Collaborative Development of a Natural-Looking Smile: Case Presentation

James Fondriest, DDS

Figure 1. Preoperative appearance displays an uneven occlusal table, asymmetric gingival display, and varied color, texture, and opacities.

Figure 1. Preoperative appearance displays an uneven occlusal table, asymmetric gingival display, and varied color, texture, and opacities.

Figure 2. Patient appearance at initial presentation with facial and dental asymmetries.

Figure 2. Patient appearance at initial presentation with facial and dental asymmetries.

Figure 3. The occlusal plane hung down on left side and the axial inclination of the central incisors was slanted.

Figure 3. The occlusal plane hung down on left side and the axial inclination of the central incisors was slanted.

Figure 4. The occlusal plane had an exaggerated Curve of Spee, and the mandibular incisal edges were canted and uneven.

Figure 4. The occlusal plane had an exaggerated Curve of Spee, and the mandibular incisal edges were canted and uneven.

Sophisticated patients want their dental concerns treated without appearing as if they have been restored. This case presentation describes the planning and treatment steps for the re-creation of an aesthetic smile. The patient had dento-facialasymmetries and an elevated occlusal risk of fracture due to bruxism. Lithium disilicate glass ceramic in a pressed version with stacked veneering porcelain was selected as an ideal restorative material for natural aesthetics and to fulfill the strength requirements for the maxillary anterior restorations.

This article discusses the use of collaborative treatment planning method in order to provide aesthetic improvement for facial asymmetries in high-stress areas. Upon completing this article, the reader should:

  • Understand the communication protocols involved in including both the patient and the laboratory technician in the entire treatment planning and restorative phase.
  • Be aware of the role of strength requirements when treating patients with proven bruxism and destructive wear patterns.

Successful delivery of indirect restorations is predicated upon a concise understanding of the patient’s existing facial architecture, his or her restorative needs and desires, and thorough communication with the laboratory. Particularly when restoring patients with dentofacial asymmetries, care must be taken to carefully determine where to create proper angulation and integration in order to develop a natural-looking result. The following case presentation details the steps required to facilitate thorough documentation, treatment planning, and communication with the technician in the treatment of a patient with asymmetrical features.

Case Presentation

A 52-year-old female patient presented following a history of having significant dentistry previously performed. Every tooth had a full-coverage restoration or large intracoronal restorations fabricated from numerous materials. The existing porcelain-fused-to-metal (PFM) restorations on teeth #6 through #9, and #13 through #15 were opaque and unnatural in shape, texture and appearance (Figures 1 and 2). The dentition without full-coverage prostheses had restorations that were chipped and leaking, and these teeth displayed different colorations. The axial inclinations of the maxillary central incisors pointed towards the patient’s right hip. The left maxillary teeth had super-erupted and were hanging lower than the occlusal table. They had super-erupted to make occlusal contact when dentistry had been performed on the mandibular left many years earlier. There was a mild reverse smile line. Much of the dentistry that had been previously performed was a result of fracture to the natural teeth or the large restorations. The wear that was created on the existing 16-month-old nightguard suggested that the patient was a heavy bruxer.

The patient desired improved symmetry within her smile and improved exposure of the uneven gingival tissue in order to provide a more homogenous and natural appearance to her teeth. The patient wanted to be involved in the treatment decisions; because she felt that the mandibular teeth did not display in her smile, she desired to limit treatment to the maxillary arch. She had previously been restored in many small “installments” by several dentists with no comprehensive planning toward a final, pleasingly aesthetic result. Overall, she desired this result.

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