PMC8295508_01
A 29-year-old patient with CCD. (a) Frontal view shows lowering corners of mouth and vermilion as well as deepening nasal-lip and chin wrinkles. (b) Profile view shows depressed nasal bridge (black arrow), frontal bossing, and prominent chin (red arrow). (c) Intraoral view before treatment shows disturbed proportions between height and width of maxillary anterior teeth with signs of tooth wear on incisal edges and posterior (right side) open bite. (d) Intraoral occlusal view of maxillary arch before treatment reveals gaps between teeth 21, 22, and 23. Tooth germs 15 and 25 are missing. Caries lesions in posterior teeth were noticed and had to be treated before placing overlays (asterisk).
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The lower facial third was notably shorter than the middle and upper ones, respectively (Figures 1(a)-1(d)).
Panoramic radiograph taken at age of 16 before orthodontic treatment.
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Despite the void of supernumerary teeth, the phenotype was specific for CCD (Figure 2).
Panoramic radiograph taken at age of 29 right before prosthodontic treatment.
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The dental diagnosis was set after a comprehensive clinical and radiological examination (Figure 3) as well as extraoral picture analysis, which showed smile disharmony in accordance with both horizontal and midface axes.
Occlusal repositioning splint used during first phase of prosthodontic treatment. In right corner, picture showing approximate thickness of each layer.
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After each 4 months, the splint height was enlarged sequentially by 2 mm, up to 7 mm final increase of the initial OVD at the lateral parts of the splint (Figure 4).
(a) Wax-up of maxillary arch. (b) Mock-up of maxillary arch, new occlusion was tested for over a month.
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Hence, the final treatment was initiated on the wax-up formation, and the mock-up was set on the upper dental arch (Figure 5). Figure 5 indicate disharmony). For over a month, the patient used the mock-up, which increased the OVD about 7 mm and elongated the anterior teeth up to about 10 mm without any complains.
A 29-year-old patient with CCD. (a) Intraoral view of final restoration. It was patient's strong wish for restorations to be this bright, even though it did not match her natural teeth. (b) Intraoral occlusal view of maxillary arch after accomplished prosthodontic treatment. (c) Lateral view of the right side after 24 months follow-up. (d) Lateral view of the left side after 24 months follow-up.
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The posterior teeth (17, 16, 14, 24, 26, and 27) were prepared for the composite overlays, while the anterior teeth (13, 12, 11, 21, 22, and 23) for the ceramic veneers (Figures 6(a)-6(d)). Since the elongation of the incisors' crowns might have jeopardized the crown-to-root ratio, to enhance the stabilization of the anterior teeth, the orthodontic retainer was placed along the palatal surfaces of the teeth: 13, 12, 11, 21, 22, and 23 (Figure 6(b)). The patient request was to match the color of her restoration and natural tooth (Figure 6(d)).
Comparison of facial appearance before (a) and after (b) treatment. (a) While smiling, maxillary teeth are not visible, giving impression that patient is edentulous. (b) Anterior teeth are visible during smile and dental midline correlates with facial midline.
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After 24-month observation, the entire reconstruction acted steadily (Figures 7(a) and 7(b)).
Panoramic radiograph on a follow-up appointment after 24 months.
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A panoramic radiograph was taken for evaluation of periodontal soft and hard tissues and search of the potential periapical lesions (Figure 8).