Three Problems, One Treatment Plan

The Patient's Journey

This patient had an impacted upper canine, a tooth that had formed in the bone but never erupted into the arch. The space where it should have been read to everyone who looked at her as a missing tooth. Around that gap sat an uneven gingival line and a set of chipped incisal edges, so there were three separate problems visible in the same photograph.

What she said was that she wanted a nice smile, and that she had been overwhelmed by how many separate things appeared to be wrong with the one she had. She wanted somewhere that would deal with all of it, rather than sending her to three offices for three parts of it.

Understanding the Challenge

An impacted canine is a surgical problem before it is a cosmetic one. The tooth has formed and lies in the bone, in a position from which it cannot erupt, so it is either brought into the arch orthodontically or it is removed. Orthodontic exposure and traction is the preferred route in adolescence. In an adult whose skeletal growth is complete and whose arch has closed around the space, both the timescale and the predictability deteriorate considerably.

The gingival asymmetry was a separate finding with a separate cause. It would have persisted through any amount of restorative work. Gingival heights are read comparatively rather than absolutely, which is why nobody measures them and everybody notices when the margin over one tooth sits at a different level from its counterpart.

The chipped incisal edges were the least significant of the three clinically and the most conspicuous socially, and they also carried diagnostic information. Enamel does not fracture without an opposing surface loading it, so the chipping indicated that the incisal relationship between the arches needed attention alongside the appearance.

How Dr. Mehdizadeh Approached Treatment

The impacted canine was extracted and an implant placed at tooth six, which converts an unpredictable adult orthodontic problem into a restorative one with a defined timescale. The canine position matters more than most. It occupies the corner of the arch, where the smile turns from the anterior teeth towards the posterior segments, and a gap there flattens the entire line.

Aesthetic crown lengthening followed, across the upper anterior teeth. Gingival tissue was removed and the underlying bone recontoured, so that the margins sat at the heights the planned restorations required. Carrying out the surgery before the veneers allows each restoration to be designed to a known gingival position. Reversing the order means fabricating ceramics to accommodate tissue that has not settled.

Nineteen veneers followed. Nine were placed across the upper arch alongside the implant crown at tooth six, and ten in the lower arch. The lower veneers are there for color and for the occlusion. Restored upper teeth against an untreated lower arch diverge in color within a year or two, because natural enamel takes up stain and ceramic does not. The edges that had been chipping also needed an opposing arch designed to stop chipping them.

The Result After Five Months

The gap at the canine is closed with an implant crown, and the gingival line runs level across the upper anterior teeth. The incisal edges are restored in a material considerably harder than the enamel that had been fracturing.

All three problems were treated inside a single plan. The order was not arbitrary. The surgery preceded the ceramics because the ceramics had to be made to a settled gingival position, and both arches were treated together because the fracturing edges needed their opposing surfaces designed alongside them.