CASE 2

Age: 35

Sex: Male

Chief complaint: “I have Bugs Bunny teeth, and I’m getting married in two months”

Medical history: No significant findings

Periodontal assessment: AAP type II, Grade A with some inflammation and plaque. Gingival recession associated with lower anteriors

Function/TMJ: No clicks, no joint pain, no functional limitations, good range of motion

Tooth structure: Two direct composite restorations

Esthetics: Poor shape and form of maxillary anterior teeth, evidence of tooth wear, black triangles

Clinical scenario: The patient did not like the appearance of his smile and wanted a change before his wedding (in two months.) He had undergone orthodontic treatment in the past and although he could benefit from retreatment, he was not interested. He was happy with the color of his teeth but did not like the shape of his central incisors and their dominance within his smile. He asked for veneers to change the shape of his two front teeth and wanted them to be less triangular and prominent

Problem list:

1. Unattractive smile

2. “Triangular” teeth

3. Prominent central incisors

4. Wear on multiple teeth (bruxer?)

5. Uneven gingival zeniths

6. Narrow buccal corridors

7. Occlusal plane asymmetry

8. Gingival recession in multiple areas

9. Black triangles (large interdental spaces) (Figs. 1.8a, 1.8b)

10. Poor root inclination (Fig. 1.9)

Treatment plan: Porcelain veneers on teeth 7 to 10 and direct composite bonding on the maxillary canines

Summary of treatment performed: Porcelain veneers were fabricated and placed on teeth 7 to 10, and two direct composite fillings were placed on the maxillary canines to improve their shape and balance the smile (Figs. 1.10a, 1.10b) [25]. The treatment helped fulfill the patient’s desires and needs prior to his wedding

Treatment analysis: The patient’s chief complaint was related to the shape of his teeth and their prominence within his smile framework (Fig. 1.11). Orthodontics would have been the ideal treatment recommendation for this patient as it would have helped improve the overall smile, occlusion, and function [22, 23]

The narrow buccal corridors could have been addressed well with orthodontics (Fig 1.12). Temporary esthetic procedures, including teeth whitening and composite build-ups to change the shape of the teeth in the cervical region, could have been accomplished prior to the wedding. Before initiating orthodontics in this situation, it would be best to additively bond composite material to the teeth to optimize their shape so that the orthodontist would be able to move the teeth and roots into a more favorable position (Fig. 1.13) [26]. The bone support could be assessed using a cone-beam computed tomography (CBCT) scan [27]. A periodontal consult would help address the gingival recession and benefits of soft tissue grafting (Figs. 1.14a, 1.14b) [24]

CASE 2 > continues

This approach would provide the optimal treatment and patient outcome. However, for some patients, if they don’t have a gummy smile, this may not be an issue (Fig. 1.14b)