DIAGNOSTICS

DIAGNOSTICS: why see a specialist?

Diagnostics: Treatment directed to facial balance

During the first consultation, Dr Nalbandian discusses all the options available to a patient, including the consequences of proceeding with no treatment. This is a critical decision making process. This is about the patient and how they face the world. It is about the confidence and realities of life. Beautiful smiles help to make beautiful people. He encourages them to look at their own teeth in the mirror and talk about what they like and do not like. When both parties are satisfied with a suitable treatment leading to the best result for the patient, they will proceed. We need to look at the scientific rationale: Is the treatment sound? Does it fulfil improvement in health, function and aesthetics?However, the key issue is to inform the patient before the treatment.

Let’s get to know each other.

Diagnosis & Patient centred treatment planning

Once we have determined their needs and expectations and when the patient is ready, we begin to restore their teeth to optimal function and aesthetics. This can be done all at once or over a period of time, whichever is suitable to the patient. Due to the multi-disciplinary nature of many treatments, every aspect is coordinated with the referring dentist and other dental specialists. The prosthodontic reconstruction involves fillings, veneers, crowns, bridgework, dentures and implants, to ensure optimal aesthetics and function. Dr Sarkis Nalbandian considers the use of magnification reconstructive dentistry and implant surgery as leading-edge technology, essential to the delivery of high quality service.

“One of the most dangerous diseases is diagnosis”

… George Bernard Shaw

The question is “Can we deliver?”

And this is why we need diagnosis.

Diagnosis involves

Consultation & examination
Special tests: x-rays, CBCT, study models, Intraoral scanning, images, direct composite or diagnostic wax up, provisional restorations
Referral to other specialist colleagues

There is only one diagnosis and many ways for treatment. Incorrect diagnosis will lead to incorrect treatment.

Let me help you achieve your desired dentofacial aesthetics, tooth replacement even a simple dental filling!

Diagnosis takes time, expertise& patient involvement for that special gift: your oral health and your smile!

When it comes to aesthetics or complex oral rehabilitation, we need to visualise the treatment outcome.

Consenting process is not signing on a piece of paper
Or digital manipulation It takes time

Therefore we want you to understand the following:

The need/rational for treatment
The nature of treatment
The effects, risks & benefits
The likelihood of success
Length of treatment
Any alternative treatment
Cost of the treatment
The consequence of no treatment
Specifically tailored for you the patient

This is to help you to understandthe limitations, risks and modalities of treatments.

The level of tooth display

Arch form

Gum line

Lip line, thickness and outline

Dynamics of smile and speech and level of tooth exposure on both arches.

NEED VIDEO OF ELENA, GEORGINAL AND ME -IM TAKING PHOTOS-IN HER PP

We ask the help of our patients for that important decision-making process during diagnostics

Understanding form, function& aesthetics and sharing clinical findings with our patients.

Building rapport with our patients is an integral part of my practice.

DIAGNOSTICS: Do you see what I see?

NEED VIDEO OF ELENA MOCK UP AND ME -IM TAKING PHOTOS-IN HER PP

You see in poetry, which I enjoy, one paints a picture in the mind.

However, aesthetic dentistry is poetry in motion.

The dynamics of a smile, facial expression, teeth display, lip frame, the eyes, the cheek bone

All these features combine to form aconcerto and this is music to the eyes!

As a specialist, I see the whole picture and this is where science merges with art.

I see a beauty & elegance, don’t you?

Final treatment outcome and we have a happy patient

We have restored aesthetics, however most importantly we have complemented our lovely patient’s facial aesthetics.

Hence the term: dentofacial rejuvenation by Dr Sarkis Nalbandian

Final treatment outcome and we have a confident and happy patient

Facial Proportions & Symmetry

This most attractive patient with ideal facial proportions presents with dental asymmetry that was corrected initially using composite mock up to visualise the treatment possibilities. The lower arch crowding was not a concern.

In an ideal world we would consider orthodontics and surgical correction on both jaws to;

Reposition maxilla (upper jaw) and mandible (lower jaw) followed by restorative correction.
However surgical correction and orthodontics in this case would have affected the” cuteness “of the lip thickness, outline, symmetry & support that is an integral part of facial aesthetics.
Patient had consulted numerous surgeons who also confirmed my clinical findings.

As a specialist in reconstructive dentistry, the diagnosis & treatment planning is the key to optimal aesthetic and functional outcome.

Note the canted maxilla, that also creates a canted gummy smile. Excessive gummy smile is possibly due to delayed passive eruption or vertical maxillary excess.

The Power of Direct Kesling set up year 2003

Direct composite Mock Up

Case is easily solved with small gum lift on teeth 12,11(marked in black) and composite veneers. In the future porcelain Veneers can be considered

One Visit Smile Lift
Minimal
Intervention
No Orthodontics /
No Orthognathic Surgery
No Discomfort

No patient burnout

10 years post op note how elegant the lips are formed. The fullness of lower face & pleasant aesthetics.

Orthodontic & surgical intervention would have destroyed that delicate balance that existed for an optimal facial aesthetics in this case

In this case the composite veneers after few years appear slightly discoloured, however it can be replaced with another composite and porcelain veneers, since the lip support and that “cuteness”” of the lips are maintained over 13 years and more with minimal intervention aesthetic dentistry.

When patients ask why do we have to pay for diagnostics?

Because this is more important than treatment. That’s why you are seeing the specialist.

As a specialist prosthodontist, I also coordinate complex multidisciplinary treatments involving an orthodontist, periodontist, paediatric dentist and oral-Maxillofacial surgeons.

Here are some examples of patients presented. You may find more detail writing in this site-provide link

I sincerely believe that we have achieved the desired functional and aesthetic reconstructions to complement our beautiful patients.

All the procedures were performed by Dr Sarkis Nalbandian, specialist in Reconstructive Aesthetic & Implant Dentistry

Education and Experience are everything.

Something to think about

Art & Speed Do Not Mix

Must Think in 3D and Visualise

4th Dimension – TIME: affects people with all ages. All we want is a youthful and fresher look.

Composite Veneers

Lithium DisilicateeMax™ Porcelain veneers 10 years later we have more youthful & fresher look

Importance of single items measuring dentofacial aesthetic concerns

Overall facial appearance

Tooth alignment

Tooth shape

Worn smile

Initial presentation
Worn upper front teeth
Worn reverse smile line

Final Presentation 2007
Smile rejuvenation with
CompositeVeneers
One Visit Smile Lift

Initial presentation

Direct Composite mock up - Kesling set up

Final Presentation
Composite Veneers

After 10 years we are ready for new restorations since composite veneers are in need for replacement. Patient decided to proceed with porcelain restorations

Porcelain veneers, Implant & tooth supported crowns

Can you tell?

Porcelain veneers, Implant & tooth supported crowns

10 years later we have more youthful & fresher look

Why? Because we planned this 10 years earlier wit initial diagnosis and treatment planning. We planned for the future and not simply for present.

This elegant smile belongs to this beautiful patient

This is why you need a specialist for Correct diagnosis & treatment planning since many reconstructive cases are simply complex

I spend considerable time in educating post graduate students the importance of integrating art & science in dentistry.

Case Study 2 Presentation: complex smile with skeletal class III anterior open bite.

Oblique and Sagittal views showing the severity of the anterior open bite

Examination, study models, photos and x-rays confirm the presence of anterior skeletal open bite. There was also general canting of the teeth 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.

Anterior open bite, creating anterior negative space: affecting speech and aesthetics.

Note anterior open bite, creating anterior negative space, affecting speech and aesthetics.

Adequate periodontal (gum stability), Normal Craniomandibular (jaw) function. Skeleta class III anterior open bite.

DIAGNOSTICS: Composite mock up

Frontal and Sagittal view of diagnostic smile mock up. Note improved aesthetics.

Treatment Objectives

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 bit and midline deviation. How do we plan 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 & dentofacial aesthetics. This is where Art meets Science.

Direct composite mock up: Correct diagnosis and treatment planning is the key to successful outcome.

We ask the help of our patients for that important decision-making process during diagnostics: Following composite mock up, we assessed the speech, smile line and aesthetic in general. Speech was improved, with diminished residual lisping remaining. Patient can see the end point of treatment. Initial diagnostic AESTHETIC INTEGRATION complementing the Dento-facial aesthetics of this elegant patient.

We discussed using composite or porcelain veneers as well as orthodontic/surgical correction, however due to time factors and at this stage in the patient’s life, an orthodontic/surgical treatment was not an option for the patient. There are always simpler and minimal invasive alternatives. Dr Nalbandian wears “7 hats”in critical decision making process for the best possible outcome for our patients.

DIAGNOSTICS: DIRECT COMPOSITE MOCK UP: Sagittal View

DIAGNOSTIS: DIRECT COMPOSITE MOCK UP: restoring symmetry, complimenting patient’s Dentofacial aesthetics. Frontal view

Diagnostics: For our patients to see the dramatic effect of the aesthetic direct composite mock up.

Immediate post op: ONE VISIT SMILE LIFT. No pain, No injections. Non invasive smile make over. The TV shows of extreme makeovers involved destruction of sound tooth structures. Dr Nalbandian can achieve in most cases the same makeovers in one simple visit with minimal intervention dentistry.

Immediate post op: ONE VISIT SMILE LIFT. No drilling, no injections and no pain.

PRESERVING BIOLOGY: DIRECT AESTHETIC COMPOSITE RECONSTRUCTIONS

The key to ultimate aesthetics is to maintain biology! Indiscriminate tooth cutting does not make a dentist a great cosmetic dentist. Good aesthetics is to imitate nature.

Whenever possible, Dr Nalbandian will do everything possible to maintain tooth structure integrity. There are many options of treatment. The best option is tooth conservation when it comes to aesthetics.

Aesthetic Dentistry is imitation in Greek wording meaning “mimesis” as defined by Aristotle. What we are doing is imitating the nature.

Specialised knowledge and experience is required to create these beautiful smile

Dentofacial aesthetics: imitating the nature in with composite technology developed at Designer Smiles by Dr Sarkis Nalbandian

Multiple Missing Teeth: Complex Smile Dynamics-Both arches on the “show”

This is a high aesthetic zone and quite a difficult case. Note high smile line, where teeth on the both arches are on the show.

Placement of three implants on upper jaw supporting four missing teeth and two implants on lower jaw to support six missing teeth.

Patient wears a partial denture that is causing discomfort, during function and phonetics, not to mention poor aesthetic presentation that has haunted this lovely patient since childhood, affecting her confidence.

Critical planning & assessment is required.

The aim is to maintain her gum architecture and “fit” the teeth on the gums to create a natural emergence profile, as if the implant supported tooth is growing out of the gum.

Careful planning and understanding of all biologic-aesthetic parameters are required to biomimetics: biologic-aesthetic integration whenever possible.

Naturally we cannot control biology, but critical implant positioning and aesthetic planning helps the aesthetic integration.

High smile line, difficult with implants to always achieve optimal aesthetics
Patient has good oral hygiene, healthy no known allergies
Regularly attends her recare visits at the dentist
Good bone support
Thick gingival biotype: this helps to form the nice madding – the gums around the implant crown.
Both arches and the gums are on the show
Smoker- Patient was strongly advised to quit smoking-quitted!

In summery we have the following concerns;

Bone deficiency support/gum contour
Post operation healing and gum maturation as we may have some implant greyness showing through the thin bone and the gum tissue where should the gum recession occur in a high smile line (gummy smile) affecting the crown/tooth exposure levels, smile line.

These two points are clearly pointed out to simply assure the patient that every effort will be made to enhance the outcome of aesthetics.

The smoking must cease to help implant healing and tissue grafting process; otherwise we may have a catastrophic failure. The Idea is to generate an excess gum tissue for better maintenance and preservation of gum aesthetics. I may also elect to consider a connective tissue graft to thicken the tissues as well. This is more relevant to the upper jaw. Implants proposed are;

Three on the upper jaw at sites: 13 to support two teeth (13 & 12) and sites 23, 22 (supporting teeth 23 & 22).
Two on the lower arch at sites 43 & 33 to support six- unit bridgework. Tooth 73 (deciduous tooth at site 33 is about to exfoliate).
Once the implants have integrated with the bone, the aim is to construct aesthetic crowns and bridgework (ovate) pontics (missing teeth replacement), as well as closing the midline space (teeth 11, 21 using composite or porcelain veneers).

Complex smile line.

Al the teeth and gums are on the show on both arches.

Complex Smile Dynamics-Both arches on the “show”

Dr Nalbandian assesses the following;

Upper and lower

Lip symmetry

Gingival symmetry

Ridge shape angulations

Note how the implant crowns emerge from the gum.

We not only have the implants integrating with the bone but soft tissue integration is also achieved. We have achieved an aesthetic Integration.

Restoring the anatomy: mimesis-imitating nature (Aristotle)

Note how the implant crowns emerge from the gum.

We not only have the implants integrating with the bone but we have achieved an aesthetic Integration.

Dr Nalbandian has discussed the complexity of the treatment in detail. Patient also followed all the instructions outlined, so we can achieve a favourable outcome.

This elegant result can only be achieved by a realistic patient who has a realistic expectation. The complexity of the case as discussed in detail:

Patient to quit smoking and maintained regular professional hygiene and home care.

High smile line with complex smile dynamics, where everything is on the show is a most difficult aesthetic dilemma to reconstruct, especially where dental implants are required.

We thank our patient for her commitment to achieve an optimal aesthetic, comfort and function.

X-rays showing the position of the implants in both jaws with optimal bone support. Planning for success is not always simple and depends on the dentist, patient and most importantly the BIOLOGY. Achieving that level of aesthetics is complex, but not impossible. In summary, prosthodontics requires the training and qualification to deal with complex dental health problems. Dr Nalbandian has attended an internationally recognised and formally structured university program to give him the extra skill and knowledge required to plan and manage complex dental problems. The qualification takes several years of training and practice. This has been over 7 years of post-graduate University training, multiple examinations etc. For instance, rather than simply providing cosmetic solutions, which after all, only focus on “how things look”, he is trained to correctly diagnose and treat any underlying problems beforehand. This concept is carried over into all aspects of reconstructing or improving smiles and appearances, including fixed or removable teeth, giving the patient a long-term result rather than a “quick fix” which might break down early or even damage the teeth. The implant surgery involves additional skills obtained for surgical planning and placement of dental implants as an overall diagnosis and treatment for our patients. To gain any formal post graduate qualification, one must have their relevant knowledge tested in any examination or pass any professional critical review process at world class universities. In other words, doing 2-day motel course does not make a dentist an implantologist or an expert in reconstructive dentistry. Dr Sarkis Nalbandian is a Specialist Prosthodontist and an Implant Surgeon. This dual qualification helps the patients to have both implant placement and reconstructions completed in one roof with reduced costs. Our diagnostic centre is unique and you the patient can have all the relevant diagnostic information in one centre at Cremorne. Our referring dental colleagues like this because their patients are looked after in one centre and by a specialist who cares about his patients just like his own family.

The Bride is Ready!

Pleasant aesthetic achieved for this beautiful patient

Magnification

The uses of operating microscopes for prevention and maintenance in reconstructive dentistry are four-fold:

Following insertion of restorations, there is the advantage of being able to track any problems by periodic video examinations utilizing the intraoral camera. Visible and sometimes invisible potential marginal problems can be greatly enlarged. Certainly, the ability to diagnose and treat a defective margin as early as possible can prolong both the aesthetic and functional life of restorations.
Patients cannot see for themselves what we can see; thus, highly enlarged views made available by operating microscopes enhance patient compliance in home care. Typically, patients wait until something is sensitive before seeking treatment. Periodic examinations utilizing the intraoral camera can play a significant role in prevention of inevitable aesthetic failure due to marginal pathology.
Operating microscopes can and should also be used to show patients areas of their mouths that lack proper hygiene maintenance. For example, enlarged lingual views give patients the opportunity to see the inside of their mouths like never before.
One of the most frequent causes of restoration failure is lack of gingival hygiene, with both flossing and brushing. When images of the mouth are magnified while the explorer is used to remove plaque from the sulcus, patients become visually aware of the importance of ongoing maintenance. Restoration longevity is normally expressed in averages. For instance, full crowns is 5 to 15 years. However, a patient should be aware that not even the normal range of life expectancy will be achieved unless these gingival areas are maintained on a daily basis.
Operating microscopes are also highly useful in showing patients existing micro cracks. These micro cracks (in teeth and restorations or crowns with less than ideal marginal integrity) can stain and cause other aesthetic problems for patients. Photographs and permanent records of these micro cracks can be of tremendous benefit to the patient in accident cases. Documentation of micro cracks also provides a baseline for assessing subsequent staining or changes. Link to cracked teeth
The intraoral camera can be used to magnify and photograph areas of obvious bruxism. Identify problems at subclinical stages before it is recognised clinically by the patient who has persistent discomfort.

Dr Nalbandian uses special Leica ® operating microscopes due to the delicate nature of his work. Magnifications at 10 x plus improve accuracy and comfort to our patients saving a multitude of problems later on.

Children also visit our practice as we also cater for the whole family. Dental visits are fun and educational and children’s curiosity is amazing. Our staff are highly trained in today’s multifaceted and sophisticated dental care.

Experience and post graduate training is mandatory for thorough diagnosis and treatment planning to deliver high quality care to our patients.

Our practice provides a full range of diagnostic services including digital x-rays, OPG’s and CT (CAT SCAN). It is a one stop shop for all dental needs from simple to full mouth rehabilitation using tooth or implant supported restorations.

Diagnostics:

Benefits the patient
Immediate diagnostic information for the patient and the dentist
Saves crucial time in your busy life
We can also diagnose other dental concerns at the same time as the scan sees all the structures around the teeth, jaws and face

Dental implant supported teeth require additional expertise, because the patient does not want a titanium screw in their mouth, they want teeth! It is all about the patient. Dr Nalbandian has placed and treated thousands of patients from single teeth to complex full mouth implant supported bridgeworks. Our centre is equipped with state of the art diagnostic facilities (CT scans, digital x-rays & imaging). His dual specialised qualifications in both implant surgery and prosthodontics (oral reconstruction) helps the patients complete all the procedures in “one stop shop”, which save time and the cost of the delivery of the treatment. This is also a referral practice from other dental surgeons for complex implant reconstructive & cosmetic cases.

Link to Scanora PDF and comparable Radiation Data ( provide a link) for our Cone Beam CT (CBCT)

Integrating Cone Beam CT in my practice over 10 years

This has provided my practice with the convenience of having diagnostic information at my fingertips and I have been very happy with this system. Patients are happy to not be referred elsewhere for radiography.

Today time is an issue, not only for the patient but also for the dentist.

The CBCT available today has a much reduced radiation level and produces images which are clear and software friendly to use. Patients appreciate seeing their CT images on the screen immediately and are thrilled to be involved in their diagnosis and treatment planning. This has become a standard of care in the diagnosis and consenting process today.

Our diagnostic information not only requires simple assessment in 2D, especially in my practice of Implant Surgery and Prosthodontics, but in 3D where immediate diagnosis is required. This information is crucial to patient treatment especially those travelling long distances to come to our practice.

Having 3D images and the ability to reformat in different sections is immensely valuable to diagnosis and aids in all disciplines of dentistry. In my practice I need information NOW! And can get this NOW!

The new Scanora 3D helps me taking CBCT (cone beam CT) and sending the copies of the CD to my referring dentists for continual care of their patients. It is also very valuable when referring to colleagues such as ENT surgeons, OMF surgeons and orthodontics.

The diagnostic information obtained from CBCT in many ways depends on your treatment requirements and diagnostic assessment.

Here are some of the points worth mentioning:

Prosthodontic and Implant Surgery: 3D, reslicing at any angles, nerve tracking, and 3D guided surgery applications, panoramic images that are second to none. TMJ provides the anterior and laboured views.
Periodontics: assessing amount of bone support in 3D-this visual process is the best diagnostic and essential for patient education. Patients do not understand periodontal charting and plaque scores, but can see the bone loss, tooth migration and over eruption in the 3D image.
Orthodontics: orthodontic diagnosis in 3D, Cephalometric in with 3D analysis, superimposition: measuring/comparing tooth movement, pre/post orthodontic measurement, volumetric space change etc. This combined with 3D imaging will change the face of orthodontics. Assessment during orthodontic treatment for implant surgery and grafting. Small tooth movements in simple tooth movements using TAD (temporary device anchorage).
Sleep Apnoea/anti snoring adjunct diagnosis and therapy. Measuring 3D volumetric space: the physical airway, video viewing, and excellence in patient education.
The Scanora 3D is two systems in one, with true digital panoramic and low dose CBCT with four different fields of view.

Having this information at your fingertips is Gold! A new era has begun.

This is the ‘Gold Standard ‘in diagnostics.

This means our patients do not have to wait weeks for correct diagnosis and treatment planning, when most of the time this is done immediately, since the information is on the screen.

Special diagnostic measures such as composite mock-ups (trial restorations) help the patient to visualise their results from simple aesthetic to complex reconstructive procedures. It is all about helping our patient in communicating all steps of the required procedures.

DIAGNOSTICS: why see a specialist?