, which can impair quality of life.11,12 Accurate diagnosis and careful treatment planning with a preconception of the final outcome should be the priority. The patient presented in this article is unique. He had
C 2015 by the American College of Prosthodontists Journal of Prosthodontics 25 (2016) 247–251
249
Telescopic Prosthesis Rehabilitation of Nonsyndromic Oligodontia
multiple missing permanent tooth buds with overretained deciduous teeth. In this patient, preservation of the deciduous dentition was of prime importance because of the absence of multiple permanent teeth. Because of decreased clinical crown lengths and fragility of the existing dentition for prosthesis load, the deciduous teeth had to be endodontically treated followed by augmentation with telescopic metal copings to preserve the structural integrity of the remaining tooth structure. Metapex was used as the root canal filling material for deciduous dentition and gutta-percha for the permanent teeth.13 Prosthetic rehabilitation in children must be adapted to growth and development. It is a general rule that the final prosthetic solution should be avoided until the end of growth and development.14 In this situation, the patient was a borderline case with an age of 16 years. The permanent mandibular first molars and erupting permanent maxillary left first molar were not a part of the planned definitive prosthesis. Considering the growth of the patient, rehabilitation with a PFM removable telescopic prosthesis was planned.4 The treatment of patients with oligodontia includes RDPs, overdentures, implant-supported prostheses, and fixed dental prostheses.15-17 The removable prosthesis has the option of modification for converting to a fixed PFM prosthesis by removal of the denture bases once patient growth is complete. The other added advantage of a removable telescopic prosthesis is that modifications could be done in case of any deciduous tooth loss. Frequent follow-up of the patient showed that he was able to speak and function better. The facial appearance had improved, leading to a perception of an increased quality of life. The patient’s sociophobia with his surroundings had markedly improved. Delaying the treatment of patients with oligodontia would lead to loss of the deciduous tooth structures, leading to residual ridge resorption, and limited treatment options. Long-term followup was planned to evaluate the physiologic changes occurring in the individual and modifying the prosthesis, accordingly. The root canal filling material used for deciduous teeth was Metapex. If in any case root resorption occurs and the deciduous tooth exfoliates, the prosthesis could be modified, and the crown of the exfoliated tooth could be converted into a pontic and the prosthesis reinserted. Retained primary teeth with no permanent successor are mostly lost due to caries or periodontal breakdown. Root resorption is not the primary cause for loss of these teeth.18 A recent study assessed infraocclusion, root resorption, and restorations in 111 patients with retained primary mandibular molars lacking successors.19 Infraocclusion was estimated to be a more critical factor for the prognosis of retained primary molars than root resorption. Haselden et al20 conducted a study on root resorption in retained deciduous canine and molar teeth without permanent successors in patients with severe hypodontia. The problem was studied using 356 orthopantomogram radiographs from the records of 249 patients who had attended a specialist hypodontia clinic and had retained deciduous teeth with no permanent successors. The study concluded that lower canines had a predictable lifespan that appeared to be good. Upper canines also presented a predictable lifespan, but of lesser duration than lower canines. Molars have a poorer and less predictable lifespan. In this clinical report the primary teeth were protected from caries by cementing telescopic copings. Root resorption was not 250
Sethuram et al
a major concern, as studies have already quoted the long-term prognosis of the retained primary teeth without a permanent successor.19 There was always an alternative option present for replacement of lost deciduous teeth (if any) with an implantsupported restoration. The added advantage in this patient was the removable telescopic prosthesis that could be modified according to the patient’s needs and could increase the longevity of the prosthesis. Even if all the deciduous teeth exfoliated over a period of time, nothing would be lost, and there is always an alternative option of advanced implant therapy in such patients. OVD is an important factor to be considered while treating such patients. In our patient OVD was not increased after the definitive prosthesis insertion. OVD was recorded at the diagnostic stage, and the same was replicated in the definitive prosthesis. The mandibular prosthesis was fabricated first at the determined OVD followed by tooth preparation of the maxillary arch. The upper member was then articulated with the mandibular telescopic prosthesis with a centric bite record. A minimal increase in OVD can be done in such cases as the condylar growth still exists in these patients.
Conclusion This clinical report describes rehabilitation of a nonsyndromic oligodontia patient with a PFM removable telescopic prosthesis. There was a significant improvement in the patient’s quality of life. A coordinated interdisciplinary approach is required for the long-term follow-up of patients with nonsyndromic oligodontia.
Acknowledgments The authors thank all the staff and technicians of CMDC (CC) for being a part of this project.
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