Case Study: Gaps, Spaces Between Teeth of Mature Patient

Patient aged 41 years, initially expressed desire to improve the aesthetic appearance of upper teeth including tooth colour, spaces(gaps) at upper and lower front teeth. Smoker wishes to quit smoking.

Patient aged 41 years, initially expressed desire to improve the aesthetic appearance of upper teeth including tooth colour, spaces(gaps) at upper and lower front teeth. Smoker wishes to quit smoking.

Clinical examination, x‐rays, photos, study models and composite mock up confirmed the following:

1. The high smile lines with the upper teeth midline are in symmetry with the upper lip. During full smile we have asymmetrical exposure of gums while both upper and lower lips are symmetrical. After the composite mock up a more pleasing tooth/smile exposure would be achieved by closing the large spaces, improving colour and tooth anatomy (aesthetics) of ten teeth (six upper teeth: 13, 12,11,21,22 & 23 and four lower teeth: 42, 41,31, 42, 32).

2. The periodontal (gum) health is guarded. We have carried out extensive gum cleaning procedure. The smoking must be stopped for the best oral and general health. All teeth tested vital.

3. Normal range of craniomandibular (jaw) movements and function.

Note how damaging the smoking is. There is a causal link between smoking, oral cancer, gum disease and related bone loss around the teeth. Patients who lose teeth from gum disease and smoking are more prone to loss of implants, as we replace the missing teeth with implant supported crowns. Gum disease is also related to a range of cardiovascular diseases.

Post periodontal treatment. Patient demonstrated good home care and maintenance. He regularly visits for re‐care visits. We refer this as SPT (supportive periodontal therapy). Naturally smoking must stop.

Following considerable discussion regarding various options of treatment which included: no treatment, orthodontic treatment to reduce bimaxillary protrusion, porcelain veneers etc, we decided to proceed with restorative treatment using composite veneers on teeth (15‐25) to improve the overall symmetry, spaces, arch form, tooth colour and arrangement. Naturally porcelain veneers was also an option, however finances were a major concern for this patient.

Most importantly this treatment is the conservative and least biologically invasive to the tooth. It maintains the integrity of the tooth; furthermore repairs are easy to make. There may be some sensitivity, which is rare and transient.

Between cosmetic dental procedures a habituation period of a few weeks of recovery is to be expected. This meanwhile allows us to improve colour and harmonise the patient’s smile to create a naturally pleasing appearance.

Any bruxing/grinding habits and gum care will play an important role in the future longevity of restorations and dentitions as a whole. A night guard can be provided to control any bruxing.

Smile Dynamics

Note the improvement in symmetry across the midline. The surface texture and tooth anatomy, flowing with optimal lip support and symmetry.

Composite veneers are the real direct aesthetic dentistry as it tests dentist’s skills in aesthetic/cosmetic dentistry. Anyone can cut the tooth and find a good dental laboratory to make a porcelain veneer. But the problem is the tooth is cut and is gone. Therefore patients must be informed of this procedure. All our patients are informed of this procedure and give consent for any tooth invasive procedure required for porcelain veneers.


The treatment comprised:

1. Composite veneers teeth: 13, 12,11,21,22 & 23 on the upper arch and teeth 42, 41,31,7 32 on the lower arch.
2. Night guard is recommended ‐ Item 965

We need to regard this as an interim restorative measure to serve us as a guide for future reconstructions including porcelain veneers if required. 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, porcelain veneers can commence by removal of these veneers, since the teeth are sound underneath.

A direct composite veneer is an art in its purest form. Very few dentists in the world have excelled in this procedure. Today we have computer generated veneers (CAD CAM), turning out assembly line porcelain veneers. However ART remains ART when an experienced clinician commits to his craft.

Dentofacial Smile Dynamics



We pride ourselves with the quality of dentistry we provide. However, there are always limitations placed on us by materials and oral environment. One can be reassured that at the end of the treatment all should be well, however if anything unexpected does show up or unusual symptoms occur, please let me know. We are always here to look after you.

We recommend regular 6 monthly checkup and maintenance visits to help to enhance the longevity of the restorations and oral health.

Pictures speak for themselves. We improved this patient’s smile with minimal financial cost and zero biological cost.

Patient also regularly attends our centre for gum care and oral health maintenance.

One Smile says it all! All above procedures performed by Dr Sarkis Nalbandian. Please feel free to contact me should you have any queries.

Designer Smiles® is a one stop shop for most implant, surgical and reconstructive (prosthodontic) oral rehabilitation solutions. Dr Sarkis Nalbandian

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