Prosthodontics

Enhanced CPD DO C

Joshua Hudson

Gulshana Choudhury and Ken Hemmings

The Use of an Overdenture in a

Patient with Numerous Partially
Erupted and Unerupted Teeth
Abstract: Some medical conditions present with missing or malformed teeth and other unusual oral manifestations that complicate
prosthodontic treatment. Outlining the simple and complicated treatment options to the patient allows them to make an
informed decision about the treatment they wish to pursue. This report describes the management of a patient diagnosed with
pseudohypoparathyroidism. Taking a patient-centred approach, with their involvement in the planning process, was essential to a
successful outcome.
CPD/Clinical Relevance: Adopting a holistic approach to treatment planning enables patients to make informed decisions, ensuring
patient-centred care that not only targets the condition, but supports overall wellbeing.
Dent Update 2024; 51: 696–702

Numerous medical conditions present with hypodontia and deformities relating to the fabrication of dentures or overdentures) to
unusual clinical features that complicate hard and soft tissues. These concurrent restore the dentition to proper function.
dental management. Table 1 presents issues make conventional dental treatment An overdenture can be a complete
a list of some of these more frequently challenging. Numerous prosthodontic or partial denture that replaces worn or
encountered conditions. As a result of their challenges are encountered when teeth or missing teeth with prosthetic teeth.2 They
rarity, aside from cleft lip and palate, there tissues are missing or malformed that require can be made of acrylic or cobalt chromium
are no clear, standardized guidelines on the careful planning and execution. Approaches and their design can be quite variable. The
management of these patients. Therefore, to the dental management of these patients following definitions can be helpful when
a pragmatic approach to addressing the encompass a range of interventions, describing these appliances.
patient’s specific aesthetic and functional including direct composite resin restorations  Overdenture: a denture that replaces
concerns is required. of hypoplastic teeth, extraction of impacted worn teeth ± missing teeth with
These patients may exhibit a range of teeth and subsequent tooth replacement prosthetic teeth and an acrylic flange;
dental anomalies as a symptom of their (including implant placement, conventional  Overlay denture: a denture that
conditions, including hypoplastic teeth, fixed prosthodontic treatment and the covers worn teeth with a full labial
veneer facing;
 Onlay denture: a denture that covers
the occlusal or incisal surfaces of the
Joshua Hudson, BDS (Hons), MFDS, RCS (Glasgow), PGCert, FHEA, Registrar in abutment teeth.
Restorative Dentistry, Sheffield Teaching Hospitals. Gulshana Choudhury, BSc (Hons)
An overdenture facilitates alveolar
BDS (Hons) MFDS RCS (Glasgow) PGCert, Registrar in Restorative Dentisty, King’s
bone preservation and denture support
College Hospital/William Harvey Hospital, London. Ken Hemmings, BDS, MSc, DRDRCS,
and stability. However, the risk of caries
MRDRCS, FDS RCS, ILTM, FHEA, Consultant in Restorative Dentistry and Honorary Clinical
and periodontal disease affecting the
Associate Professor, Eastman Dental Hospital and Institute.
abutment teeth is increased owing to
email: [email protected]
the accumulation of plaque underneath

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 Prosthodontics

Medical condition Main clinical features 2 1 1

Cleidocranial dysplasia Absent clavicles, large skull with frontal bossing, short 2 2 1
stature, delayed eruption and then prolonged retention of Table 3. Patient’s BPE scores.
deciduous teeth, many supernumerary unerupted teeth,
high arched palate and sometimes cleft palate
Cleft lip and palate Cleft lip: unilateral or bilateral. Palatal cleft: bifid uvula, soft large anterior open bite. This was a cause of
palate only, both hard and soft palate. Combined lip and embarrassment when socializing and eating
palatal defects. Enamel defects, hypodontia, anomalies in out with her friends and family.
tooth shape or form, supernumerary teeth, ectopic and Medically, she had PHP with associated
impacted teeth and tooth transposition developmental delay, for which she was
Treacher–Collins syndrome Characteristic narrow face with small zygoma and outward under the care of an endocrinologist
slanting eyelids. Colobomas (notches) on lower eyelid with whom she had regular reviews. She
and absent eyelashes, deformed outer and middle ear, was taking calcium and levothyroxine for
deafness, high arched palate and crowding, cleft palate in this condition.
one-third of cases She had a history of treatment within
secondary care and had undergone
Down’s syndrome Short stature, brachycephaly, muscular hypotonia,
surgical extraction of multiple deciduous
increased joint flexibility, congenital cardiac defects,
teeth under general anaesthetic as a child.
thyroid dysfunction, hypodontia, delayed eruption
She had been seen for an orthodontic
Ectodermal dysplasia Hypodontia, hypotrichosis (scanty hair), anhidrosis opinion following this, and a removable
(inability to sweat), reduced saliva, malformed teeth, appliance was used to close the midline
spaced teeth, hypodontia diastema. Further orthodontic treatment
was not feasible owing to her complicated
Pseudohypoparathyroidism Short stature, frontal bossing, thick short neck, hypoplastic
malocclusion and the patient’s reluctance
teeth, hypodontia, delayed eruption, presence of
to undergo further surgical treatment. An
supernumerary teeth
overdenture had previously been provided
Gardner’s syndrome Multiple osteomas of the jaw, fibromas and epidermal to which the patient struggled to adapt,
cysts. Odontomes, supernumerary teeth and sclerotic zone and she therefore requested that any future
of bone in the jaw treatment provided should be fixed and
Table 1. Medical conditions with orofacial features.1 avoid the use of a denture.

Patients with generalized severe tooth wear Clinical examination

Partially erupted teeth not in occlusion Oral hygiene was poor with BPE scores
shown in Table 3. There was a sinus present
Need to retain worn/compromised teeth to maintain bone with suppuration buccal to the UR2, UR3
Need to retain poor prognosis teeth owing to risks of complications with tooth extraction and UR4 region, and suppuration noted
from the gingival margin of the partially
To reduce the treatment burden in terminal dentitions erupted UL2 and LL3. No teeth were mobile
To manage patients with severe dental anomalies and unusual occlusions or had any apical tenderness. Multiple
partially erupted teeth were present,
Table 2. Indications for overdentures. and there was a generalized hypoplastic
appearance to the remaining teeth. Caries
were noted clinically in the UL5 occlusal,
the denture if this is not effectively a stepwise approach. Treatment was guided UL6 occlusal and the LR6 occluso-buccal.
removed.3–7 Nevertheless, the use of by the patient, whose wishes changed as The patient had a median diastema
overdentures prevents the need for tooth treatment was provided. measuring 4 mm. The UL7 and the LL7
extraction and slows down the subsequent were the only teeth with occlusal contact
ridge resorption. in the inter-cuspal position (ICP). There was
Overdentures can be useful in
Case report an anterior open bite extending to 9 mm
cases with significant dental anomalies, A 20-year-old female patient presented to measured at the incisal edges.
such as hypodontia, retained primary the prosthodontic department following
teeth, multiple unerupted teeth and previous treatment in the hospital’s Radiographic examination
gross malocclusions. This case study paediatric department. The patient’s main Owing to the uncertainty about which
demonstrates the use of an overdenture in concern was poor aesthetics associated teeth were present and the cause of the
a patient with pseudohypoparathyroidism with the diastema between her upper sinus in the UR2, UR3 and UR4 region,
(PHP). The objective of the case was to central incisors. In addition, she reported an orthopantomogram and long cone
achieve a successful outcome through a difficulty eating owing to the lack of peri-apicals were taken (Figures 1 and 2).
combination of restorative treatments using posterior contacts and her subsequent Tables 4–6 show which teeth were present.

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Figure 1. Pre-operative orthopantomogram (OPG).

8 3 (S)

Table 4. Unerupted teeth present

radiographically. (S): supernumerary.

5(S)2 235
c
32 23
Table 5. Partially erupted teeth present. (S):
supernumerary.

7641 14678
76541 14567
Table 6. Fully erupted teeth present.

Generalized biofilm-induced gingivitis

Primary failure of eruption of the UR5,
UL345, LR3 and LL3
Generalized enamel hypoplasia
Chronic apical abscess associated with
the upper left supernumerary
Figure 2. Pre-operative intra-oral peri-apical with Figure 3. (a–c) Cone beam CT (CBCT) of the
Active caries affecting UR4, UR5 and LR6
gutta percha point in situ to identify the cause of upper left quadrant to identify which teeth were
infection in the upper left quadrant. Table 7. Diagnoses. present, and the cause of the infection.

The cause of the sinus in the upper interdisciplinary meeting was arranged any invasive surgical treatment.
left quadrant was still unclear, so a involving an oral surgery consultant, a Consequently, she expressed a desire to
small-volume CBCT scan of the area was restorative consultant, the patient and retain all of her unerupted and partially
requested (Figure 3). This revealed an her father. After discussing the available erupted teeth despite the associated
apical radiolucency associated with the treatment options, the treatment plan risks of infection. As such, the sinus
upper left supernumerary. A full list of given in Table 8 was proposed. located in the upper left quadrant
diagnoses is present in Table 7. The patient was given time to remains under review.
Owing to the complexities of the review the treatment options with her Initially, she decided to undertake
buried teeth and chronic infection, an family and opted against undergoing only composite resin addition to the

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a b
Oral hygiene instruction and professional
mechanical plaque removal
Restoration of carious lesions
Surgical extraction of UR23S5, UL235, LR3
and LL3 under general anaesthetic
Composite resin addition to the UR7
and LR7 to increase intercuspal position c d
(ICP) contacts
Composite resin build-up of the UR1 and
UL1 to close diastema
Fixed dental implant-retained
reconstruction to replace missing teeth
Table 8. Proposed treatment plan.
e f

Oral hygiene instruction and professional

mechanical plaque removal
Restoration of carious lesions, UR4, UR5
and LR6
Composite resin addition to the UR7 and
LR7 to increase occlusal contacts g h
Composite resin build-ups of the UR1 and
UL1 to reduce the median diastema
Provision of cantilever resin-retained
bridges UR21 and UL12
Provision of a maxillary partial cobalt
chrome overdenture Figure 4. (a,b) Extra-and intra-oral pre-operative view. (c,d) Extra- and intra-oral views post composite
Table 9. Treatment plan provided. build-up of central incisors. (e,f) Extra- and intra-oral views post resin-retained bridge placement.
(g,h) Extra- and intra-oral post-operative views.

UR7 and LR7 as well as composite resin

build-up of the UR1 and UL1 to close
her midline diastema. In discussion
with the patient, it was decided not
to fully close the midline diastema to
optimise aesthetics.
After seeing the improvement in her
appearance following this treatment, Figure 5. Pre-operative occlusal view.
the patient wished to explore the Figure 6. Post-operative occlusal view of the
option of replacing her missing upper patient with overdenture in situ.
lateral incisors. Resin-retained cantilever
bridges were provided from the upper Discussion
central incisors to replace the upper
Pseudohypoparathyroidism, also known
lateral incisors bilaterally. Once this tooth and bone mineralization.10 PHP can
as Albright’s hereditary osteodystrophy be subdivided into groups depending on
treatment was completed, the patient
then expressed a desire to replace her (AHO), is a rare metabolic disorder the clinical and hormonal phenotypes.10
missing posterior teeth with a removable affecting 1:100,000 individuals.8 It is Dysregulation in PTH results in
appliance, despite originally objecting caused by genetic mutations affecting hypocalcaemia and hypophosphataemia,
to this as a treatment option. A maxillary the GNAS gene, resulting in the resistance manifesting in a range of systemic and
partial overdenture was made, which was of kidneys and bone to the peripheral orofacial manifestations.11
well accepted. The final treatment plan action of the parathyroid hormone (PTH).9 Systemic manifestations of PHP include
provided is presented in Table 9. The parathyroid hormone (PTH) plays a short stature, frontal bossing, thick short
The pre-, mid- and post-treatment vital role in the regulation of calcium and neck and considerably reduced length
photographs are shown in Figures 4–6. phosphorus homeostasis and ultimately of the third and fourth fingers and toes,

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along with dimpling of the corresponding general anaesthetic, likely bone grafting provision of the resin-retained bridges;
knuckles.9 Oral manifestations are common and then the morbidity of the implant however, it was not until the patient’s
and seen in more than one-third of cases treatment itself. If extractions were not trust was gained with the initial treatment
with hypoparathyroid conditions.9 These considered and the decision was made that she decided to pursue a more
include enamel aplasia or hypoplasia, to use her existing dentition to achieve involved option.
hypodontia, delayed eruption, impaction optimal tooth positioning, orthognathic When considering the prosthesis
and presence of supernumerary teeth.10 surgery and difficult orthodontics may design, a metal-based denture was favoured
Dental management of a patient with have been required. This would have for accuracy of fit and reduced bulk. While
PHP is underpinned by multidisciplinary posed a substantial treatment burden there was adequate interocclusal space
input, which is aptly demonstrated in the for the patient. Taking into consideration anteriorly, the use of metal connectors
case described. There are very few cases the patient’s concerns, expectations for in thin sections reduced the chance
detailing the long-term management of a treatment, and alternative options, the of fracture.19 An acrylic denture with
patient with PHP because they are usually patient considered this option too invasive. increased thickness may not have been so
under the care of multiple dental specialties A patient-focused approach to care well tolerated.
for most of their lives. In some cases, where planning has been termed patient or Conventional denture design principles
the patient presents with a compromised person-centred care. The Health Foundation were followed with appropriate bracing,
dentition, the dentist should aim to offer reported that this approach allows reciprocation and minimal gingival
treatment that is minimally invasive with professionals to work with individuals to coverage (Figure 6). As a result of the
minimal ongoing maintenance. give them the knowledge and confidence uncertain prognosis of the cantilever
The clinical considerations in the to make informed decisions about their resin-retained bridges UR12 UL12, palatal
treatment planning and execution of this own health.15 The ‘Involving people in their backings and connectors were provided
case can be applied to patients with other own health and care’ statutory guidance to allow possible future additions of these
conditions presenting with similar orofacial document for NHS England emphasizes the pontics if required.
manifestations, such as Down syndrome, importance of focusing on what matters There are many benefits to the provision
Gardner’s syndrome and cleidocranial in the context of their lives rather than of overdentures; however, they can increase
dysplasia. These conditions are also typically treating them as a mere list of conditions.16 the risk of caries and periodontal disease
characterized by disruption in systemic This allows clinicians to empower patients affecting the abutment teeth. Therefore,
development and dental anomalies by understanding what is important to optimal oral hygiene is essential for long-
including multiple impacted or unerupted them, identifying their goals and educating term success.
teeth, hypodontia and odontomes.12 In them on how to achieve them.
addition to this, the strain and mental The clinical and biological aspects of Conclusion
distress placed on these patients from a dental treatments account for less than A patient presented with significant
psychological perspective resulting from one-third of all determinants of health, and and multiple dental anomalies. Simpler
multiple missing teeth and compromised therefore, the wider context of the person is treatment was provided after the patient
aesthetics is significant. essential in improving and achieving what rejected a fixed approach as being too
Dental professionals can be keen to find may be considered optimal oral health.17,18 invasive. By allowing the patient to help
an ‘ideal’ solution – one that would solve all The authors’ concerns regarding aesthetics guide the treatment decisions, and building
the problems perceived to be present. Many and the presence of chronic infection were trust through this process, a satisfactory
treatment options are available; however, not shared by the patient. In this case, outcome was achieved. A simple
there is a growing preference for implant- the patient’s priority was eliminating the overdenture proved to be satisfactory for
supported prostheses over traditional risks associated with general anaesthesia this patient. This approach may be suitable
removable complete/partial dentures.13 The and reducing the morbidity of treatment, for other patients presenting with unusual
provision of implant-supported prostheses accepting that this may lead to problems dental anomalies and occlusions.
is a viable treatment option and has in the future. By giving the patient all the
been shown to be successful in patients options, undertaking a rigorous consent Compliance with Ethical Standards
with developmental conditions, such as process and empowering them to change Conflict of Interest: The authors declare that
Down syndrome, although an increased their mind as the treatment progressed, they have no conflict of interest.
likelihood of complications is anticipated a successful outcome was still achieved. Informed Consent: Informed consent was
in this cohort.14 Patients may prefer fixed This was accomplished by employing a obtained from all individual participants
replacement of teeth, but this can mean stepwise escalation of treatment techniques included in the article.
embarking on a difficult and prolonged culminating in the use of an overdenture,
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