Smile Makeovers for Missing Teeth and Uneven Gumlines

Porcelain Veneers as Best Option for a Smile Makeover with Missing Lateral Incisor

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Many patients who look for a smile makeover present with a more complicated aesthetic scenario than they are aware of. Occasionally, they present with missing teeth in the smile-exposed region of their dentition. Lateral incisors are most frequently absent (reference). These conditions are very challenging for various reasons.

Missing lateral incisors are best treated earlier in life. A meticulous analysis of the dimensions of teeth, jaws, face, and the skull will determine whether the spaces of the missing teeth should be closed orthodontically by moving all teeth behind the open space towards the front, or by optimizing the space for the future placement of implants.

An uneven gumline presents a particular challenge in these cases. The periodic scalloped demarcation of the gingival tissue is usually highly irregular. The difficult task for the orthodontist is to move the teeth not just horizontally, but also vertically to establish a gumline that looks like there is no tooth is missing.

The canine, if moved into the position of the lateral incisor, presents a particular problem. The canine and the lateral incisor could not be any more different. While the lateral incisor is small and delicate, usually considered the “sexiest” and most feminine tooth in the human dentition, the rather "masculine" canine is large and dominant, with a gumline that is displaced above the gumline of all other teeth. Even if the orthodontist succeeds in positioning the canine and the height of its gumline in harmony with the neighboring teeth, it will be impossible to reduce its much wider dimension. For this reason, a valid treatment alternative would be to optimize the available space for the placement of an implant and the development of a natural emergence profile of the implant crown. In many situations, the treatment outcome with this strategy leads to more aesthetic results.

The case presented here illustrates the intricate challenges that coincide with a missing lateral incisor. The patient is already in his professional prime and not interested at all to undergo any lengthy orthodontic treatment and/or oral surgery. He insisted to have his smile improved by placing porcelain veneers.

He was carefully apprised of his situation and informed that a mere placement of porcelain veneers would not suffice to obtain optimum results. An option was presented that included a gum lift of varying degrees at several upper teeth to align the gingival zeniths of all involved teeth and to better mask the misalignment and dominance of the upper right canine. The patient agreed.

He was sent to a periodontist who was instructed straighten the individual heights of the gum lines of the smile-exposed upper teeth. Gum lifts were performed and evaluated two months after surgery. Once it was determined that the best possible result had been achieved, impressions were taken to fabricate a diagnostic wax-up that would allow us to optimize the design of each individual porcelain veneer. The wax-up was used to discuss the aesthetic goals with the patient, establish realistic expectations for the treatment outcome, and to fabricate matrices to be used to determine the amount of tooth structure that had to be removed and to fabricate provisional veneers that to observe how the new smile design would fit into the patient’s mouth. Upon approval by the patient, the dental laboratory was instructed to finalize the smile design. Ten days later, the new porcelain veneers were inserted.

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Porcelain veneers are a remedy for a variety of dental conditions, including small teeth. Despite the apparently unrelated aesthetic and functional challenges, the same principles of smile makeover as well as occlusal and temporomandibular function apply.