Complex Aesthetics: Skeletal disharmony-class-III skeletal anterior cross bite, toothwear& Discolouration. This study will show:
Examination, study models, photos and x-rays confirm the presence of localised anterior (front) teeth wear. Slightly narrow maxilla (upper jaw) and prominent mandible (lower jaw); the effect of prominent mandible is apparent. There was also general canting of the teeth alignment (smile line) with left side higher. Optimal lip outline, thinner upper lip and prominent lower chin. Upper dental midline is almost with upper lip and facial midline. Upper dental midline is slightly canted. Upper and lower lips are symmetrical. Overall we have good lip thickness and symmetrical outline.
The anterior teeth wear has created what we refer to as a “reverse smile line”. This tends to create ’dark” spaces during normal speech and smiling, which we both feel has affected his dental appearance.
The narrow upper arch was assessed after the composite mock up, giving more prominence and reducing the prominence of the lower jaw/chin, we both agreed with the overall aesthetic improvement.
Reverse smile line
Periodontal examination shows thin biotype. We have completed initial scaling and root planing. Patient has an adequate oral hygiene (however regular 4 monthly cleaning visits are advised at his stage), normal craniomandibular (jaw) function. Tooth 22 is non vital (requires root canal therapy) and all other teeth tested vital. Bite relationship: skeletal class III base with straight to concave facial profile. Class III skeletal anterior cross bite. To improve the level of tooth display on the upper arch and correct the canting of smile line. The aim is to improve the level of tooth display on the upper arch and correct the canting of smile line and improve the spaces and appearance of lower front teeth. The images post composite mock up is provided. The speech was fine. The facial height was altered significantly, to help in correcting the anterior cross bite, therefore the bite will be opened slightly to accommodate new restorations and level the lower front teeth. Following periodontal therapy, in overall, we will have good oral hygiene and excellent improvement in periodontal health.
Asymmetry, skeletal inter-arch discrepancy. In summary: we have asymmetry, skeletal arch discrepancy, orthodontic/surgical levelling and alignment was not an option. To improve and compensate this discrepancy, we decided to proceed with restorative correction using minimal tooth intervention methods as per composite mock up. This is to improve the level of tooth exposure during speech and smile dynamics.
X-ray shows good bone stability and support for restorative correction.
We discussed initially using composite reconstructions on upper teeth (16-26) and lower teeth occlusal build ups (or wherever it may be applicable). The missing tooth 15 will also be restored using fibre-bonded composite bridgework. The composite mock application allowed us to assess the effect of tooth alignment, arch broadening and tooth emergence and arrangement across midline as well restoring teeth length: improving the smile line and general symmetry. The speech was also satisfactory after the mock up. Gum aesthetics is not a concern, since there is a symmetric gum exposure during speech and smile dynamics. Some period of habituation will be also required, which is usually transient. This will improve colour, broaden the smile line and aesthetics in general. We need to regard this as a long term provisional measure to serve us as a guide in future reconstructions: orthodontic/surgical, porcelain veneers if required, crowns on teeth (12, 22) with compromised structural integrity 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. Once the initial treatment is complete, with time we will make provisions to reconstruct teeth that are structurally compromised and in need for full crowns and missing teeth 15 and 25 with a more definitive solution.
Slightly narrow maxilla (upper jaw) and prominent mandible (lower jaw); the effect of prominent mandible is apparent.
Direct composite mock up
Why is this diagnosis important? Because it allows me to test the system, that is the adaptability capability of the patient. If the patient is able to tolerate the changes and cope with the new tooth length, speech, comfort and aesthetics, then it is simply matter of time that we can accomplish this procedure. In this case we are able to complete the whole reconstructive procedure in one visit. The patient is the decision maker.
The images post composite mock up is provided. The speech was fine. The facial height was altered significantly, to help in correcting the anterior cross bite, therefore the bite will be opened slightly to accommodate new restorations and level the lower front teeth.
Diagnostics: composite mock up, in relation to improving the teeth: colour, length, symmetry, and smile line in general. However most importantly the aim is to reduce the effect of the skeletal discrepancy of large lower jaw, trying to create symmetry and improve facial profile, using restorative rather than the combination of surgical-orthodontic-restorative correction. We came to this conclusion after considerable discussion, diagnostic mock up. The referral to my orthodontic and surgical colleague was suggested; however as the patient explained, this is not an option for him at this stage of his life. Patient preferred non-invasive solution. He had been to other dental specialists that recommended orthodontics (braces) for 2-3 years, jaw surgery and then braces. Since there is always healing time and potential complications associated with surgery, this was not something the patient wanted to endure.
The importance of suggested conservative treatment, would also keep hisfuture treatment options open, since tooth structure is intact underneath the proposed composite reconstructions.
Reconstructive process: this involved no injections, no facial numbness and no pain. Preserving biology. We started at 9.00am and finalised the procedure at 5.00pm. There is no doubt that this is a complex treatment and I am highly experienced and have prior training in this area of dentistry (prosthodontics).
This picture demonstrates the importance of correct diagnosis, discussion of all the options o treatment with the patient. Ideally patient required multidisciplinary oral rehabilitative work: orthodontics-orthognathic surgery and prosthodontics. However at age of 50 years and taking into account the stage in his life he is at, the patient decided to opt for restorative (prosthodontic) correction of his Dentofacial asymmetry. The skeletal asymmetry is still present (as this would have been corrected by the orthognathic surgery), however the dental-restorative compensation or correction was able to hide the skeletal misalignment.
Although the ideal option (orthodontics-orthognathic surgery and prosthodontics) would have been a textbook treatment, however we need to take into account patient’s life timetable, his wishes. Unfortunately his teeth have deteriorated because he did not wish to have surgery that was suggested long time ago. There are many solutions. I will explore all your options and consult my specialist colleagues for the optimal option of treatment for my patients. However, our patient’s wishes always prevail and within reason.
Smile lift dentistry is provided at a special level that that maximizes the original facial features of the patient. This is a process where art meets science that creates a synergy, optimising the natural facial aesthetics of this lovely patient. The fundamental concept is to balance the face by working on the teeth.
State of the art dentistry is non-invasive aesthetic dental reconstructions that use the existing tooth structure without grinding down your natural teeth. Yes, It does require specialised dental skills that few dentists can deliver. The treatment is remarkably easy for the patient and technically difficult for the dentist and takes years to master. Experience and education is everything.
Note the new level of teeth display, lip symmetry across the midline. Note before the canted smile line was restored. The severe bite discrepancy was corrected. Overall improve occlusal(bite) plane and stability, which the patient lacked and as a results was posturing forward. This is the reason for heavy restorations on upper front four teeth. Tooth 12 past root canal therapy and post-crown, would fail if the bite was not corrected. We have accomplished five major chances:
We pride ourselves with the quality of dentistry we provide however, there are always limitations placed on us by materials, oral environment, etc. One can be reassured that at the end of the treatment all should be well, however if anything untoward does show up or unusual symptoms occur, we are always here to look after our patients.
Regular 6 monthly check-up and maintenance visits help to enhance the longevity of the restorations and oral health. I must stress that future bruxing/grinding habits will play important role in future longevity of restorations and dentitions.
The composite veneers appear whiter and brighter in colour and may be given the circumstances, the experience has shown that patients with severe discolourations in general prefer brighter teeth. For this patient there was only one wish “I just want to be able to smile”.
Thank you for taking the time to explore this patient's story. I hope this gives you an idea of what I can do for you if you are having difficulty and need help, because there is always hope.
Dr. Sarkis Nalbandian
Visiting Professor YSMU
Specialist Prosthodontist & Implant Surgeon
B.D.S. (Hons), Dip. Clin. Dent. (Oral Implants) Uni Syd, M. Clin. Dent (Prosth) King’s College, Uni London
D. Clin. Dent (Prosth) Uni Syd, FRACDS, MRACD (Prosth) FIADE, FPFA