The Award contest 2017/ 13 February 2017/

Case 25 | The Award 2017 | Portugal

Dr. Morvarid Keshvari / DT Alvaro Eguia

The perfect imperfection

–Simultaneity in light is harmony, the rhythm of colors which creates the Vision of Man. –Robert Delaunay

Every day we are faced with patients, with skeletal disorders, where creating harmony and function must be done with orthognatic surgery, otherwise we put the patient in funcional and aesthetic facial disharmony if he/she is just treated by orthodontics.

The facial exam must always start by observing the patient sitting in front of you, looking him/her in the eye and at a same height.

Firstly, we have to detect if the patient has vertical disorders, then transversal disorders and at last, sagittal complications. The latter one must be observed with the patient on his/her side-face.

In 80% of the cases, only with clinical examination we can reach the diagnostic of maxillomandibular asymmetries, which is the most complicated skeletal alteration, almost impossible to cover up.

In this particular case, the patient has the same alterations in the three levels of space.

In the upper jaw region, what most calls our attention is not the issue at the levels, but that the upper jaw is turned on its axis. That means that the left side is lower than the right side, in the vertical axis and that the left side is sticking out in relation to the right side.

Therefore, the problem that this patient present is that her condition is almost impossible to cover up, since she refuses to have an orthognatic surgery.

Sometimes our patients are not ready or just don’t want an orthognatic surgery and refuse orthodontic treatment as well.

So, many times they cannot afford implants and they are left with an desharmonical smile.

Many times, the patients are nor oriented to find the right alternative, motivation for a better smile.

We ALL KNOW HOW AN UNBALANCED SMILE CAN AFFECT THE psychological, SOCIAL and PERSONAL life and how all of us live in a world where the image and the smile mean power, beauty, sensuality and health.

This is a typical case where we have many problems, beginning with rotation of the maxima in the 3 dimensions, as well the bad restoration and the periodontal situation also is engaged.

After 20 years of practicing I am becoming more and more conservative and I try to save the natural roots, to motivate and keeping the implants for edentulous regions and for -really- hopeless roots.

We believe in biology and we consider that the psychological effects of extracting teeth in especial front teeth and young patients are enormous and many times irreversible.

So many times, the patient looses their teeth and by using a total denture the whole facial expression gets envolved.

The big challenge in this case at the first view was to recover the huge space created for lateral.in the later restoration which, at the first glance, looked impossible or orthodontic treatment was a must. Also the periodontal conditions and the right design. To keep her original forms.

After 2 months of provisionals the periodontal health was in perfect condition, the patient was motivated and we decided to make ceramic restorations in 6 anteriors and a partial prothesis for posteriores, bringing back the self-esteem and confidence while the patient gets herself ready economically to do the implants in the posterior sectores.

When planning the case as protocol, by analyzing the photos, face and motion by the digital smile design, we can easily see how the reference lines are inclined and the question is what to do? which planes must be used?

In these cases we decide to create harmony just following the lip line, because any attempt to change the planes would just emphasize the existing disharmony.

We created the design of the new shape by using the shell technique, created by Dr. Paulo Kano, as – Skyn concept- by selecting a natural arch in this case de F8 FROM THE ANTERIORS book of Dr. Hatjo and composite veneers were prepared and bonded to the enamel.

After the acceptance of the shape, all the old restorations were removed.

The impressions were done and we chose the Cerec system do make the restorations. We made an exact replication of the mock-up in the models and by using the bio-copy function we replicated the final restorations in Vita Blocks Realize 2M1 color.

The incised edge was redone by cutback and used a little makeup just to emphasize the ceramic.

The color of the gums was calculated with Anaxgum and 2 partials were made. At the end, we had a nice harmony and patient told us that she got her smile back.