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Multiple Gaps Between Teeth
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Multiple Gaps Between Teeth - Patient Story

This quite upcoming and soon to be famous opera singer and actor were referred by his dental practitioner, presented with request for improving his smile (wants to brighten up his smile and close the spaces on upper (13-23) and lower (42- 32) anterior teeth) using minimal or zero tooth intervention approach. Examination, x-rays, images & study models confirmed the following:

  1. Close the spaces (gaps) of upper and lower front teeth
  2. Prominent (pointy) canines
  3. Flaring of upper teeth
  4. The reverse smile line was most evident during his professional performance
  5. Mouth breather & anterior tongue thrust

The high smile lines with the upper teeth midline are in symmetry with the upper lip. During full smile we have symmetrical exposure of gums while both upper and lower lips are symmetrical. After the composite mock up a more pleasing tooth/smile exposure would be achieved by closing the large spaces, improving colour and tooth anatomy (aesthetics) of ten teeth (six upper teeth: 13, 12,11,21,22 & 23 and four lower teeth: 42, 41,31, 42, 32). The periodontal (gum) health is excellent and the patient has good oral hygiene. All teeth tested vital. Normal range of craniomandibular (jaw) movements and function.

Clinical and diagnosis established the formulation of the following treatment plan: Placement of direct composite veneers on seven upper front teeth (13, 12,11,21,22, 23 and 24) and selective composite additions on 41 and 42 as a non-invasive option of treatment.

Diagnostics

Direct Kessling set up. Composite Mock up establishes:
  1. Overall Dentofacial aesthetics
  2. Speech
  3. Comfort
  4. Patient tolerance-habitation level
  5. Assess smile line, teeth arrangement, gum symmetry

Direct Kessling set up. Composite Mock up establishes:

    Desired tooth form/shape
  • Symmetry across the midline
  • axial tooth alignment
  • Lip support and profile

Composite mock up helps both you (the patient) and myself assess:

  1. Overall Dentofacial aesthetics
  2. Speech
  3. Comfort
  4. Patient tolerance-habitation level
  5. Assess smile line, teeth arrangement, gum symmetry

Note immediate improvement in both arches. Overall Dentofacial aesthetics. Smile line, teeth shape, teeth arrangement, gum symmetry and teeth display. Correction of Reverse Smile Line.

Note immediate improvement in both arches. Overall Dentofacial aesthetics. Smile line, teeth shape, teeth arrangement, gum symmetry and teeth display. Correction of Reverse Smile Line.

Diagnosis: reverse smile line with multiple spaces. After considerable discussion regarding all options of treatment, including porcelain veneers as well as no treatment and the consequences of no treatment we agreed to proceed with composite veneers as per patient request.

Orthodontic treatment in this situation to close the spaces is contraindicated, because we have a tooth mass problem. This means we have lack of tooth mass for the size of the dental arch, therefore best treatment option is additive: hence zero tooth intervention. This treatment can be considered using either composite or porcelain veneering system. The cost was the determining factor for patient decision making process.

Naturally porcelain veneers were also an option, however finances were a major concern for this patient.

Lower arch aesthetics is also an essential part for this professional actor and singer. May I also say that most patients presenting in our surgery also ask for improvement of lower teeth aesthetics. This is more evident during 35-45yrs as lower lip drops slightly as part of aging process.

Treatment

Note the improvement in symmetry across the midline. The surface texture and tooth anatomy, flowing with optimal lip support and symmetry. Most importantly this treatment is the conservative and least biologically invasive to the tooth. It maintains the integrity of the tooth; furthermore, repairs are easy to make. Any post op sensitivity, is rare and transient.

Pictures speak for themselves. We improved this patient’s smile with minimal financial cost and zero biological cost. Patient also regularly attends our centre for gum care and oral health maintenance.

Final Outcome

A direct composite veneer is an art in its purest form. Very few dentists in the world have excelled in this procedure. Today we have computer generated veneers (CAD CAM), turning out assembly line porcelain veneers. However, art remains art when an experienced clinician commits to his craft.

  1. Speech dynamics was maintained and smile dynamics improved.
  2. Softening of prominent canines

The treatment comprised: composite veneers teeth: 13, 12,11,21,22 & 23 on the upper arch and teeth 42, 41, 31 and 32 on the lower arch. Night guard is recommended – Item 965.

We need to regard this as an interim restorative measure to serve us as a guide for future reconstructions including porcelain veneers if required. 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 the teeth are sound underneath.

We recommend regular 6 monthly check-up and maintenance visits to help to enhance the longevity of the restorations and oral health.

A direct composite veneer is an art in its purest form. Very few dentists in the world have excelled in this procedure. Today we have computer generated veneers (CAD CAM), turning out assembly line porcelain veneers. However, art remains art when an experienced clinician commits to his craft.

  1. Speech dynamics was maintained and smile dynamics improved.
  2. Softening of prominent canines

The treatment comprised: composite veneers teeth: 13, 12,11,21,22 & 23 on the upper arch and teeth 42, 41, 31 and 32 on the lower arch. Night guard is recommended – Item 965.

We need to regard this as an interim restorative measure to serve us as a guide for future reconstructions including porcelain veneers if required. 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 the teeth are sound underneath.

We recommend regular 6 monthly check-up and maintenance visits to help to enhance the longevity of the restorations and oral health.

Treatment completed in one visit using specially designed concepts by myself: Minimal tooth intervention (in this case we have zero tooth intervention). One Visit Smile Lift™: No Pain, No Discomfort, No Iinjections. One Smile says it all!

All above procedures were performed by myself. Education and Experience are everything. Designer Smiles is the centre implant, surgical and reconstructive (prosthodontic) oral rehabilitation solutions.

Thank you for taking the time to explore this patient’s story. I hope this gives you an idea of what I can do for you if you are having difficulty and need help, because there is always hope.

Dr. Sarkis Nalbandian
Visiting Professor YSMU
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) FIADE, FPFA