I saw a new patient last month, who was referred to our office by my new dental assistant. Her previous dental visit was 2 years prior. Her chief complaint was that she broke her nightguard and was interested in a new one. After restoring a couple proximal lesions that could be seen with the naked eye, she returned last week for a consultation, records, photos, etc. as she showed interest in improving her smile, and I would be happy to listen and try to help her out. Here’s some background:

“Nikki” is 30 yr old female, who works full-time in marketing/HR for a large hotel company, and has a part-time job working nights bartending. She has a history of bulimia 5-10 years ago but is now healthy and she reiterated that this is no longer a struggle for her. Her teeth seemed to lock it well when I had her bite together, and her models hand articulate well but now that I’m thinking about it, I can’t remember if she fought me when I tried to find her CR position. This I will have to verify next week when she comes back in to review the findings.

I have not done a full mouth rehabilitation case yet, but I feel comfortable that her case would be pretty straight forward, or should I say ‘more managable’ as nothing seems to be straight forward in dentistry… teeth are weird.

I wanted to post these pictures last week but wanted to wait until I had time to review the articulated casts, and now I’ve barely had time to do that.

My initial concerns/questions:

Do I need to intrude the centrals to yield a more esthetic/ ideal gingival architecture? Ortho or perio? My initial thought is no, as she does not have a high smile line when I tried to get her to smile big. However, she even mentioned that she trained herself how to smile and purposely does not show much teeth. I’m afraid if I can’t get her to show me a relax lip, true smile, and we restore her as is, will she like the new appearance of the teeth?
We will need to open her bite 1-2mm in back, yielding 6mm or so in the anterior, and I feel like she will be able to tolerate as I watched her speak to evaluate her space. I did not take facial measurements of VDO/VDR but will get this next visit.
Can this case be tackled with composite? (I think yes) How?—very carefully
Has anyone used SnapOnSmile before as a temporary prosthetic to open VDO? I have not sent the case to the lab yet for a wax up, and I’d like to do a try in at the next visit but may have to wait for the following visit as I don’t want to eat this lab bill as I have done in the past. If she has financial concerns about the cost of full mouth rehab ($1170 * 14= $16,300 before insurance), would a SnapOnSmile be a decent option (I’d charge $2,000) to buy her time until she saves up?
Or if she wants to get started with the temporaries, how would you recommend phasing? I’m sure there’s cases on the forum that you wiser ones can link for me, as I haven’t been able to find any yet.

Please review the photos and let me know your thoughts. I was hoping to finish my Smile Design and include it in the post but haven’t done that yet either. Any encouraging advice on how to proceed would be greatly appreciated. Thanks in advance for your time.

Jared

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