Complex Aesthetics: Severe retro lined upper and lower teeth with deep bite: affecting lower half of the Dent facial aesthetics.
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Patient initially presented for improving the aesthetic apperance of upper teeth (severe crowding and retrocllined upper front teeth) The lower teeth crowding was also a concern.. Patient had preferred more fuller smilehe is a professional dancer. Orthodontic treatment has been suggested in the past and also during our last visit (this would also involve surgical correction for an optimal result and referral to a colleague would be required, since this would be a multidiscilinary treatment). However at this stage of his professional careeer, Dr Sarkia Nalbandian was asked  to consider a restorative correction option.     


Functional assessment.

  1. Missing teeth 18, 17, 16, 26, 27, 28, 36, 37& 47. The main chewing units are on the premolars. The loss of posterior support has resulted in further deepening of the bite. Although the patient can function well on the shortened dental arches, I would recommend in the future we consider implant supported crowns ( 16,17,26,27,36) and crowning tooth 47 with compromised structural integrity ( past root canal therapy) to improve the bite support.
  2. The periodontal (gum) health is adequate, all permanent teeth tested vital.  
  3.  Normal range of craniomandibular (jaw) movements: function. Bruxer (tooth grinding) and teeth wear that has affected your smile is most evident.

 



Initial presentation:  Smile and Dentofacial smile dynamics: assessment of position and relationship of the upper arch with the face

Note the retro-inclination of the upper and lower front teeth. This is a complex aesthetics and requires a considerable experience by the dentist. Therefore it is imperative that correct diagnosis and treatment plan is implemented. This is the reason that our patients are invited to come in for this important consultation and diagnosis visit.

 

 

Note the presence of deep bite -2mm anteriorly

This is the result of diagnostic mock up. This diagnosis tells us: can ve help our patient. We do special tests to determine if this is correct for our patient.

 

Aesthetic Assessment

  1. Moderate smile line with upper teeth midline is in symmetry with upper lip. Both upper and lower lips are symmetrical.  During full smile we have asymmetrical exposure of the gums; however gum levels on teeth 12, 11, 21 would require teeth recontouring to improve the gum symmetry and tooth emergence profile and anatomy when veneers are constructed.  You present with skeletal class II with div -2 deep >100 % overbite.

 

  1.   Due to wear of upper front teeth, we have a shorter central incisors, the dominance of the centrals are lost, where the large canines have dominated the smile. 
  1. We also have reverse as well as canted smile line (smile line runs at an angle rather than parallel to the lower lip. Presence of narrow upper arch for the size of the lip frame.

 

Patient approval is sought prior to any treatment or quotation of the fee for the procedure.
32.jpg4-Following composite mock up we agreed that better more pleasing tooth/smile exposure would be achieved by correcting smile line cant, improve central incisors (11, 21), tooth emergence profile gum levels of upper teeth,  as well as restoring “restoring”, improving the width of the smile to balance the smile and pleasing teeth emergence profile. Therefore the aim of the treatment is to improve tooth proportion, the position of the upper arch in the lip frame: to restore optimal smile dynamics, teeth brightness and fullness of the envisaged smile as we discussed during your last visit. Speech was fine and you were happy with the thickness of the mock up and the level of the smile line. Naturally we will be refining this for the most optimal outcome.

 
We discussed all options of treatment (naturally orthodontic treatment, followed by implant placement etc. However, at this stage this is not an option for you).  I am happy to consider your treatment options in the future. The treatment proposed as per composite diagnostic mock up, the aim is to give you an immediate smile, while leaving your future treatment using implant st open, using minimal intervention methods as discussed below.

Treatment proposed using composite veneers on upper ten teeth as per composite mock up. This minimally invasive concept as per composite mock up will achieves the following changes;

  1. Immediate cosmetic improvement
  2. Minimal post-op discomfort.
  3. Easy to make modifications

 

Following considerable discussion re; various options of treatment which included: no treatment,  Orthodontic leveling and alignment followed by restorative correction, porcelain veneers etc, we decided to proceed with restorative treatment using composite veneers on teeth (16-26) for improving overall  colour, symmetry, arch and tooth form.

Most importantly this treatment is conservative and least biologically, it will maintain the integrity of your tooth structure.  Repairs are easy to make.  This will improve incisal/smile plane, aesthetics and function in general invasive to the tooth structure. There may be some sensitivity, which is rare and usually transient. 

As always, following cosmetic dental procedures a habituation period of few days to week is anticipated. This will allow us to improve colour and harmonise your smile to create a naturally pleasing appearance. I must stress that any bruxing/grinding habits will play an important role in the future longevity of your restorations and your dentitions as a whole.  A night guard can be provided to control any bruxing.

 


Post op smile, established with direct composite technology. This is a process of oral rehabilitation where we not only improve the smile (position and profile of the teeth and the upper and lower arch) but we also opened the bite anteriorly by 5mm. This procedure increased the vertical dimension of the lower half of the face, softened the facial appearance.

The new smile complimenting the upper lip profile.

In summary;

  1. Severe wear of upper and lower anterior (front) with a resulting canted and irregular smile line affecting the aesthetic appearance of the teeth display during speech and smile dynamics.
  2.  Patent  categorically refused any form of orthodontic treatment-invisalign/lingual/labial etc. 
  3. Reduced VDO (inadequate space for improving the teeth form and display and we agreed that satisfactory result would be achieved with opening the bite in the front area by 3-5 mm.  We tested speech, comfort, habituation and smile line  hence bite opening would be required as per  diagnostic composite mock up visit,
  4. The lower incisor teeth 45-35 as per mock up will be restored ( to level the bite and smile line on the lower arch) for improved smile line in conjunction with the upper arch, as well as function, speech and comfort.

 

5-Composite veneers upper teeth: 15, 14, 13, 12, 11, 21, 22, 23, 24 & 25.  Items: 582x 10. Teeth 12, 11 & 21   require some recontouring and gum levelling. Items: 231.
6-The lower incisor teeth 45-35 as per mock up will be restored (to level the bite and smile line on the lower arch) for improved smile line in conjunction with the upper arch, as well as function, speech and comfort.  523x6/533 x2 
7- Night-guard is recommended   Item 965.


15.jpgDentofacial Smile dynamics complimenti7F.jpgng this handsome man.
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I always feel that happy patients are happier with a glowing smile
This procedure was established using no injections and no drilling on the upper arch and minimal intervention to correct the crowding of he lower arch.
Please view the video provided
We need to regard this as a interim restorations to serve us as a guide in future reconstructions: porcelain veneers if required etc. However we can from time to time extend the life of these restorations by resurfacing the veneers with new composite materials at a minimal cost. In the future orthodontic treatment, porcelain veneers etc. can commence by removal of these veneers, since the teeth are sound underneath the composite veneers. We pride ourselves with the quality of dentistry we provide however, there are always limitations placed on us by materials, oral environment, etc. Regular 6 monthly check-up and maintenance visits help to enhance the longevity of the restorations and your oral health.

Please feel free to contact me should you have any queries.

Sincerely,
Dr Sarkis Nalbandian

 

 

 

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