1) Making the decision for tooth extraction and implant placement.
Due to the extreme positioning of the upper left lateral incisor, and the treatment limitations set by the patient, there really isn't any appropriate way to make an improvement with this tooth's appearance.
Bringing the tooth forward by placing some type of restoration would either make the tooth ridiculously thick or strangely misshapen. And doing so could have consequences for the neighboring teeth and surrounding gum tissue.
That means the only solution that remains is to pull it and replace it with either a dental implant or bridge. In our "after" picture, we've illustrated how we think things would turn out if an implant were placed.
As a criticism of the cosmetic outcome of this approach, the dental crown that's used to restore the implant will end up looking narrow when compared to the same tooth on the other side. That's because a full-sized tooth simply won't fit in a crowded-tooth space.
2) Completing the makeover for the upper teeth.
Our "after" picture also illustrates changes for a few other teeth, which collectively create a better appearance for this smile. It seems likely that porcelain veneers might be used to make these changes, although a decision about their suitability over crowns would be a decision for the treating dentist to make.
We'll admit that we've cheated somewhat in our "after" picture. We've show significant gum-line changes for the lateral incisor on the patient's upper right. That amount a change would most likely require a minor surgical procedure termed "gum sculpting."
3) The lower teeth.
Our "after" picture illustrates how some minor trimming of the lower teeth could make their misalignment less apparent.
An alternative (and better) treatment plan.
Treating this smile as a dental implant case really seems a bit extreme. But given the limitations discussed above, we didn't see another option.
As an alternative plan, and one that seems a realistic compromise, here's an approach that could provide the same outcome without having to extract the tooth and place an implant, if the patient would just accept it.
Instead of full orthodontic treatment, just move the single tooth out of crossbite and back into a more normal positioning. Moving an individual tooth would take much less time than full treatment. And it could probably be accomplished with some type of removable appliance (like Invisalign) instead of fixed braces. (Actually, moving the same tooth on the other side into better alignment could be completed simultaneously, using the same appliance.)
The tooth may need to be narrowed before it can be guided into its new location, but its shape could be perfected afterward by placing a dental veneer.
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