CASE STUDY

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). 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. Tooth12 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.
   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.

Treatment planning options

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.

Treatment progress

Provisional Veneers refinedto test the systemfor 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.

Now we have the definitive final cementedporcelain 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 andimproveher 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’slip 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 Dr Nalbandian’s technical team.

Smile: tooth form shape/arch form shape/lip form/shape

& BITE CORRECTION simultaneously

Intra -Oral images showing simultaneous smile and bite correction.

The procedure required four visits

1. Assessment
2. Diagnostics mock up
3. Procedure for porcelain veneers & temporisation
4. Final porcelain veneer cementation

Please Note thefollowing 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

Natural smile

This is the art & science behind Dr Nalbandian’s creations in achieving Biomimessis.

Smile must look natural in all angles in 3Dimension.