Initial Presentation

Smile line consonant: following the curvature of the lower lip.

Patient initially presented to improve the appearance of upper teeth (gummy smile and small teeth for the size of the face). Past orthodontic treatment with good levelling and alignment.

Patient has beautiful features which will be complemented by the treatment plan.

High smile line with optimal thick lips, with upper teeth midline is in symmetry with upper lip. Symmetric lip outline at rest and full smile, however there is a general canting of the entire upper arch due to severe tooth wear.

High smile line with optimal thick lips, with upper teeth midline is in symmetry with upper lip. Symmetric lip outline at rest and full smile, however there is a general canting of the entire upper arch due to severe tooth wear.

During full smile we have asymmetrical exposure of gums, which combined with canted maxillary smile line affects facial and dental aesthetics. Vertical grower, ideal cheekbones and good symmetry across the face.

Diagnosis and treatment planning confirms the presence of maxillary excess combined with delayed passive eruption, short upper lip and severe tooth bruxing (severe bruxer who at 19 years of age has managed to wear 2.5mm of her teeth!) contributing to the current aesthetic concern. Generally an ideal treatment would include orthognathic surgical-orthodontic, followed by restorative correction; however, patient has refused any form of orthodontic/surgical treatment-invisalign/truline/lingual/labial at this stage.

• Upper skeletal and dental midlines coincide.
• Ideal cheekbones with slight nasal deviation.
• Dietary factors: considerable fruit juices, we discussed in detail to avoid acidic foods and carbonated beverages.
• The smile pattern has created flatter smile line as is evident during full smile, where the upper incisors are short and have failed to erupt to the normal smile/bite line.
• Teeth: 11, 21 41 31 with hypoplastic (white spots decalcified areas that would be treated with micro abrasion, especially on lower front 41 & 31 teeth to be treated at a later date.
• Normal range of craniomandibular (jaw) movements: function.

Diagnostics

Average tooth is 10-12mm at central incisor. The initial measurement shows centrals as being 6.5mm. Therefore gum recontouring is indicated, since the smile line is good.

Direct composite mock up. Build your Smile!

Composite mock up was completed and the patient was happy with the initial effect of gum levels, level of teeth exposure and smile line.

Treatment proposed as per composite mock up that has confirmed amount of gum and tooth exposure required for improved aesthetics and lip support on teeth 13, 12,11,21,22 & 23.

Dr Nalbandian discussed all modalities, risks and benefits of composites, porcelain and orthodontic treatment as well as no treatment. Patient was happy to proceed with composite veneers and accept gum recontouring of 13, 12, and 11,21,22,23, to balance the smile as discussed during composite mock up.

Composite mock up showed that a better more pleasing tooth/smile exposure would be achieved by improving the smile line and restoring “dark lateral corridors” –improving the length and the width of the smile (this will be combined with gum recontouring creating flow, and balancing the smile and pleasing teeth emergence profile.

We discussed all possible options of treatment;  

1. Ideal treatment using orthodontics and orthognathic corrective surgery (this is a multidisciplinary treatment but with our patient’s timeframe, this surgical-orthodontic procedure was not an option) followed by restorative correction of teeth and further smile enhancement.
2. Only restorative correction.
3. Traditional porcelain veneers combined with lower orthodontic treatment.
4. Composite veneers.

Gum lift-recontouring: One week Post OP.

This is achieved with minimal discomfort and only slight numbness to the gums. Lips are not numbed to allow lip-gum symmetry to be evaluated during surgical procedure. Healing time is about 10 days. However all patients resume work immediately. Final gum maturity is achieved after a maximum of 4 weeks. Most procedures are completed usually at patient’s request in 2-3 weeks. If you do not smoke, then we can archive healing much quicker.

Following considerable discussion of all options, we decided to proceed with composite veneers on upper 10 teeth.  This minimally invasive concept as per composite mock up will achieve the following changes;

1. Immediate cosmetic improvement
2. No intervention with existing restorations, unless replacement is required
3. Minimal post-op discomfort.
4. Easy to make modifications
5. Options for future orthodontics, porcelain veneers etc. if required

As always, following cosmetic dental procedures a habituation period of few days is anticipated. This will allow us to improve colour and harmonise the smile to create a naturally pleasing appearance.  Any sensitivity, which is rare, if present is usually transient.

Any bruxing/grinding habits will compromise the future longevity of restorations and dentitions as a whole. A night guard may be provided to control any bruxing.

Summary

The treatment fee is outlined as follows:

1. Gum lift (teeth: 15,14,12,22,23,24 & 25), some form of contouring of teeth 12 & 22 to allow better tooth emergence profile and composite veneers teeth: 15, 14, 13,12,11,21,22,23,24 & 25. Items 582×10/245 x 8
2. Night guard may be required – item 965

Most importantly this treatment is conservative and the least biologically invasive to the tooth structure. It will maintain the integrity of your tooth structure and repairs are easy to make.

We need to regard this as interim restorations to serve us 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. In the future porcelain veneers can commence by removal of these veneers, since your teeth are sound underneath the composite veneers.

We pride ourselves with the quality of dentistry we provide 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, please let us know. We are always here to look after our patients. Regular 6 monthly check-up and maintenance visits help to enhance the longevity of the restorations and oral health

Final completed smile and a happy patient with full confidence

Note that the gums are healing after 2 weeks of gum lift and direct composite veneers.

We enjoy and share our patient’s happiness and her new confidence that glows.

Six months post op

The so called gummy smile does not look gummy anymore because the dentofacial dynamics are balanced. If we removed excessive gums, then teeth will look disproportionately long to the face!

Therefore one must evaluate the whole facial dynamics of expression, beauty and balance. There are many gummy smiles that are beautiful.

Have you noticed your friends with gummy smiles, and as they age some how they look more youthful then those who did not show any gums during speech and smile? This is more evident in women than men. Women prefer to show at least 4-5mm of teeth during rest and 10mm at least during full smile!

Well as aging progressses and we lose facial fat, collagen and elastic fibres, the upper lip loses its thickness and elongates which can go from 3mm-5mm on average. Eventually they no longer have a gummy smile, but a youthful smile! However those without gums showing, eventually show a reduced amount of teeth (refer to antiaging menu)