Robert M. Klaich, DMD

Porcelain veneers are indeed the best way to get a uniform shade on every tooth that will never require whitening. The uneven gum tissue above the darkened tooth should also be resculpted using a soft tissue laser to create a more uniform round arch to match its neighbor. Ten veneers on the upper and ten on the lower would cover the whole smile and provide the most ideal uniformity.
Another option would be to first have professional whitening and do anywhere from 2-10 veneers on the upper. The only drawback would be that you’re limited in how bright of a shade you can select based on how white the natural teeth can get. Doing 10 on the top and just whitening the lowers does give you a bit more freedom to go brighter with the uppers as a whole.

If you’re looking for a conservative way to reshape the teeth for better symmetry and proportion, I’d first consider recommending gingivectomy, which is laser trimming of the excess gummy tissue above the teeth that look short. There’s only so far you can go with this and measuring the tissue attachment will help the dentist or periodontist determine the precise amount that can be removed without creating chronic inflammation.
Enamelplasty is a fancy word for re-sculpting the shapes of the teeth using a series of polishing discs. I would recommend this on the right canine especially since it reaches lower than the left when looking at the arc of the lower lip. Again, you can only go so far with this, but it could provide a nice improvement without getting too invasive. As for the crowded two front teeth, using Invisalign express or a product like that could correct the crowding in a few months. You could ask to have a ‘fixed’ retainer to provide better retention and stability. This is a wire that’s cemented behind the two front teeth.

It’s unfortunate that your dentist is failing to offer you an option that sounds reasonable. Perhaps your dentist has never done this type of procedure or doesn’t have much confidence with providing it. I’d recommend searching for someone who has more experience with All-on-4 and seek a consultation with them. ‘To wait til the rest of them fail’ offers no solution for right now.

When administered properly, Botox is a very conservative way to address decreasing the gummy show. Referring to your photos, I’d recommend injections not only in the LLSAN muscles, but also the Levator Labii Superioris, and Zygomaticus Minor, due to the appearance that your gummy show extends from the front of your smile posteriorly to the back as well.

To answer your question, these injections would only affect the muscles that elevate the lip and should only affect your smile in a positive way (that is, covering the excess gums). It should have no effect on limiting how wide you can smile.

The photos show the narrowness of your arch from the front view quite well. To answer your question, there are several options. Further orthodontic arch development can still be achieved with an LVI dentist/orthodontist trained in physiologic orthodontics or at Dr. Gallela’s Facial Beauty Institute. There are techniques and appliances that these practitioners can apply to get that robust arch form you are looking for. It would, however, take about 2 years in appliances/braces.

From a porcelain standpoint, though it would be more ideal and complete to have 10 units of porcelain perfectly matching with optimal widths, it could be done in less. I think you’d fall short with 4. Including the canines also (making 6) would go a long way as this is THE transition tooth between the front teeth to the back and it sets the tone for the angle and thickness that you desire on the back teeth to fill the space known as the buccal corridor. 

As for no prep veneers, maybe. Most of your goal is additive in nature which makes this a possibility. Sometimes very minimal prep can be more effective and dependable in this type of instance if you are open to that. That decision would involve looking at stone models and more photos to make the call.

When it comes to how teeth are prepared for veneers, it can vary greatly from patient to patient, based on several parameters. In any case, it should be the dentist’s goal to remove the least amount of natural tooth structure possible to get the desired shape for the final result. 

If a patient has virtually no crowding and slightly undersized teeth, the veneers can be sometimes made with no preparation to the teeth at all. This is not often the case, but as a general rule otherwise, it is most ideal to keep the preparation within the enamel (the outer layer of the tooth). This is desired because not only is it more conservative, but also bonding a veneer to enamel rather than dentin produces a superior adhesion to the tooth.

There are some cases when there is a significant amount of crowding, misalignment, or existing fillings/restorations and further preparation into the dentin is necessary to get a satisfactory result. This can still be predictably addressed, but more tooth structure must be removed. Typical preparation in this example would involve removing1-2mm from the biting edge, front, and adjacent sides of the teeth.

As a general rule, it’s not a good idea to extract teeth to ‘straighten’ an arch of teeth. There are some orthodontists and dentists who aren’t very concerned about this practice, but from a physiologic standpoint, it can impinge on the space for your tongue to function comfortably and de-stabilize the result. 

To answer your question, it will be very unlikely that the upper and lower dental midlines will line up at the end of this treatment. That’s not often noticeable to the lay-person unless looking directly at a close up photo for more than a few seconds. It’s also doubtful that you would expect your lips to look misaligned, but it is possible that you may notice the jaw to be misaligned visually or functionally. 

Overall, it would be more ideal to treat both upper and lower arches with orthodontics and replace the now missing tooth with an implant once the teeth have been aligned.

There are a few ways to non-surgically improve your downturned smile using injectables. The most profound improvement should come from using a medium to high viscosity filler like Juvederm Ultra or Juvederm Ultra Plus directly to the nasiolabial folds and marionette lines and cross hatching the material perpendicularly to the lines. 

1-2 units of Botox can be placed in each of the Depressor Anguli Oris muscles to knock out their ‘pulling down’ function of the corners of the mouth as well.

Yes, veneers are an option for patients with overbites. That depends of course on exactly what you’re trying to accomplish with the veneers. If you want to improve the shapes, shades, and/or crowding of these teeth, veneers can help. However, if you’re trying to fix the overbite with veneers, there’s a good chance that just veneer treatment will not be enough. You may need to address the overall bite as well.

If the cross bite is on your back teeth, it’s unlikely that Invisalign treatment alone will correct that. Depending on the severity, an appliance, surgery, or limited treatment with braces would have to be used in combination with Invisalign to address a cross bite of the back teeth. 

If front teeth are in cross bite, however, Invisalign alone may be able to correct them, depending on the severity.