Designer Smiles
Complex Aesthetics: Anterior Skeletal Class I/ III Open Bite

Correcting bite problems and improving aesthetics.

This patient initially presented with:

  1. General tooth discolouration.
  2. Concerned about “The problem of having an uneven bite. The gap between my upper and lower teeth, uneven bite that is causing a lisp: Hoping to correct the bite and remove the lisp.” Due to anterior open bite “V” shaped upper arch, and the large negative spaces were present bilaterally. Presence of considerable lisp which may be related to an anterior open bite due to childhood thumb sucking. Residual tongue thrust is also present.
  3. The presence of uneven lower anterior teeth.
  4. Wish to improve her smile.

Examination, study models, photos and x-rays confirm the presence of general discolouration. There was also general canting of the tooth alignment and of the centreline. The smile line also canted to the left (lower). There is also canting of the midline and uneven gum line, where the premaxillary (upper front part of the jaw) segment has tipped upwards and maxilla normal growth downwards.
Because the patient tends to grind on the back teeth, this can result in possible propagating crack, hence the suggestion of a night guard once treatment is completed to protect the teeth and the new restorations.

Adequate periodontal (gum stability), normal craniomandibular (jaw) function. Skeletal class I/III anterior open bite.

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Treatment Plan The aim of the treatment is to improve dental harmony to complement the facial appearance of this beautiful patient. We need to correct the jaw discrepancy, anterior open bite and midline deviation. How do we know if our proposed changes will work? It is a system developed by Dr Nalbandian that involves direct application of proposed tooth coloured material on teeth without bonding to assess speech, comfort, dental aesthetics and dentofacial aesthetics. This is where art meets science. Following composite mock-up, we assessed the speech, smile line and aesthetics in general. The speech was improved, with diminished residual lisp remaining. Comfort and aesthetics were also improved.
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We discussed using composite or porcelain veneers as well as orthodontic/surgical correction, however due to time factors and the stage of the patient’s life, an orthodontic/surgical treatment was not an option.
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Diagnosis:Direct composite mock-up restoring symmetry, complementing patient’s dentofacial aesthetics. The composite mock application allowed us to assess the effect of tooth alignment, future tooth colour, arch broadening and tooth emergence and arrangement across midline as well improving the smile line and general symmetry. Speech function was also satisfactory after the mock up.
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Using composite veneers is a conservative treatment, since there is minimal intervention to the teeth and a biologically favourable treatment. We also discussed no treatment and consideration of porcelain veneers, which we both agreed in this case would possibly be an invasive treatment. Considerable tooth preparation would be required, which is irreversible, and therefore opted for composite veneers on upper teeth: (14, 13,12,11,21,22,23 and 24). The lower front teeth (4 and 31) will be slightly built up and selective composite placed to improve general tooth alignment.

At this stage we decided to proceed with composite veneers, which are adequate from tooth conservation point of view and the fact that modification in shape contour, colour is easily achieved. Naturally some teeth will require slight recontouring (upper front teeth: 11, 21) as discussed to improve the emergence profile and tooth arrangement. Some period of habituation will be also required, which is usually transient. This will improve colour, broaden the smile line and aesthetics in general. Slight gum recontouring at 14 may also be required.

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We need to regard this as a long term provisional measure to serve as a guide for future reconstructions: porcelain veneers if required. However we can from time to time extend the life of these restorations by resurfacing the veneers with new composite materials at a minimal cost.

We pride ourselves with the quality of dentistry we deliver however, there are always limitations placed on us by materials and oral environment. One can be reassured at the end of the treatment that all should be well, however if anything unexpected does show up or unusual symptoms occur we are always here to look after our patients. Regular 6-12 monthly check-up and maintenance visits help to enhance the longevity of the restorations and your oral health.

We always stress that bruxing/grinding habits will play important role in longevity of the restorations and dentitions as whole.

The Reconstructive / Restorative phase

Composite veneers on teeth: teeth: 14, 13, 12, 11,21,22,23 and 24. The lower teeth (41 & 31 small built up), slight recontouring, any selective composite placement to improve general tooth alignment and night guard.  The lower cervical erosive lesions (teeth: 34, 36, 33, 43, 44 & 45) would also be restored with composites.
Aesthetic Dentistry is ‘imitation’, derived from the Greek word “mimesis” defined by Aristotle. What we are doing is imitating nature.
Specialised knowledge and experience is required to create this beautiful smile.
Dentofacial aesthetics: imitating nature with composite technology, developed at Designer Smiles by Dr Sarkis Nalbandian.
Composite veneers on teeth: (14, 13, 12, 11,21,22,23 and 24). The lower teeth (41 & 31 small built up), slight recontouring, any selective composite placement to improve general tooth alignment and night guard. The lower cervical erosive lesions (teeth: 34, 36, 33, 43, 44 & 45) would also be restored with composites.

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Aesthetic Effect
Should establish harmony and balance between dentition and surrounding soft tissues

This is aesthetic dentistry at its best. Remember no teeth were cut. Zero tooth invasion. Why?
Because the teeth underneath are intact!
One Smile says it all! It was a pleasure treating this charismatic patient!
Final treatment outcome and we have a happy patient
However most importantly we have complemented our lovely patient’s facial aesthetics.

Hence the term: dentofacial rejuvenation by Dr Sarkis Nalbandian
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

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