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Video: Smile & Bite Symmetry & TMD/TMJD

Smile & Bite Symmetry and Temporomandibular Joint Dysfunction (TMD)

TMD patient with bite instability affecting her temporomandibular joint left. Correction of bite tooth form, arch form and creation of symmetry. Improvement in tooth display during speech and smile dynamics. This study will show:

TMD bite instability due to dental asymmetry

Dental asymmetry

Initial Presentation

Ms M was referred by her general dental surgeon for specialist assessment in improving the aesthetic appearance of upper teeth: presence of generalised gum recession, moderate discolouration, correction of asymmetry of the upper arch due to missing upper right lateral incisor (12, as well as improvement to overall smile).

Upper arch asymmetry

The lower teeth were of a lesser concern at this stage (small dark triangles between triangular central incisors etc) where past tooth whitening had resulted in sensitive lower teeth. Dental asymmetry: tooth12 is missing, midline shifted to the right into RHS area. We noted the following:

  1. Optimal lip thickness and outline symmetry, great lip frame, Tooth: 11 also retroclined, bruxing patient and severe wear incisally of 11, creating step in the incisal plane during smile and speech dynamics.
  2. Tooth 12 is missing. Contralateral tooth 22 is present.
  3. Cross bite on RHS: this is more skeletal then dental/functional. There is also slide at this site and this slide can be contributing to slight clicking on the right TMJ. Small occlusal/bite refinement will help to reduce this slide when restoring the lateral smile. We note that having missing 12, combined with retroclined 11 and cross bite on RHS, slightly deviated mandible (lower jaw); gives more pronounced asymmetry on RHS due to presence of large negative spaces.
  4. This combined with thin biotype, triangular teeth; high smile line scalloping gingival margins and multiple gum recessions with sensitive erosive lesions on premolars makes the treatment quite complex that requires careful planning for optimal function, comfort and aesthetics.
  5. The presence of generalised gum recession is due to probable excessive tooth brushing and presence of thin tissues (thin biotype). However, we do have periodontal (gum) stability.
think like an artist

Diagnostic Aesthetic Direct Mock Up

Must think like an artist. Following composite mock up we agreed with the colour, symmetry, level and arrangement of tooth display, improving the arch width, shape and teeth exposure and gum level. Composite mock up corrected the centerline and recreated 13 into 12, 14 to 13 16 to 14, built the RHS of the collapsed arch laterally, where considerable build up was required. Patient wishes to have white teeth; however some incisal translucency is required to create that natural look to complement overall dentofacial aesthetics.

Direct composite mock up

Direct composite mock up

Treatment planning options

Orthodontic levelling and alignment

Orthodontic leveling and alignment

Orthodontic leveling and alignment to open a space for missing lateral incisor and correct cross bite is all very well. In an ideal world, we would need to place an implant at site 12, followed by porcelain veneers, crowns etc. However, very careful planning is required, since with slight leveling and alignment, we may lose these valuable gum triangles that will affect aesthetic emergence of teeth display on upper six front teeth-further exposing the dark triangles. Hence the consideration of restorative correction, instead of orthodontics, where time for orthodontic treatment is also a concern.

Optimal symmetry restorative correction

Restorative correction

The thin triangular gum tissue between the upper teeth (papilla) is at the same height across the smile line, which means that (as per diagnostic composite mock up) can be treated restoratively using porcelain veneers (16-25) and crowning tooth 26.

The aim is to build RHS, jump the cross bite, restore midline, and create symmetry, central incisal prominence in the critical midline aesthetic zone. (See the diagnostic mock up as this is the best guide in restoring dentofacial aesthetics.)

  1. Periodontal assessment and charting: good periodontal stability and oral hygiene.
  2. Teeth 12, 11, 22 have past composite restorations with defective marginal integrity requiring replacement to facilitate aesthetics and seal defective tooth margins.
  3. The replacement of amalgam restorations on teeth 14, 24, 36 was also requested for aesthetic reasons.
  4. Night guard wear post treatment is mandatory to maintain bite stability and reduce bruxing/tooth grinding forces on natural teeth, while maintaining the integrity of new restorations.
  5. Normal range of craniomandibular (jaw) movements: function. Patient tends to brux (grind) and clenches her teeth; I feel this would have contributed to the wear of the upper teeth.

Following considerable discussion regarding various options of treatment including: no treatment, composite veneers, orthodontics/orthognathic surgery etc., we decided to proceed with restorative treatment using porcelain veneers 17,15,14,13,11, 21, 22, 23, 24, 25 and crown 27 for improving overall tooth symmetry, arch form, tooth colour arrangement to improve function and aesthetics.

As always, following cosmetic dental procedures a habituation period of a few days is anticipated. Any sensitivity, if present is usually transient. I must stress that any bruxing/grinding habits will play an important role in the future longevity of the restorations and the dentitions as a whole. A night guard will be provided to control any bruxing.

  1. Porcelain veneers teeth: 17, 15, 14, 13, 11, 21, 22, 23, 24, and 25. Crown 27. Items: 583x10/613
  2. Replacement of defective restorations on teeth 12, 11, 21 items: 523 x3, and amalgam replacement on teeth 37, 14 & 24. Items: 532 x3.
  3. Night guard will be provided. Item 965.

Treatment Progress

Teeth were minimally prepared requiring no local anaesthetic, since the preparation is very slight and since we employed the diagnostic guide, the procedure required minimal tooth intervention. The provisional veneers were constructed directly to allow patient habituation and to add that additional assessment time for the best outcome. Now the patient can “wear” these veneers and test the system.

Provisional Veneers refined to test the system for comfort function and aesthetics. Improved: colour, symmetry: level and arrangement of tooth display, improving the arch width, shape and teeth exposure and gum level. Correction of collapsed arch and cross bite on RHS. Excellent lip support and anterior tooth display during speech and smile dynamics.

Temporary veneers and new smile line at rest. Beautiful lips complementing provisional veneers.

smile line

Smile line consonant with lower lip

Now we have the definitive final cemented porcelain veneers: This is called Bio-mimesis. Imitating nature. Can you see where the missing upper right lateral was? Can you see how, with the help of an aesthetically understanding and realistic patient, we were able to restore and improve her smile? Consonant smile: Most desirable smile. Smile line consonant with the curvature of the lower lip. Establishing an optimal symmetry to complement this beautiful patient’s lip form and facial aesthetics.

Beautiful smiles take time. These veneers are placed above the gum and “hidden below toe gum. This reduced the chances of future gum recessions. These veneers are specially constructed by my technical team. Tooth form shape. Arch form shape. Lip form/shape and bite correction simultaneously.

veneers placed above the gum

Veneers placed above the gum

intra oral images of bite correction

Simultaneous smile and bite correction.

The procedure required four visits:

  1. Assessment
  2. Diagnostics mock up
  3. Procedure for porcelain veneers and temporisation
  4. Final porcelain veneer cementation
cross bite correction

Please Note the following improvements:

  1. Correction of arch form
  2. Improvement in arch outline
  3. Reduction in negative spaces
  4. Fuller smile that complements patients lip form/thickness
Final smile

Natural smile. This is the art and science behind my creations in achieving Biomimessis. Smile must look natural in all angles in 3Dimension. Beautiful smiles take time, expertise and experience. Aesthetics using implant supported restorations (crowns and bridges) is not simple when restoring the Stomatognathic System (the Mouth), but not impossible.

Lips

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

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