A Prosthodontic Approach to Enhance Esthetics in a Patient with Malaligned Upper Anterior Teeth

Introduction: This clinical report describes a prosthodontic treatment alternative to orthodontic treatment to obtain a desirable esthetic outcome. Clinical case report: The patient was unwilling to receive orthodontic treatment to correct the chief complaint of a flared anterior tooth. However, this case presented a favorable situation, as an existing crown preparation allowed room to adjust the malalignment of the area of concern for the patient to achieve aesthetic results. Conclusion: The prosthodontic approach can be beneficial in obtaining desirable outcomes in selected cases and should be presented


Introduction
Dental esthetics can have a significant impact on the psychosocial well-being of people.It has been demonstrated that dental esthetics can negatively affect others' perceptions of one's social competence, intelligence, and personality.[1,3] This can create a disadvantage in everyday social situations for those who struggle with dental esthetics.A poor perception of dental esthetics can also affect how one views oneself and one's level of confidence in their appearance.
[4,5] These concerns may arise later in a patient's life and should receive attention to ensure improved well-being.[6] Those with increased severity of malocclusion have decreased self-confidence, decreased dental self-confidence and increased psychosocial impacts.

[4]
In the case of severe malocclusion, orthodontic treatment is the ideal treatment plan.However, not all patients may accept orthodontic treatment, even when the patient is well informed of the advantages of orthodontic treatment over restorative treatment and the limitations of this treatment.A camouflaging prosthodontic approach can be beneficial in obtaining desirable outcomes in selected cases and should be presented as a treatment plan option with adequate patient education.

Clinical Case Report
A 67-year-old male patient reported to the undergraduate dental clinic of the Schulich School of Medicine and Dentistry at Western University with the chief complaint of a flared anterior tooth and was seeking cosmetic rehabilitation.Informed consent to document the case report was obtained from the patient.

Treatment Planning Process
The patient was presented with a ceramic crown on tooth 21, cemented in 1976.He felt that the crown was bulky and too prominent.
He stated that his friends constantly made him uncomfortable about it.He was seeking to have the crown replaced, and the alignment improved.The patient has canine guidance on lateral excursions.Since the patient's tooth 21 was observed to be buccally positioned, a pre-prosthetic orthodontic treatment was proposed, as simply replacing the crown may not result in a satisfactory esthetic outcome.
We expressed that we would prefer the patient to have pre-prosthetic orthodontic treatment followed by replacement of the existing defective crown, as this would be the most conservative treatment option.We discussed both the benefits and limitations of this option.
After a discussion with the patient and allowing him time to think about the proposed plan, the patient decided not to pursue orthodontic treatment for his chief complaint at his age.
Several alternative treatment options were also proposed.One alternative option was to replace the existing crown on tooth 21 with a new all-ceramic crown (ACC) that would have a more esthetic contour and be a better match in terms of shade.Another alternative was performing pre-prosthetic root canal treatment (RCT) on tooth 21 and over the reduction of tooth 21 to achieve better alignment with the adjacent teeth to improve the esthetics further.Wax-ups of these options and benefits and risks were presented to the patient.After a discussion, the patient recognized the benefits of preserving the vitality of tooth 21 and opted out of having RCT on tooth 21 to improve esthetics.
A third treatment option consisted of replacing the existing crown on tooth 21 and adding ceramic veneers to tooth 11 and tooth 21 with minimal tooth preparation to camouflage the malalignment concerning the patient.A wax-up of tooth 21 with the crown and the two veneers on teeth 11 and 21 were presented to the patient along with the treatment option like other operators did for a similar case.
[7] As the defective crown on tooth 21 was planned to be replaced with an ACC, space would be created for ceramic build-ups on the adjacent teeth 11and 22 to camouflage the existing malalignment.This was possible because heavy occlusal forces were not involved with the teeth in question from teeth 11 to 22, as the patient had canine guidance on both right and left lateral excursions and no contacts on teeth 11 and 22 in protrusion.We noted limited space between the distal incisal corners of tooth 22 and tooth 32 on a left lateral excursion; therefore, an enameloplasty on the distal incisal corner of tooth 32 would be beneficial to create adequate space for a veneer.
We spoke with the patient about the limitations of veneers when the option was presented and allowed time for the patient to think about the proposed treatment plan.
Initially, the patient wished to begin removing the crown on tooth 21 and would decide about having veneers once that was completed.We proceeded with the crown removal and placed a provisional crown made of bis-acryl composite temporary crown and bridge material on tooth 21 (Figure 3).The provisional crown was used for a diagnostic purpose to evaluate esthetics, function, and phonetics as described by other operators.[8] After the patient had a better visualization of the contour of the replacement crown in his mouth, he wished to seek a more esthetic outcome.The patient decided on the third proposed treatment option (replacing the existing crown with an ACC crown and ceramic veneers on teeth 11 and 22).

Conclusion
There is importance in considering a prosthodontic approach alternative to orthodontic treatment for malalignment cases to obtain a desirable outcome.This case is an example of a patient presenting with a targeted area of esthetic concern with no interest in receiving orthodontic treatment.The patient self-identified how his esthetic problem impacted his life and wished to seek a solution.By improving the aesthetics of his smile, we hope he will experience increased self-confidence and enhanced self-perception in social situations.This case presented a favorable situation where crown preparation allowed room to adjust the malalignment of an area of concern for the patient to achieve enhanced esthetic results.

FinancesFigure 1
were not a concern for the patient.Upon clinical examination and radiographic interpretation, the crown was found to be defective, with an open margin on the mesial surface and caries on the lingual of tooth 21.Pre-treatment radiographs were taken as part of the comprehensive exam (Syed S, Srikanthan N, Ari N, Ibarra LM (2023) A Prosthodontic Approach to Enhance Esthetics in a Patient with Malaligned Upper Anterior Teeth.J Med Case Rep Case Series 4(09): https://doi.org/10.38207/JMCRCS/2023/MAY04090151

Figure 3 :
Figure 3: Frontal picture of the patient's teeth with a provisional crown on tooth 21

Figure 4 :
Figure 4: Veneer preparations on teeth 11 and 22 and ACC preparation on previously prepared tooth 21

Figure 7 :Figure 8 :
Figure 7: Frontal picture of the patient's teeth at 5 months follow-up appointment