Realistic Objectives in Orthodontic and Prosthetic Treatment of an Elderly Patient with Deep Overbite: A Case Report

Abstract

Orthodontics plays a crucial role in the restoration of oral health in adult patients, particularly when treatment objectives are grounded in accurate diagnoses that respect biological limitations. This case report describes the orthodontic management of a 65-year-old male patient presenting with Angle Class II, division 2 malocclusion. The patient was referred for orthodontic intervention to improve conditions for restoring mandibular incisors. Clinical examination revealed extensive restorations, black triangles between maxillary central incisors, severe incisal wear on mandibular incisors, and gingival recession in maxillary premolars and molars. Radiographic findings included root shortening of maxillary incisors and significant alveolar ridge resorption in the maxillary molars. The complexity of the case was heightened by the patient's age, extensive dental restorations, significant alveolar bone resorption, and gingival recession, requiring meticulous planning to address functional, esthetic, and biological challenges. Treatment was planned with realistic objectives, utilizing partial fixed orthodontics in the maxillary arch, focusing on alignment and leveling while maintaining posterior intercuspation. Interproximal reductions were performed on maxillary incisors to minimize black triangles and improve esthetics. After 10 months, orthodontic objectives were successfully achieved. Retention included a fixed retainer on the maxillary central incisors and an occlusal splint for the maxilla. This case highlights the importance of individualized and multidisciplinary approaches in orthodontic treatment for elderly patients, demonstrating how orthodontics can complement prosthetic rehabilitation to achieve functional and esthetic outcomes.

 

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Keywords

elderly - orthodontics - deep overbite - multidisciplinary treatment - prosthetic treatment - abrasion

Introduction

The first step in orthodontic treatment planning is defining clear objectives, as they are essential for achieving satisfactory outcomes.[1]

An interdisciplinary approach is essential for accurate diagnosis and effective treatment planning, particularly in complex cases where comprehensive evaluation and collaborative decision-making within a team are crucial before initiating treatment.[2] [3]

In adult orthodontics, it is important to distinguish between “young adults,” ideally treated earlier, and “older adults” over 40, who often show signs of aging and oral deterioration.[4] These patients frequently present with secondary malocclusions that worsen or develop during adulthood.[5]

Orthognathic surgery is often the ideal treatment for adult malocclusions, but many patients decline it due to cost or invasiveness.[6] Treatment is primarily sought to enhance esthetics and occlusal function, with those facing such concerns showing greater interest and perceived need.[7]

Patients often seek a natural, attractive smile that complements facial proportions and inspires confidence.[8] Smile imperfections, whether acquired or congenital, can negatively affect interpersonal relationships.[9]

This study presents a successful multidisciplinary approach to managing a patient with Class II, division 2 malocclusion, deep overbite, and severe mandibular incisor abrasion. The case emphasizes both functional and esthetic enhancements, with orthodontics serving as an adjunct to a comprehensive restorative dentistry treatment plan. A multidisciplinary approach was performed, resulting in the integrated and effective restoration of both esthetics and oral function.

 

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Case Report

The patient presented with an Angle Class II, division 2 malocclusion, characterized by a Class II molar relationship where the lower first molars were positioned distally relative to the upper first molars. The upper incisors exhibited palatoversion, resulting in an exaggerated overbite. Skeletal evaluation suggested a Class I relationship, indicating that the discrepancy was primarily related to dental positioning, compounded by discrepancies in the basal bone structures. This study was approved by the Human Research Ethics Committee of the Pontifical Catholic University of Paraná under protocol no. 3.729.413.

Black spaces were observed between the upper central incisors, likely due to gingival recession or loss of the interdental papilla. Incisal edge abrasion of the lower anterior teeth was noted, potentially associated with the excessive overbite. Significant gingival recession was observed in the upper premolars and molars, which may have resulted from chronic occlusal overload or parafunctional habits, such as bruxism, compounded by inadequate oral hygiene, exacerbating the periodontal condition ([Fig. 1]).

Fig. 1 Initial intraoral photographs.

The panoramic radiograph revealed significant alveolar ridge reduction, particularly in the upper molar region, suggesting a history of advanced periodontal disease, possibly exacerbated by occlusal overload or untreated chronic gingival inflammation. Additionally, the presence of an unerupted and vertically impacted lower left third molar was observed. The periapical radiograph of the upper incisors demonstrated moderate alveolar ridge bone resorption, accompanied by slight root rounding ([Fig. 2]).

Fig. 2 Initial panoramic radiograph, lateral cephalometric radiograph close-up revealing the verticalization of the upper incisors, and initial periapical radiograph of the upper central incisors.

The presence of extensive dental restorations in the molars and premolars requires careful consideration during orthodontic planning and tooth movement, as they may compromise the structural integrity of the teeth.

Case Management

Treatment Objectives

The ideal treatment objectives would be to position the maxillary incisors in labial inclination, creating an overjet to facilitate mandibular advancement through orthognathic surgery. This approach would enable the achievement of Class I canine relationships with proper overjet and overbite, as well as sufficient space for the reanatomization of the worn or abraded mandibular incisors.

For this, the proposed treatment involved the use of a full fixed orthodontic appliance. Alignment and leveling of the dental arches were performed to optimize intercuspation as effectively as possible. Closure of diastemas in the mandibular teeth was recommended. To facilitate tooth movement, temporary anchorage devices, such as mini-plates or mini-implants, were incorporated to assist in the distalization of the maxillary teeth. In the maxilla, the treatment plan included a slight labial projection of the maxillary central incisors to create a mild overjet, facilitating the restoration of the mandibular incisors.

However, the patient only wished to create the necessary conditions for the restoration of the mandibular incisors, as they had already been restored three times. Thus, realistic objectives were chosen, focusing solely on aligning and leveling the teeth while maintaining the original posterior occlusion.

Thus, the patient, in consultation with the referring dentist, decided to proceed with the use of a partial fixed orthodontic appliance extending from the left first maxillary premolar to the right first maxillary premolar. Alignment and leveling of the dental arches were performed without altering the positioning or intercuspation between the maxillary and mandibular teeth. In the maxilla, the upper central incisors were slightly projected to create a mild overjet, facilitating the restoration of the mandibular incisors, which were preserved in their original positions.

In both treatment alternatives, the impacted mandibular left third molar was left untouched and did not undergo any intervention.

 

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Treatment Progress

To minimize the triangular space and enhance smile esthetics, interproximal reduction was performed between the upper incisors ([Fig. 3]). The orthodontic archwires were progressively adjusted to facilitate the leveling and alignment of the upper incisors. A significant improvement was observed in the alignment of the anterior teeth, with a reduction in overbite and labial movement of the upper incisors. The treatment has progressed as planned, with a focus on correcting the anterior region.

Orthodontic brackets were bonded to the maxillary canines, premolars, and molars to provide anchorage for the initial retraction and alignment of the maxillary central incisors. Following their projection, the lateral incisors were subsequently aligned. There was no specific biomechanical objective to alter the angulation or position of the canines. Transverse arch development was achieved exclusively through progressive adjustments in archwire length at each monthly activation, without the use of auxiliary expansion appliances.

 

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Treatment Results

After 10 months, orthodontic objectives were successfully achieved. In terms of dental alignment, significant improvements were achieved, including the labial movement of the upper incisors, proper alignment, and a substantial reduction in overbite. In the maxilla, the incisors were successfully aligned and leveled, with black spaces minimized through interproximal reduction performed during the treatment. The contact between the upper and lower anterior teeth was adjusted to establish a more balanced relationship, enhancing both esthetics and occlusal functionality. These adjustments also facilitated the esthetic recontouring of the lower central incisors. Collectively, these improvements resulted in a more harmonious and esthetically pleasing smile, as shown in the final photographs ([Fig. 4]).

Fig. 3 Progress of orthodontic treatment. Brackets bonded from the second premolar to the second premolar, except on the upper lateral incisors. The lateral incisors were subsequently included in the orthodontic arch.

Fig. 4 Final intraoral photographs. Composite resin veneers were applied to the lower central incisors for esthetic recontouring and diastema closure. The procedure resembled conventional restoration, including absolute isolation, acid etching, adhesive application, and sculpting of the chosen composite resin.

There was controlled maxillary incisor proclination to create space for the restoration of the mandibular central incisor. Minimal changes were observed in the posterior teeth, as they served primarily as anchorage units throughout the orthodontic treatment.

At the 18-month follow-up, the success of the orthodontic and prosthetic treatment was evident, as it not only restored the patient's confidence in their smile but also ensured efficient masticatory function, supported by the use of a night guard ([Fig. 5]). The collaboration between the orthodontist and the restorative dentist was crucial in achieving the final outcome within 10 months, which included the recontouring of the lower incisors. This multidisciplinary approach successfully combined esthetic correction with functional rehabilitation, resulting in a balanced, healthy, and functional smile for the patient. An improvement in gingival tissue health was observed, and cervical abrasion lesions were restored. Esthetic outcomes were enhanced through tooth whitening and reanatomization procedures ([Fig. 5]).

Fig. 5 Intraoral photographs at the 18-month follow-up following the rehabilitation of the upper teeth. An occlusal splint was provided for nighttime use to ensure retention and protect occlusion. The panoramic radiograph revealed normal findings. Composite resin veneer restorations were completed from the right second premolar to the left second premolar, and gingival recession lesions were also addressed and restored.

The 18-month radiographic images demonstrated the preservation of periodontal health, with no signs of bone resorption progression or worsening of the initially diagnosed periodontal conditions. The maintenance of bone and gingival support, particularly after addressing gingival recession in the upper molars and premolars, was a significant outcome that contributed to the long-term stability of the achieved results.

The posterior teeth served as anchorage units, and no movement was intended in these regions. The patient did not undergo a lateral cephalometric radiograph; therefore, it was not included with [Fig. 6]. The observed bite opening or reduction in overbite in the frontal clinical view was due to the labial inclination and projection of the maxillary incisors.

Fig. 6 Panoramic and periapical radiographs of the upper central incisors at the 18-month follow-up.

 

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Discussion

Esthetic concerns are often the primary motivation for patients seeking orthodontic treatment. This case illustrates the benefits achieved in terms of oral health, esthetics, and function, underscoring the importance of comprehensive care in an aging population. However, in this case, the primary indication was functional: frequent fracturing of restorations on the lower central incisors. This functional issue emphasized the need for a comprehensive treatment plan that addressed not only the esthetic demands but also the mechanical and structural requirements necessary for long-term dental stability and functionality.

Our goal was to present a clinically relevant case that illustrates the value of multidisciplinary care, with clear explanations to support both general practitioners and specialists in rehabilitative dentistry.

The reasons why adults seek orthodontic treatment are multifaceted. To successfully manage adult orthodontic cases or retreatments, a clear understanding of the complexities underlying prior treatment failures is essential.[10] The need for a multidisciplinary approach to manage abrasions on anterior teeth has been widely recognized over time. This case report presented a treatment plan that carefully evaluated occlusion alongside existing restorations. The significant improvements in both function and dental esthetics were achieved through the cooperation of the patient and the synergy between orthodontics, prosthodontics, and restorative dentistry throughout the treatment process.

In many cases, treatment limited to orthodontics or restorative dentistry alone is insufficient to achieve both esthetic and functional objectives. In adult patients with malocclusion, direct restorative treatment focused solely on abraded teeth—without prior orthodontic correction of tooth positioning—can lead to undesirable outcomes, such as difficulty achieving proper morphology and long-term stability.[11] The complexity of this case was further heightened by the patient's age, the presence of significant gingival recession, extensive restorations, and alveolar ridge resorption. These factors required meticulous planning to balance functional, esthetic, and biological considerations.

Despite the presence of extensive restorations and significant alveolar ridge resorption, particularly in the maxillary molars, orthodontic treatment using fixed appliances restricted to the maxilla was able to modify the inclination and alignment of the maxillary central incisors effectively.

Age alone is not a limiting factor for orthodontic treatment. However, adult patients often present with pre-existing conditions—such as reduced periodontal support, restorative needs, or occlusal wear—that require careful interdisciplinary planning. In this case, age was relevant due to the presence of such clinical challenges. It is also important to note that the patient was extremely compliant with oral hygiene throughout the entire treatment, which contributed positively to the outcomes.

For correcting skeletal Class II malocclusion, orthognathic surgery or orthodontic camouflage treatment is typically recommended. However, in this case, orthognathic surgery was declined by the patient due to its invasive nature, and orthodontic camouflage—usually involving the extraction of maxillary first premolars—was also rejected.

Orthodontics has long set the standard for dentofacial esthetics, and adult orthodontic treatment continues to be one of the fastest-growing areas in the field. Beyond esthetic and functional benefits, a multidisciplinary treatment philosophy has played a crucial role in popularizing orthodontics among adult patients.[12]

Patient satisfaction is a fundamental measure of health care quality. However, satisfaction arises from a complex process influenced by numerous factors that are not yet fully understood.[13] Both the patient and the referring dentist were highly satisfied with the outcomes of the orthodontic and restorative treatment. Importantly, the treatment process—where all alternatives were thoroughly explained and clarified—was as critical as the outcome itself. Effective communication played a pivotal role in this process,[14] as demonstrated in the management of this adult patient.

It is important to recognize that adult orthodontic patients often differ from adolescents in terms of their psychological experiences[15] [16] and their idealistic versus realistic treatment goals.[11] The individualized approach adopted in this case highlights these differences. Orthodontic treatments should not only aim to correct malocclusions but also provide psychosocial benefits, including improved self-esteem and enhanced emotional and social well-being.[17] [18] These outcomes were successfully achieved in this case.

Our goal was to present a clinically relevant case that illustrates the value of multidisciplinary care, with clear explanations to support both general practitioners and specialists in rehabilitative dentistry.

 

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Conclusion

A realistic orthodontic approach was applied to an elderly patient with multiple dental restorations to achieve alignment, correct the deep overbite, and create sufficient space for restoring the function and esthetics of the lower incisors. A fixed retainer was bonded to the palatal surfaces of the upper central incisors in conjunction with the use of an occlusal splint.

 

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Conflict of Interest

None declared.

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Publication History

Article published online:
24 July 2025