Figure 6: Images of the try-in procedure 

7. During the final visit, the insertion phase took place. The upper denture, crafted from flexible polyamide acrylic resin (Lingchin, China), is designed to fit over the cast metal crown, functioning like an over-denture, as seen in [Figures 7A and 7B]. Conversely, the lower denture is constructed using heat-cure acrylic resin (Pyrax, India), following the traditional complete denture approach, as illustrated in [Figure 7C]. After insertion, the patient received oral hygiene instructions.

Figure 7: Images of insertion procedure A- occlusal view of a flexible upper denture, B-flexible upper denture fit over metal crowns, C- frontal view for the patient with final dentures in a month.

Discussion:

It was decided that the option of correcting the maxillary-mandibular malocclusion through additional surgery is contraindicated due to the patient's prior surgical experience. The treatment plan involving the extraction of remaining teeth followed by the placement of fixed bridges over implants for both arches was also dismissed as it was costly and entailed an extended treatment duration. Consequently, the choice of a removable denture was determined to be the most suitable treatment for this case, given its cost-effectiveness, feasibility, and the fact that it represented the least invasive procedure.

Following the removal of teeth that are non-restorable, the intention was to retain the posterior teeth to prevent alveolar bone resorption. [12] Furthermore, these posterior teeth could serve the dual purpose of anchoring the upper complete denture for improved retention and facilitating a more comfortable prosthesis design characterized by a horseshoe configuration instead of palatal coverage. [6]

The posterior teeth were saved by crowning. The root/crown ratio was 1, which proved to be the minimal ratio that is clinically feasible, as seen on the OPG radiograph. [13] It was noted clinically that these remaining teeth had slight mobility, which was solved after crowning those teeth. This could be attributed to the metal crowns establishing substantial contact with one another, effectively serving as splints for fragile, small teeth, as noted by Lindha in 2008. [14] The crowned primary teeth were not prepared, as they demonstrated tapered shapes and very short clinical crowns. These teeth were

treated like primary teeth, as documented by Duggal et al in 2005. [15] The main objective of crowing was to increase the size of the teeth and make them a viable option for prosthesis support.

The correction of the maxillo-mandibular relationship was achieved through an increase in the vertical dimension of occlusion, resulting in the mandible moving downward and backward along the arc of the opening and closing path while the condyles remained in a centric relation. This approach facilitated the alignment of anterior teeth into a typical class I maxillo-mandibular relationship, significantly enhancing aesthetics. Furthermore, it gained support from various authors who have found that increasing the vertical dimension of occlusion is generally safe, provided it does not compromise the temporomandibular joint [16].

The flexible overdenture enhances retention by utilizing the undercut regions of the tapered, non-anatomical metal crowns, contacting a smaller surface area compared to conventional dentures. Additionally, it streamlines the process, eliminating the necessity for oral preparations typically required in the creation of cast partial dentures [9].

Conclusion: 
Prosthetic approaches offer a less invasive treatment option that is both time-efficient and capable of delivering favorable aesthetic outcomes for certain hypodontia cases associated with jaw malocclusion, all while avoiding the need for extensive surgical procedures and their associated risks.    

Financial support and sponsorship: Nil.

Conflicts of interest: There are no conflicts of interest.