Video: Smile & Bite Symmetry & TMD/TMJD
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:
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).
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:
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
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.
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.)
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.
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 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
Simultaneous smile and bite correction.
The procedure required four visits:
Please Note the following improvements:
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.
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