to establish the desirable occlusion and articulation with proper inclination of teeth in deep - bite patients , orthodontic therapy alone is difficult and inefficient . therefore , orthognathic surgical procedures , which reconstruct occlusal plane by aligning teeth or correcting skeletal deformities , are preferred to obtain functional and marked esthetic results . since these procedures support the patient both physically and psychologically , they are constructive for the patient .
in fact , these procedures could simplify the prosthodontic phase of treatment without damaging the tooth structure .
anterior segmental osteotomy is an important surgical procedure for the correction of maxillary and mandibular protrusion or retrusion to achieve improved occlusion and facial profile .
this osteotomy procedure is primarily for correction of bimaxillary dentoalveolar protrusion , anterior open bite , excessive inclination of anterior teeth , excessive vertical , or anteroposterior development of the maxillary dentoalveolar process and severe skeletal problems that can not be corrected with orthodontic treatment .
in addition , the decreased vertical dimension of occlusion ( vdo ) in deep - bite patients can also cause unpleasant esthetic results , reduced masticatory capacity , muscle atrophy and pulpal sensitivity .
a progressive approach should be followed to restore vdo . for such situations , occlusal splints , fixed or removable partial dentures
the aim of the treatment was to reduce the anterior deep - bite and overjet by intrusion of the maxillary incisors to correct the maxillary protrusion .
additionally , the second aim was to create an adequate space for an implant supported fixed prosthesis through multidisciplinary treatment approaches including orthodontic , surgical , and prosthetic procedures .
a 45-year - old male patient had been admitted to gazi university , department of oral and maxillofacial surgery , with a chief complaint of difficulty in chewing and an unattractive smile .
extraoral examination showed a reduction in the lower facial height , protuberant lips , wrinkles , drooping , overclosed commissures , and excessive gingival display caused by collapsed vdo .
furthermore , the pretreatment profile demonstrated a marked protrusion of the maxilla with partial edentulism .
besides , no pocket depth of over 2 mm or mobility was observed around any of the remaining teeth .
the intraoral and radiographic examination verified that # 12 , # 13 , # 14 , # 24 , # 16 , # 17 , # 23 , # 24 , # 26 , # 27 , # 35 , # 36 , # 37 , # 44 , and # 46 teeth were lost [ figure 1 ] . during the clinical examination of the patient by the orthodontist , convex profile with upper lip protrusion and gummy smile were detected .
he also had severe deep - bite and increased overjet with anterior maxillary protrusion [ figure 1 ] .
since the cephalometric analysis showed that maxillary central incisors were proclined ( 1-na = 17 mm , 1/na = 44 , 1/ans pns = 127 ) , the overjet was not within normal ranges ( 14 mm ) [ figures 2 and 3 ] .
( c ) panoramic radiograph maxillary superposition , t0 : pretreatment , t1 : after surgery , t2 : after prosthetic rehabilitation cephalometric measurements of the patient , t0 : pretreatment , t1 : after surgery , t2 : after prosthetic rehabilitation the treatment plan was formulated in consultation with a prosthodontist , orthodontist , and an oral - maxillofacial surgeon . first , a diagnostic setup was constructed by the prosthodontist .
then , an interocclusal record was prepared with a polyvinyl - siloxane occlusal registration material ( exabite ii ; gc corp . ,
tokyo , japan ) on a semi - adjustable articulator ( stratos 200 , ivoclar , vivadent , germany ) using a face - bow record . following a careful evaluation of the patient ,
the patient had no maxillary canines or posterior teeth to provide anchorage for retraction or intrusion of maxillary incisors .
first , the patient was young and did not want to use a partial prosthesis .
he also rejected this option because of the difficulties that might occur during establishing esthetic at anterior region . therefore , to restore the lost vdo with severe deep - bite and stabilize the maxillary anterior segment in its desired position , increase the vdo by provisional removable partial prosthesis following subapical anterior maxillary segmental osteotomy .
then , full - mouth rehabilitation with implant - teeth supported metal - ceramic restorations was considered .
finally , stabilizing the maxillary anterior segment in the desired position by surgical therapy and the restoration of the edentulous maxillary posterior regions with 6 implants was suggested to the patient .
four months after surgery , the fixation system was removed [ figure 5a and b ] .
after the surgical stage , the maxillary incisors were retruded by 3 mm and impacted for 4 mm according to cephalometric superimpositions [ figure 3 ] .
( c ) provisional removable restoration the occlusal vertical dimension was determined by the niswonger method and verified with the closest speaking space method .
the space between lower centric occlusion line and the upper closest speaking line was named as the closest speaking space .
the patient 's freeway space was 7 mm ( difference between rest vertical dimension and vdo ) .
following the impaction of maxillary incisors for 4 mm , the new occlusal vertical dimension was set by approximately 3 mm increase using the incisal guidance pin of the articulator . at the first stage of the rehabilitation ,
a provisional removable restoration was fabricated at increased vdo as a guide for the definitive oral rehabilitation [ figure 5c ] to be used for 3 months .
the proper vdo was determined by using the physiologic rest position of the mandible as a guide and noting the existing interocclusal distance .
the patient 's mastication , muscle sensitivity , temporomandibular junction pain , phonation and anterior and posterior speaking space were evaluated in this period .
extensive clinical examination , including prosthetic workups , revealed that misaligned maxillary second premolar teeth would not support functional or esthetic prosthetic restoration .
six dental implants ( 4 units 4.1 mm  10 mm and 2 units 4.8 mm  10 mm ; standard plus implants , straumann ag , basel , switzerland ) were placed to the maxillary arch ( # 14 , # 15 , # 17 , # 23 , # 24 , and # 26 ) in accordance with the prosthetic and surgical guidance .
additionally , # 11 , # 21 , and # 22 teeth were prepared and provisional fixed restorations were made at increased vdo [ figure 6a ] .
six months after the first surgery , second - stage surgery was performed . for soft - tissue healing around implants ,
( a ) following implant placement . ( b ) after preparation of the teeth in consultation with the patient , full - mouth metal ceramic crowns were considered to be the best therapeutic option .
then , teeth were prepared with circumferential shoulder margins of 11.2 mm and an occlusal reduction of 1.52 mm [ figure 6b ] .
provisional restorations were prepared by the dental technician and cemented temporarily ( temp bond netm ; kerr ) .
the protrusive contact , canine guidance , esthetics , and phonetics were assessed , and 1- and 2-monthly regular checkups were performed .
definitive impressions of all teeth and abutments were made with a polyether impression material ( impregum , 3 m espe , st .
the models were mounted using an arbitrary facebow ( dentatus aed , dentatus usa ltd .
, ny , usa ) and a centric relation record was obtained using polyether bite registration material ( ramitec , 3 m espe ) on a semi - adjustable articulator ( dentatus arh , dentatus usa ltd . ) .
the patient was checked at 1 , 2 weeks , 1 , 3 , 6 , and 12 months and then examined annually by visual and radiographic examinations [ figure 7c ] .
the patient acknowledged improved function and esthetics , and was pleased with the results [ figure 7b ]
. the cephalometric analysis of the patient before and after surgery and following prosthetic rehabilitation is given in figure 8 .
follow - up panoramic radiographs were taken after treatment and annually for up to 5 years .
a satisfactory functional and esthetic result was obtained after 5 years of follow - up [ figure 9 ] .
to restore the dentition and improve the facial appearance in the present case , the vdo had to be increased to approximately 7 mm . however , there was no adequate dentition for orthodontic anchorage .
therefore , 4 mm incisor intrusion was achieved by anterior segmental osteotomy . at the end of treatment
anterior maxillary osteotomy is the most aggressive but multi - purpose treatment option for patients having bimaxillary protrusion and/or dentoalveolar protrusion with severe extrusion . in the present clinical report
, the osteotomy line was kept well above the apices of the laterals and the apices of teeth were protected without any damage . besides , for restoring the vertical height , the teeth ( # 11 , # 21 , and # 22 ) had root canal treatment , before preparation procedures .
the implant placement following virtual planning of implant positions was performed according to the multidisciplinary treatment approach which included a maxillofacial surgeon and prosthodontist .
overall , surgery and prosthetic rehabilitation resulted in greater reduction of overjet ( 12 mm ) and greater improvement in skeletal and dental aspects . in the present case ,
increasing vertical dimension with removable denture following fixed restoration of the remained teeth in upper jaw could be a treatment alternative to surgery , because surgical reconstruction might have disadvantages including the costs , length of recovery , and surgical complications .
additionally , full - mouth restoration including implants in the posterior region could be used as prosthetic method for increasing the vdo .
a previous study indicated that increasing vdo by restorative procedures should be undertaken cautiously , since this procedure disrupts a patient 's dental physiology and adaptation .
in addition , it was reported that the patient can adapt a 5 mm increase in vdo .
therefore , correction of dentofacial deformity caused by the lost vdo was treated partially with surgical procedures ( 4 mm intrusion ) and partially by fixed restorations . besides
, the increase in vdo should be achieved with fixed restorations rather than a removable denture , since it improves function and esthetics and is therefore more predictable for patient adaptation .
previous studies indicated that the testing period of increased vdo with provisional restorations could be 26 months .
the use of removable partial dentures was suggested as provisional restorations for the patients with decreased vdo . during a 3-month period ,
the patient was carefully evaluated to assess the adaptation to the vdo obtained with a removable prosthesis .
a mutually protected articulation was used to rehabilitate the present patient with provisional and definitive restorations .
furthermore , the patient had increased overbite and marked protrusion at the beginning of the treatment [ figure 1 ] .
both the facial appearance and the occlusion were significantly improved at the end of the prosthetic rehabilitation [ figure 7 ] .
the prosthetic restorations performed in the present case report improved the quality of life of the patient .
furthermore , dental practitioners should keep in mind that conventional prosthetic treatment might often be all that is needed for patients with skeletal problems .
 this case report demonstrates the full - mouth rehabilitation of a 45-year - old male patient with severe deep - bite by increasing vertical dimension . 
 the technique of anterior maxillary osteotomy performed in the present situation has been found to be effective , requiring anterior and inferior repositioning of the anterior maxilla to provide an esthetic and functional implant supported fixed prosthesis . 
 four months after surgery , the fixation system was removed , and 6 dental implants were placed . the anterior and inferior movements of the segment allowed for natural tooth anatomy and size in the definitive implant supported partial fixed prosthesis . 
 a satisfactory functional and esthetic result was obtained after 5 years of follow - up . 
INTRODUCTION
CASE REPORT
DISCUSSION
CONCLUSION
Financial support and sponsorship
Conflicts of interest