Esthetics with inadequate overbite overjet

53 Rating(s).


Posted on By R. Terry Councill In Occlusion

Attractive middle aged female presents for cosmetic consultation, desiring veneers. Noted 0 mm overbite w 2 mm. of over-jet. Moderate to advanced anterior attrition secondary to posterior excursive interferences in protrusive and balancing excursions. Zero restorative space. DSD projection includes adding approximately 2 mm. of length. Anterior slide from centric relation to centric occlusion of 1 mm.

Considering (1) cosmetic contouring and gingivoplasty to "lengthen" the anterior teeth, (2) orthodontics to lingualize lower anteriors and buccalize upper anteriors in an effort create appropriate overbite/over-jet and then restoring with veneers. ((This option concerns me as the teeth will be come more prominent during orthodontic movement and again if veneers are additive in an effort to keep bonding limited to enamel)) (3) opening the vertical and full arch reconstruction, (4) running away.

I can gain 1 mm of over-jet by equilibration but feel that would be inadequate as the restorative space would still be limited and this pt. probably requires a long centric. Wax-up and mock-up is pending.

How have you handled this challenge? All plans would include occlusal equilibration and a nighttime orthotic.

Thank you for reviewing and for your opinions!!

Anterior View
Digital facebow

Lips in repose
DSD propsal


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6 Comments

Terry. An Orthodontic consult would be my first step. If orthodontics isn't feasible I would test increased vertical and establish central relation with a Hawley bite plane appliance. A little "old school" but maybe effective in a case such as this. Good luck. Thank you for sharing. Best regards.Chuck


Reply

Terry, Ortho cons is certainly advised because as you mention if you can get the mandibular incisors pulled back then lengthening the maxillary incisors would be easy...and she does not need very much added to the incisal edges to make a big difference. At least that is what I would ideally do.


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Hi Terry;
Do you have occlusal views of both arches?
I believe that you can restorative treat this case (although a consult for limited ortho to intrude the mandibular teeth is probably advised.)
This is an absolutely minimal prep veneer case where you move the teeth out and then lengthen. You obviously cannot lengthen the teeth in their current position (Two things can't occupy the same space at the same time.) but if you move the teeth out first and then down, this will be fabulous.
1. Equilibrate to get the 1 mm of clearance.
2. Direct resin mockup to actually learn where the correct incisal edge position should be.
3. When prepping the teeth, bevel the palatal surface to keep the correct incisal edge thickness and not have the teeth too thick.
4. Shorten and bevel the mandibular anterior teeth if ortho is not an option.
5. I would consider crown root lengthening in the bicuspid region.

I did this exact case on one of my assistants 16 years ago and it remains one of my favorite cases.


Reply

Hi Terry, Invisalign on the lower anteriors can be an option. With Interproximal reduction of the lower anteriors and a few aligners, you could achieve not only some retraction but also close dark triangle between teeth. Just remember that whenever there`s Ortho, there`s also lifetime retention ! You could also , as Gerald mentioned, shave and bevel the lower incisors. Then with No or Minimal prep, place Full Emax veneers with No Feldspathic porcelain layered on the incisal. Much less chance of fracture or chipping without Feldspathic and with your restorations bonded on a 100% enamel, very little chance of debonding as well.


Reply

Thank you guys for reviewing and for your comments. Very helpful. I'll post the U/L full arch photos ASAP. I'm grateful for the support!!


Reply

I would like to know why this patient's latertals and centrals have flattened since Ortho? I'm assuming of course this happened since Ortho treatment was finished.
Over the past 33 years of practicing, I have noticed that many (not all) post 4 bicuspid extraction cases exhibit Maxillary anterior wear. Has anyone else seen this?
Perhaps the Orthodontists in this forum can comment.
I have asked these patients if they feel more comfortable with their mandible placed forward and many have said yes! So my question is this; 1)Do we get them back in ortho to put the anteriors more forward to where they were in the begining? 2) Is this even a problem or is this a case by case issue? 3) If this becomes just a restorative treatment, can we restore length predictably without porcelain fracture with a "longer centric"?


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