Whiter Teeth, Even Shapes, No More Partial

The Patient's Journey

This patient arrived with several complaints and wanted all of them addressed. Her teeth were yellow. They were also mismatched in size, with an asymmetry across the arch that made the proportions look wrong even when the color did not. And she was missing two lower teeth, which she had been managing with a removable partial denture.

Treating any one of those in isolation would have made the other two more obvious. Whitening alone would have sharpened the contrast between teeth of different widths. Restoring the proportions alone would have set new ceramics against a discoloured background. Replacing the missing teeth alone would have left both of the visible problems untouched.

Understanding the Challenge

The sequence was the whole of the plan, and it is governed by two constraints that cannot be worked around. The first is that ceramic does not respond to peroxide, so whitening precedes any shade being recorded. The second is that gingival health precedes restorative work, because margins placed against inflamed tissue sit in a position that changes once the inflammation resolves.

Hygiene therefore came before whitening, and whitening before ceramics. That ordering is not a preference. A restoration bonded to a tooth whose gingival margin is still receding to its healthy position will show a line at the join within months, and no amount of ceramic quality compensates for it.

The lower arch raised a separate question. Only the upper teeth are prominent in most of her expressions, and restoring the lower arch as well adds cost. It was restored anyway, for two reasons that have nothing to do with appearance from the front.

How Dr. Mehdizadeh Approached Treatment

Hygiene therapy was completed first and the tissue allowed to settle. Whitening followed, and the shade was left to stabilize afterwards, because tooth color rebounds for a period following any peroxide course and a shade recorded during that window is not the shade the patient keeps.

Two implants were placed at teeth twenty-three and twenty-six and left to osseointegrate. Replacing lower incisors with implants rather than continuing with a partial denture matters structurally as well as practically. A removable appliance rests on the mucosa and transmits no load into the alveolar bone, so the ridge beneath it continues to resorb; an implant loads the bone and maintains it.

Sixteen veneers were then fabricated, ten upper and six lower, together with two crowns on the implants. Treating both arches together is what resolves the width asymmetry, because tooth proportions are read in relation to the teeth above and below as well as beside them. It is also what fixes the color, since a whitened lower arch beside restored upper teeth would have diverged again within a year or two as the natural teeth took up stain and the ceramics did not.

The second reason for restoring the lower arch is occlusal. Designing sixteen restorations across two arches allows the contacts between them to be established deliberately rather than inherited from a bite that had been compensating for missing teeth. That is the part of this case a photograph does not show.

The Result After Five Months

Eighteen units span both arches: sixteen veneers and two implant crowns. The gaps are closed, the widths are even across the arch, and the color is uniform because every visible surface was either whitened or made to match the whitened result.

The partial denture is gone, and the two implants beneath the lower incisors are loading bone that had been resorbing under an appliance. The bite was established across the finished restorations rather than around the missing teeth she arrived with.