Correcting a Tilted Smile Line and Flared Teeth

The Patient's Journey

This patient came in because her smile appeared tilted and because the upper teeth projected considerably further forward than they should. She wanted a smile that was harmonious and that complemented her face rather than attracting attention independently of it. The existing teeth were discolored and irregular along their edges, and a considerable amount of gum tissue showed above them.

The photographs make the tilt easy to see in the frontal view and considerably harder to attribute. The upper edges do run uphill toward one side, but the tissue above them runs uphill by a similar amount, which is the distinction that decided how the case was approached.

Understanding the Challenge

A smile can appear tilted because the teeth themselves are tilted, or because the gum line above them is. Hers was the gum line. The teeth had erupted to different heights and the tissue had followed them, so the visible length of each individual tooth varied across the arch even where the biting edges were reasonably close to level.

That distinction matters because the two problems are corrected by entirely different procedures, and the incorrect correction is expensive. Veneers placed on an uneven tissue line reproduce the unevenness. A veneer begins where the gum begins, so tissue sitting too low on one tooth produces a short restoration on that tooth, however carefully the ceramic is fabricated.

The second problem was the flare. The upper teeth projected forward and the existing contours were bulky, which made the whole anterior segment appear prominent rather than proportionate, particularly in the frontal photographs where the flare is most obvious. Correcting that meant reducing the prominence rather than increasing it, which is the opposite of what a veneer treatment is usually assumed to do.

How Dr. Mehdizadeh Approached Treatment

The bite was analyzed first, and the smile design followed from it. The design determined the extent of the gum lifting. Until the finished proportions of every tooth are established, there is no way to measure how much tissue has to be repositioned or where. Lifting an approximate amount produces an approximate result.

The gum lifting was carried out. Six weeks were allowed for the tissue to heal and stabilize before any preparation began. Tissue repositioned surgically continues to mature for several weeks afterwards, and preparing teeth against a margin that has not finished stabilizing produces restorations whose edges become noticeable later.

Provisional restorations were placed next. She wore them throughout the period in which they were revised in the mouth, until the shape and the proportions corresponded to what she wanted. That revision is the part of the process patients have most influence over, and it happens in acrylic, where alterations cost an appointment rather than a remake.

The approved provisionals were reproduced as twenty porcelain veneers in e.max, ten in the upper arch and ten in the lower. All twenty were designed and fabricated in the practice's own laboratory by its master ceramist. The finished contours are considerably less prominent than the teeth she arrived with, which is what reduces the projection rather than disguising it.

The Result After Ten Weeks

The smile line is level, the teeth sit in proportion to her facial features rather than ahead of them, and less gum displays because the tissue was repositioned rather than because the restorations were lengthened downward to conceal it. Five appointments across ten weeks covered the analysis, the gum lifting and its healing period, the provisional phase and the final cementation of the restorations.

There is no outstanding treatment. The gum line was repositioned surgically and is maintained by hygiene. Routine cleanings and examinations are what hold the result, which makes them considerably less optional than they are for someone who has had no periodontal surgery.