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.
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
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
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
No Orthodontics /
No Orthognathic Surgery
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.
Importance of single items measuring dentofacial aesthetic concerns
Overall facial appearance
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.
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.
DIAGNOSTICS: Composite mock up
Frontal and Sagittal view of diagnostic smile mock up. Note improved aesthetics.
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.
In summery we have the following concerns;
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;
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
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.
The uses of operating microscopes for prevention and maintenance in reconstructive dentistry are four-fold:
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.
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:
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.