Case ReportAchieving Lingualized Balanced Occlusion in a Fixed-RemovableRehabilitation for a Maxillary Complete and Mandibular KennedyClass II Case

Ibrahim Tulunoglu and Samuel Cohen

Case Western Reserve University School of Dental Medicine, Department of Comprehensive Care, 2124 Cornell Rd, Cleveland,44106 OH, USA

Correspondence should be addressed to Ibrahim Tulunoglu; ixt45@case.edu

Received 1 August 2019; Accepted 1 October 2019; Published 30 October 2019

Academic Editor: Hüsamettin Oktay

Copyright © 2019 Ibrahim Tulunoglu and Samuel Cohen. This is an open access article distributed under the Creative CommonsAttribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work isproperly cited.

In this case report, a method to achieve an adequate compensating curve and bilateral balanced lingualized occlusion in a caserequiring maxillary complete denture and mandibular Kennedy Class II removable partial and fixed prosthodontic rehabilitationis described.

1. Introduction

With the aging population in the advent of the baby boomers,tooth replacement is becoming more of a frequent procedure,especially with the increasing demands on patients’ quality oflife. Postponed or lack of replacement of missing teeth is animpending detriment to the remaining dentition. The mesial,distal, and coronal migration of unopposed teeth can be mit-igated by the prosthetic restoration of edentulous spaces.

Occlusion plays a critical role in influencing the reten-tion, stability, and the overall masticatory performance ofremovable prostheses. There is ample literature on lingual-ized, bilateral balanced, and neutrocentric occlusion [1–5],although there is no clinical evidence pertaining to thesuperiority of a certain tooth form or arrangement overothers [6]. On the other hand, lingualized occlusion, basedon a merging of esthetic and food penetration advantagesof anatomic form teeth and the mechanical freedom of thenonanatomic form [3], has become more widely acceptedin recent years [2].

Using a system that incorporates the tools and theartificial teeth for a lingualized tooth arrangement is usefulin providing ease and consistency of the initial tooth set-up,as well as in achieving a balanced occlusion in excursivemovements.

Although the methodology for fabrication of maxillaryand mandibular complete dentures is well documented, ithas not been well established in cases involving a maxillarycomplete denture (CD), opposing a mandibular removablepartial denture (RPD) and fixed restorations to provideharmonious lingualized occlusion.

This paper defines a method to achieve an adequatecompensating curve and bilateral balanced lingualized occlu-sion in a case requiring fixed and removable prosthodonticrehabilitation.

2. Case Report

2.1. Examination. A 64-year-old female presented to theDMD admitting clinic at the School of Dental Medicine withan ill-fitting maxillary acrylic-based removable partial den-ture. The patient’s chief complaint was to get “a new set ofteeth,” seeking an improvement in her esthetics and mastica-tory function. The patient had no major related medicalconditions aside from suffering from depression and anxiety.Oral hygiene was fair and there was no periodontal diseasepresent.

Clinical and radiographic examination revealed edentu-lous spaces in both arches, extensive presence of nonrestor-able teeth, and active caries. The patient’s plane of

HindawiCase Reports in DentistryVolume 2019, Article ID 2046421, 4 pageshttps://doi.org/10.1155/2019/2046421

occlusion was not harmonious, and the lack of a stable poste-rior occlusion led to moderate wear of her remaining anteriorteeth and a collapse in her vertical dimension of occlusionwhich were not addressed with the previous fixed partial res-torations on teeth #14, 13, and 11 (Figures 1–3). The differ-ence between the vertical dimension of rest (VDR) andvertical dimension of occlusion (VDO) of the patient wasfound to be 9mm.

After removal of the restorations, teeth #14, 13, and 11revealed deep carious lesions, and #5 vertical root fracture.Teeth 17 and 27 showed furcation defects on the distalaspects. The patient was given various treatment plans,including full arch-supported fixed prosthodontic rehabilita-tion with periodontal treatment on furcation defects andcrown lengthening for teeth #13, 11, 32, 31, 41, and 42 and

placement of implants to support the fixed partial denturerestorations replacing the tooth loss at the edentulous spans,and opted for the treatment plan involving crowning of teeth#35, 34, 43, 45, and 47 and the fabrication of a maxillary com-plete and mandibular removable partial denture because ofthe patient’s avoidance from surgical placement of implantsand the cost of an implant-supported rehabilitation.

2.2. Treatment. After thorough oral hygiene instructions, thepatient’s active disease was stabilized with surgical, operative,and prosthodontic intervention. An interim maxillary com-plete denture and mandibular partial denture was deliveredimmediately after the extraction of the remaining maxillaryteeth and mandibular incisors (Figure 4). In this provisionalphase, the patient was rehabilitated at a 2mm increasedVDO that allowed her to be monitored in terms of any pos-sible adverse reactions or changes in the stomatognathic sys-tem. After 6 months of osseous healing and observationperiod, the definitive phase of prosthetic treatment began asno adverse effect was observed in the stomatognathic system.

The maxillary wax occlusal rim was adjusted intraorallyto provide the correct location and position of the occlusalplane relative to the VDO lip line and smile line of thepatient. Using a semiadjustable articulator (Stratos 100, Ivo-clar Vivadent, Schaan, Liechtenstein), the maxillary mastercast was mounted using the maxillary wax occlusal rim andthe Maxillary Mounting Table (Stratos 100, Ivoclar Vivadent,Schaan, Liechtenstein) of the system. The mandibular archwas mounted in centric relation (CR). Maxillary anteriorteeth (Vivadent DCL, Ivoclar Vivadent, Schaan, Liechten-stein) were set using the Mounting Table that representsthe defined occlusal plane location, and the mandibular teethwere set as to obtain 1mm of overbite and 1.5mm of overjet.Then, the maxillary cast was removed from the upper mem-ber of the articulator, and the guide plane jig for compensat-ing curve (2.5D Setup Template, Ivoclar Vivadent, Schaan,Liechtenstein) was inserted. The simulation of tooth prepara-tions was made on the mandibular cast to ideal dimensionsbefore the wax-up was made (Figure 5). An artificial toothset-up for the maxillary posterior teeth was made to fabricatethe fixed restorations accordingly.

After preparations for abutment teeth for PFM crowns#35, 34, 43, 45, and 47, the final impression was made inPVS impression material (3M Imprint 3 Heavy Body and

Figure 1: Fontal view of teeth in occlusion before treatment.

Figure 2: Panoramic radiograph before treatment.

Figure 3: A view of mounted diagnostic casts.

Figure 4: Clinical remount of interim prostheses.

2 Case Reports in Dentistry

3M Imprint 3 Light Body). A jig for proper VDO was madeon the articulator against the maxillary tooth arrangement.This jig is used as a vertical stopper for the intermaxillaryrelationship record to replicate the VDO. Surveyed crownrestorations with guide planes parallel to the defined pathof insertion and ledges were made, to improve retention, sta-bility, and support of the RPD and tried intraorally. A copingpick-up impression was made with the PVS impressionmaterial (Figure 6) and poured with stone (Microstone,Whip Mix Corp.) (Figure 7). The guide planes and gingivalledges were refined and milled once more, including thedovetail-shaped rests between the splinted copings on 21and 22. Then, porcelain was built on the copings following

the 2.5D template and the maxillary tooth arrangement wasalso made according to the same template (Figure 8). Afterthe crowns were made, the RPD metal framework wasfabricated for the Kennedy Class II mod II mandibular arch.The metal framework and the crowns were tried in together,and the final tooth arrangement was made with the sametemplate (Figure 9). Final try-in of the maxillary CD,mandibular RPD, and fixed prostheses allowed for minoradjustments in the tooth set-up. The final tooth arrangementin wax shows the harmonious occlusion between the fixedand removable elements of the prostheses. At delivery, min-imal occlusal adjustments were done intraorally to achievelingualized occlusion with balanced centric and eccentriccontacts (Figure 10).

3. Discussion

With such a dilapidated dentition and loss of vertical dimen-sion, it was of utmost importance to restore the patient’socclusal plane so that proper function could be obtained.Not only is having proper centric contacts on all teeth essen-tial for function, but having those contacts orientated in thecorrect occlusal plane and compensating curve was impera-tive. Extractions, surveyed metal-ceramic restorations withparallel guide planes, a mandibular removable partial den-ture (RPD), and maxillary complete denture (CD) were treat-ment avenues used to rehabilitate this patient. An approachutilizing the Stratos 100 Articulator and 2.5D guide plane

Figure 6: Pick-up impression of metal copings made.

Figure 5: Wax-up for PFM crowns on teeth #21, 22, 27, 29, and 31.

Figure 7: Metal copings with their exact spatial relations obtainedon the master cast.

Figure 8: Final mandibular tooth arrangement made using the 2.5Dguide plane.

Figure 9: View of final tooth arrangement made.

3Case Reports in Dentistry

was sought to harmonize the occlusion between the fixed andremovable elements of the mandibular prostheses.

A concern that will inherently come with any system thatdoes not include a face bow transfer may be whether thiswould cause a big discrepancy between a patient stomatog-nathic system and articulator. Kumar et al. compared twomethods, one with and one without face bow transfer andconcluded that balanced occlusion can be achieved success-fully with a system that does not require face bow transfer[7]. In this clinical case, we did not observe a differencebetween the interarch relationship in the patient’s mouthand the articulator. The system allowed to establish thedesired occlusal plane location and position as well as thecontact patterns that are designed as part of the standardsestablished with the Stratos system. This included establish-ing the occlusal configurations as well as the positions andlocations of both fixed restorations and artificial teeth onremovable dentures with minimal adjustment at delivery.Instead of maxillary and mandibular posterior teeth withsteep cuspal angles, using artificial teeth fabricated purposelyfor lingualized occlusion also contributed to the fact thatfewer adjustments overall necessitated.

The Glossary of Prosthodontic Terms defines the com-pensating curve as “the anteroposterior curving (in themedian plane) and the mediolateral curving (in the frontalplane) within the alignment of the occluding surfaces andincisal edges of artificial teeth that is used to develop bal-anced occlusion” [8]. A balanced occlusion is desirable forall removable complete denture rehabilitations. In otherwords, this is one of the five major determinants of bal-anced occlusion expressed in Hanau’s Quint and Thiele-mann’s formula [2, 3]. The compensating curve isprovided by the 2.5D template, and the cusp heights arealso provided by the artificial teeth set produced specifi-cally for lingualized occlusion.

4. Conclusion

Using the principles of lingualized occlusion in completedentures, it is possible to achieve lingualized balanced occlu-sion in a maxillary edentulous and mandibular KennedyClass II fixed-removable rehabilitation case.

Conflicts of Interest

The authors declare that they have no conflicts of interest.

References

[1] T. E. Jacobson and A. J. Krol, “A contemporary review of thefactors involved in complete denture retention, stability, andsupport. Part I: retention,” The Journal of Prosthetic Dentistry,vol. 49, no. 1, pp. 5–15, 1983.

[2] V. Rangarajan, B. Gajapathi, P. B. Yogesh, M. M. Ibrahim, R. G.Kumar, and P. Karthik, “Concepts of occlusion in prosthodon-tics: A literature review, part I,” The Journal of Indian Prostho-dontic Society, vol. 15, no. 3, pp. 200–205, 2015.

[3] V. Rangarajan, B. Gajapathi, P. B. Yogesh et al., “Conceptsof occlusion in prosthodontics: a literature review, part II,”The Journal of Indian Prosthodontic Society, vol. 16, no. 1,pp. 8–14, 2015.

[4] R. L. Engelmeier and R. D. Phoenix, “The development oflingualized occlusion,” Journal of Prosthodontics, vol. 28, no. 1,pp. e118–e131, 2019.

[5] C. M. Becker, C. C. Swoope, and A. D. Guckes, “Lingualizedocclusion for removable prosthodontics,” The Journal ofProsthetic Dentistry, vol. 38, no. 6, pp. 601–608, 1977.

[6] A. Farias-Neto, “Complete denture occlusion: an evidence‐based approach,” Journal of Prosthodontics, vol. 22, no. 2,pp. 94–97, 2013.

[7] M. Kumar and D. S. J. D’Souza, “Comparative evaluation of twotechniques in achieving balanced occlusion in completedentures,” Medical Journal Armed Forces India, vol. 66,pp. 362–366, 2010.

[8] K. J. Ferro, “The Glossary of Prosthodontic Terms: NinthEdition,” The Journal Prosthetic Dentistry, vol. 117, no. 5S,2017.

Figure 10: View of patient’s smile at delivery.

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