Case study: Treatment (orthodontics and prosthodontics -tooth reconstructions) by Dr Nalbandian.
20/04/2010 commencement of treatment
Patient presented with a complaint of severe upper and lower crowding, which affected booth aesthetics, speech and you also felt that clicking of your joints has been getting worse as he crowding continues. This crowding combined with the collapsed bite ( loss of bite support) and front teeth wear has resulted in deep bite, painfull left TMJ (jaw joint) and tooth 45 during chewing and reverse smile line: affecting comfort function & aesthetics.
We discussed all options of treatment (no treatment, consequences of no treatment, orthodotnic treatment, followed by restorative correction of bite, implants at missing teeth site (46) tooth shape and form) and agreed to proceed with orthodotnic treatment, followed by restorative correction.
“After seven children, it is now my turn to look after myself”
The orthodontic treatment (levelling & alignment) once completed would improve the overjet, since upper teeth are retroclined. The lower teeth can only slightly come forward, however this will help to compensate the prominant chin and concave facial profile to more straight facial profile. Once we have completed the restorative correction to restore tooth form , shape and final smile line: this could be accomplished by composite or porcelain veneers, crowns etc, I feel good lip support may be also obtained. This is an immense benefit to patients seeking aesthetic rejuvination of smile, facial form, since teeth support the bone and the lower facial volume.
Note convex facial profile
Reduced upper and lower lip support
Exaggerated nasolabial groove
Note deepened nasolabial groves as a result of collapsed bite (reduced facial height due to loss of back teeth and collapsed arch form) this gives accelerated aging phenomena. Patient is also trying very hard to smile, since she is not happy with the dental appearance. No amount of lip, face augmentation or any plastic surgery can help the patient. Why?
Because teeth hold the bone and the position of the teeth and the arch-form provide the scaffolding for facial support and youthfulness.
Naturally loss of collagen and elastin fibres as a result of aging occurs, but for this patient aesthetic dentistry (orthodontic-restorative care) is indicated.
Note narrow arch form, reverse smile line, teeth wear, arch asymmetry and canting as a result of tooth grinding (bruxing) and life!
Posterior teeth with compromised structural integrity such as 17, 26 & 45 nay require further assessment and final crowning.
Clinical examinations, x-rays, photos and study models confirmed the following;
Cephalometric Facial analysis has confirmed the following;
1- Skeletal clsssII base, dental molarI/II borderline and anterior Div-2
2- Profile Sraight/convex,
3- Good lip thickness and outline. Thje lip support can be improved post orthodontic and restorative correction
Following periodontal ( gum) treatment and good home care, we can now proceed with the orthodotnic treatment.
Patient’s requirement is mainly aesthetic improvement of smile i.e. levelling and aligning of teeth. The treatment will involve placement upper and lower molar bands to hold the arch and clear orthodontic brackets, followed by forthnightly adjustment.
Invisalign or similar clear retainers wuld have delayed the orthodontic treatment phase. Hence the decision for traditional straight wire orthodontic tretament was indicated here. The treatment was completed in 10 months.
Both upper and lower teeth will also require slight enamelopasty (small adjustment of enamel between the teeth), the idea is to develop the arches and assess the amount of space required. This is in response to reducing the need for removal of upper second premolars (this treatment normally would take 18-24 months to close the spaces) as suggested elswhere as well as reducing treatment time to about 12 months if possible.
Orthodontics, as explained is simple measure and will improve tooth alignment, restoring arch symmetry. I also discussed that we may have an overjet, as this correction would require surgical intervention, however this is not an option for the patient and she is happy with the proposed treatment.
Same day the braces are removed Date: 2/2/2011
Teeth are in an optimal position in the arch to be restored. The new arch shape holds the lips and face and enhances the facial aesthetics.
The restored tooth form-arch form complex in the correct anterior-posterior position in the face completes the aesthetic picture.
This is where science-engineering and art meet.
Due to crowding of upper and lower arches, there is a natural wear at an exisitng level, however once we level and align teeth as per their anatomical emergency profile, there will be resulting irregularity that may require restorative correction using composite or porcelain veneers improve overall aesthetics.
Restoratiove correction of tooth form will commence after the orthodontic treatment.
The cost of post-orthodontic restorative correction involving upper front teeth will be given once we have completed the orthodontic treatment.
Composite veneers/reconstructions procedure
Composite is applied to the tooth surface, moulded directly to restore original tooth anatomy and improve colour
Today direct composites are non invasive, as in our patient.
We accomplished both braces removal and direct composite placement in just ONE VISIT SMILE LIFT procedure. There was no discomfort, NO PAIN, PATIENTS TEETH WRE INTACT!
Many dentists do not advise this non invasive method because it is simply difficult to work directly in the mouth. Sometimes it is easier to ‘CUT THE TOOTH’ AND LET THE DENTAL TCHNICIAN MAKE THE VENEERS OR CROWNS. Naturally this may be required and depends on the clinical situation. However every dentist must think first before cutting the tooth. Why? Because once you cut the tooth it is gone.
You see, one has to be Scientist, Engineer and an Artist to make these beautiful creations. This takes time and considerable dedication for clinical excellence.
There are very few dentists in the world who have mastered the art of direct composites.
Ask your dentist about aesthetics and tooth conservation, because in our practice this is the norm.
Composites do not last as long as porcelain veneers, but the tooth is there for continual re-application of the bonding material!
We also have developed ultrathin porcelain veneers to help those patients, where porcelain veneers are indicated, again using minimal invasive techniques developed by Dr Nalbandian ( to be published) where additive procedure is contemplated such as improving narrow arch form, restoring fractured tooth, parts of etc.
Please refer to ULTRATHIN PORCELAIN VENEERS IN THE MENU
Dentistry meets nature.
RECREATING THE NATURAL TOOTH FORM AND NORMATIVE SMILE- ONE VIST
Recreating Smiles is a jig-saw puzzle
Composite veneers: direct bonding in dentistry is an ART in its purest form that distinguishes clinician’s ability to understand and appreciate beauty.
Clear orthodontic retainers
When orthodontic treatment is complete we will place permanent retention wire on the palatal aspect of upper front teeth as well as back of the lower front teeth, since adults do not like wearing removable retainers! Latest research suggests that retention should be as long as possible.We can also place clear removable retainers after an orthodontic treatment, as was the case for this lovely patient.
Oh yes “WE Do Smile with Our Eyes” Darwin 1882, Duchenne 1990
Completion date 2 Feb. 2011
This is immediately after the braces removal and composite addition (composite reconstruction/veneers) Once again creating beautiful smiles complimenting this lovely patient’s facial beauty.
The clinician must have a vision to see the end point in mind prior to starting the treatment.
The aim of this treatment, irrespective of the journey, is the destination.
But we certainly enjoyed the journey!
I am indebted to our patient for giving me the opportunity to create beautiful smiles complimenting Dentofacial aesthetics.
One Smile says it all. It is absolutely amazing to me how our patients transform in front of my eyes once the aesthetic dentistry is completed!
I know it is my work, but the effect is simply unbelievable. This work gives me the greatest of all pleasures in dentistry. It is so true that picture is more than thousand words. How can you otherwise describe such a beautiful picture in words?