Designer Smiles
CASE STUDY- 4 MARIA MACRIC

Smile & gum lift

Restore facial volume& facial form 

Failed aesthetics: childhood trauma

This beautiful Ms.M presenting with childhood accident resulting in intraoral scarring (drinking caustic soda at 2years of age)has left extensive oro-pharyngeal scarring resulting in partial loss of tongue and developing tooth germs. This has caused immense functional and aesthetic disability over the years. Cutaneous grafting and mouth floor reconstruction has helped to a degree.

Due to scarring the lower facial height growth has been affected, the alveolar bone that houses the teeth have failed to develop preventing natural lip support and increased facial folds not commensurate to this young patient. One would agree that Ms. M looks much older than her true age as a result of childhood accident.

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Past surgeries during last 3 years for tongue lifting and muscle expansion, unfortunately has not been successful.

Intraoral scarring has affected tongue volume, mouth volume and reduced normal jaw –teeth development: reduced facial height (reduced occlusal vertical dimension).

Currently the main complaint was to improve her smile and eventually replace missing teeth.

Treatment: reconstruction of maxilla (upper arch) and mandible using initially orthodontic intrusion; leveling and positioning maxilla (upper arch) in correct position to restore the lost facial height(volume), followed restorative correction. Each step was orchestrated as per diagnostic mock up and always in consultation with this beautiful girl who has waited forover  30years!

This study will show

  • Complexity of treatment
  • Treatment outcome
  • Patient’s assessment
  • Please refer to the video provided

 

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Initial Presentation

Patient was referred by her employer and friend, seeking specialist’s opinion and treatment in relation to fixed option of restoring dentofacial aesthetics. The scarring from childhood trauma has left considerable soft and hard tissue defect reducing affecting access for reconstructive dentistry.

Chief concerns: improving  the aesthetic apperance of  her smile. The concern is to improve the upper arch shape and smile line as well as tooth colour. This lovely patient wants to smile with confidence and feel beautiful.

Diagnosis:  Unacceptable dental aesthetics & function due dissatisfaction with failing fixed restorations, general tooth discolourationand peri-oral scarring due to childhood accident

Following the diagnostic mock-up, we achieved the following;

  1. Improved upper arch form teeth display
  2. Improved level of teeth display, shade and shape of teeth.
  3. Symmetry across the midline
  4. Arch width & lip/facial support improved lip symmetry
  5. Optimal speech, comfort and smile dynamics.
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Diagnostic mock-up: improved confidence & smile

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Our Aim:  to improve the aesthetics of upper and lower arches: Gum level, arch shape and positiontooth shape, display, tooth colour, length, symmetry and smile line in general, as well replacing missing teeth. The aim is to complement Ms M’s facial aesthetics

This was accomplished with minimal discomfort to the patient (please refer to Videos provided).

Treatment

Following with discussion of all risks and treatment modalities with our patient that included

Levelling and alignment with an orthodontic treatment. The primary aim is to correct the dental/facial midline, proclining upper fron teeth, improving upper & lower facial profile.

Frontally it is evident that maxillomandibular complex is “retroclined and rotated” within the facial frame. The ideal treatment is orthodontic and orthognathic surgical followed by restorative correction. However, since this beautiful girl having multiple dental-surgical treatments in the past, time factors, life factors, were all taken into account for patient centered treatment planning. Therefore, prolonged surgical-orthodontic treatment at this stage in her life is not an option. 

  1. No treatment: this is not an option as the restorations are failing and affecting longevity of supporting teeth
  2. Repair existing restorations and make removable partial denture: this is a temporary measure and not accepted by the patient
  3. Orthodontic treatment to intrude and procline upper teeth: accepted by Ms M
  4. Finalize the treatment with gum lift and composite veneers on both arches: accepted by Ms M
  5. Future porcelain and implant technology will be considered; accepted by Ms M

Procedure &Results

Let the treatment begin!

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Orthodontic leveling and alignment using: TAD to intrude and procline maxillary anterior(front) teeth.

This was followed by as per diagnostic mock up gum lift and composite veneers

Note improvement in lower facial volume

Lip support and jaw line

The work was completed in 18 months using orthodontic treatment with PAOO (this is to speed up the orthodontic treatment process in reducing 50% of the time to treat) and TAD (temporary anchorage device) to intrude upper six teeth, followed by gum lift and composite veneers. It is best not to rush biology and allow optimal healing.

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Final treatment outcome and we have a happy patient

Note improvement in lower facial volume

Reduced facial folding

Full natural smile

No facial musculature exertion during smiling

Beautiful lips and beautiful teeth

Beautiful face

As a specialist in aesthetic and reconstructive dentistry this lovely patient “the Girl from Brazil” having been through so much in life, never failed to amaze me with her sincerity, gracefulness and patients.

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To “The Girl from Brazil”

I thank you for giving me the opportunity to treat you and thank you for allowing me to share your story with the world.

Because there is always a hope.

Dr. Sarkis Nalbandian

Registered Specialist   

Prosthodontist & Implant Surgeon
B.D.S. (Hons), Dip. Clin. Dent. (Oral Implants) Uni Syd, M. Clin. Dent (Prosth) King’s College, Uni London

  1. Clin. Dent (Prosth) Uni Syd, FRACDS, MRACD (Prosth)