Esthetic Management of Maxillary Anterior Teeth in a Patient with Midline Diastema Having Deep Bite using Palatal Loop Connector: A Case Report
1-5Department of Prosthodontics, Postgraduate Institute of Dental Sciences (Govt. Dental College and Hospital), Pandit Bhagwat Dayal Sharma University of Health Sciences, Rohtak, Haryana, India
Corresponding Author: Sujata Chahal, Department of Prosthodontics, Postgraduate Institute of Dental Sciences (Govt. Dental College and Hospital), Pandit Bhagwat Dayal Sharma University of Health Sciences, Rohtak, Haryana, India, Phone: +91 9416763313, e-mail: firstname.lastname@example.org
Received on: 31 December 2022; Accepted on: 30 January 2023; Published on: 02 March 2023
Aim: To rehabilitate the missing anterior teeth with already existing diastema through a fixed partial denture (FPD) with loop connectors.
Background: When a conventional FPD is used to replace missing teeth with already existing diastema, the anterior teeth may become overly wide, resulting in poor esthetics. Implant-supported prosthesis or FPD with loop connectors can be used to address the diastema caused by missing central incisors.
Case description: This clinical report discusses the fabrication of a modified FPD with loop connectors to rehabilitate the missing maxillary anterior teeth with a wide span created by an existing diastema.
Conclusion: Diligent treatment planning and patient motivation regarding oral hygiene are crucial steps for the success of the restoration.
Clinical significance: The modified FPD with loop connectors improves the natural appearance of the restoration, maintains the diastema and the emergence profile, and preserves the remaining tooth structure of the abutment teeth.
How to cite this article: Chahal S, Dahiya D, Nagar P, et al. Esthetic Management of Maxillary Anterior Teeth in a Patient with Midline Diastema having Deep Bite using Palatal Loop Connector: A Case Report. CODS J Dent 2022;14(1):20-23.
Source of support: Nil
Conflict of interest: None
Patient consent statement: The author(s) have obtained written informed consent from the patient for publication of the case report details and related images.
Keywords: Diastema, Esthetics, Fixed partial denture, Loop connector, Spacing.
Diastema is a very frequent clinical scenario observed in natural teeth. It is caused by a disparity between the skeletal and the dental elements of the oral cavity and mostly due to the misalignment of natural teeth in the arch.1 Patients with existing midline diastema along with missing teeth have limited treatment options to rehabilitate the edentulous arch. Conventional FPD results in overly wide and overcontoured anterior teeth with compromised esthetics. This can be managed by either the use of an implant-supported prosthesis or FPD with loop connectors.2-4 However, the implant-supported prosthesis may be an expensive alternative and is not favorable in certain medical conditions, and also, a few patients tend to avoid the treatment option due to the invasive procedure.5 Maximum esthetics can be provided by minimally altering the contour and morphology of the adjacent tooth along with maintaining the existing midline diastema. This case report describes the technique to rehabilitate missing central incisors with midline diastema through the fabrication of an FPD using palatal loop connectors to provide maximum esthetics and healthy periodontium to the patient.
A 30-year-old patient reported to the Department of Prosthodontics with the chief complaint of missing upper anterior teeth due to trauma. The medical history of the patient revealed congenital deaf-mutism with no relevant syndromic findings. He was accompanied by his brother for a better understanding. He wanted the esthetic replacement of the maxillary anterior teeth. Intraoral examination revealed missing maxillary central incisors with proclined lateral incisors. On further examination, a traumatic bite was present due to the super eruption of lower incisors (Fig. 1). No history of abnormal habits or parafunctional activity was noted by the patient or the attendant. The patient had class II malocclusion with increased overjet and excessive deep bite of >7 mm. The edentulous area was wide mesiodistally, and there was spacing between existing anterior teeth. A radiographic examination revealed vital lateral incisors and canines with good periodontal support. The patient was not willing to do the orthodontic treatment, so various prosthetic treatment plans, including implant-supported prosthesis, conventional FPD, and FPD with palatal loop connector, were suggested. The patient opted out for a less invasive treatment plan, as the edentulous span available was greater than the approximate size of the central incisors; a 6-unit FPD with palatal loop connector was planned for a better esthetic outcome with a diastema between two central incisors and central and lateral incisors.
Diagnostic impressions of the maxillary and mandibular arches were made and a wax trial was done to explain to the patient the outcome of the treatment. The patient was advised endodontic treatment of the lateral incisors due to the severe labial proclination of the teeth in order to enhance the esthetic outcome, following which tooth preparation for porcelain fused metal (PFM) was done on the maxillary right and left lateral incisors and canines (13, 12, 22, and 23) with an equigingival finish line (Fig. 2). Enameloplasty of lower incisors was done due to the limited interocclusal space. Following which, the gingival retraction was done using the single cord technique (Fig. 3), and the final impression was made through the single-step putty-wash impression technique (Fig. 4). The maxillomandibular relationship was recorded using the interocclusal registration material, following which the provisional restoration was luted using noneugenol temporary cement. The impression was poured using the type IV dental stone to obtain the master cast. The wax pattern was then fabricated using the blue inlay wax after providing adequate relief, and the casting was done. The ovate pontic design was fabricated, and the loop connector was made 2 mm thick with the palatal extent of the connector labial to the incisal edge of lower anteriors, keeping in view the excessive deep bite and occlusion of lower anterior teeth. A metal try-in was done to check the fit of the prosthesis (Fig. 5), following which the porcelain was fired, glazed, and polished. The final 6-unit PFM prosthesis with a loop connector was luted using resin-bonded glass ionomer cement (Fig. 6). Postcementation and oral hygiene instructions were given to the patient. A 1 week’s follow-up was done to assess the oral hygiene and any discomfort to the patient. The patient was highly satisfied with the esthetic outcome (Fig. 7).
A connector is that portion of FPD that connects the retainer with the pontic. It is an important constituent of an FPD. A loop connector is a nonrigid connector allowing limited movement between the retainer and the pontic.6 A large edentulous span due to the missing central incisors is difficult to be rehabilitated using the conventional FPDs. Loop connector is indicated in various clinical scenarios like when an existing diastema is to be maintained, pathological migration of teeth, excessive pontic space, and prosthetic restoration with generalized spacing between the abutments. The design of the connector determines its rigidity and the health of the periodontium.7,8 There are various factors which affect the design of the loop connector, including the gender of the patient, esthetics, length of the edentulous span, its location in the mouth, and opposing occlusion. The FPD with loop connector amplifies the emergence profile and gives a natural aspect to the restoration. However, loop connectors have certain disadvantages, including difficulty in maintaining oral hygiene, relative flexibility, and interference with tongue movements and speech, especially the linguo-palatal sounds. The relative flexibility can be compensated by enhancing the rigidity of the loop connector by increasing the diameter and decreasing the length of the connector. The round cross section and small size of the connectors will minimally affect the phonetics.9 The present clinical condition was compromised due to the increased overjet and overbite. Deep bite affects the normal functioning of the stomatognathic system with the tendency of hyperactivity of masticatory musculature.10 Orthognathic treatment must be considered in such patients as a better treatment modality but due to the unwilling nature of the patient, prosthetic replacement was the treatment of choice. The best prosthetic option, keeping in view the existing diastema and golden proportion, was to rehabilitate with loop connectors. The existing inherent overjet and overbite lead to the minimal thickness of the loop so that it does not hinder occlusion and other functional movements, which might lead to a compromise in the thickness of loop components. In the present clinical conditions, the loop connector prosthesis was the minimally invasive and esthetic solution to obtain good clinical results and longer durability of the prosthesis.
The clinical report discussed the rehabilitation of a wide edentulous span created by the missing central incisors by the fabrication of an FPD with loop connectors to enhance esthetics. In the present case report, the patient is young and had a deep bite along with the existing diastema; the feasible and economic solution in such conditions is rehabilitation with the loop connectors. The loop connector provided an esthetic outcome while taking into consideration the stomatognathic function. Diligent treatment planning and patient motivation regarding oral hygiene are crucial steps for the success of the restoration.
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