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RealSmile Dentistry Miami

INTRODUCTION
Social Media has arguably become a global obsession. For teenagers and young adults, Facebook, Twitter, Instagram, Snapchat, and TikTok have become the most common platforms for communication. If you have ever left your feeds feeling bad about yourself, you are not alone! Self-esteem often takes a hit when one starts comparing him- or herself to other people too much, which is something social media seems to be made for.

Social media presents a unique set of challenges for those who are feeling vulnerable. Today’s teenagers comprise the first generation that cannot imagine life without the internet. Some of that interaction can be positive, allowing teens to find a sense of belonging, but less known is the negative impact of social media on body image.1

Beauty standards have changed significantly over the past several decades. Photo-editing technology applications such as Facetune and Snapchat have created new beauty standards and will continue to change peoples’ concepts of attractiveness. The notion of “beauty perfection” once only applied to celebrities, but it has spread to different parts of society, perhaps mostly to our teenagers and young adults in today’s world. Today’s beauty standards are undermining the self-esteem of millions of people globally. These perceptions of beauty can trigger body dysmorphic disorder, warn researchers at the Boston Medical Center.2
Selfies are accessible to us on every social media platform, as individuals flood the virtual world with their photos. The most credible way to promote your relevance rests in the number of “likes” on your selfie.1 There are apps to enhance all these images. Reshape your face, smooth your skin, thin areas of your body, and whiten your teeth. The result is a perfect picture. However, as we know, these app-edited photos aren’t real, nor do they equal permanent changes. The results do not reflect accurate images, which leads to severe dissatisfaction with how we actually look and who we truly are.1

A new phenomenon, Snapchat Dysmorphia, is occurring at an alarming speed. Selfies and photo filter apps are driving people to plastic surgeons and cosmetic dentists. Patients are seeking procedures so they will appear like the filtered versions of themselves.

So as our social media and selfie culture continues to grow, it’s no surprise that more and more young people and adolescents are seeking out cosmetic dentistry as a way to enhance their appearances. The dental world has taken notice, and we need to respond with easy, conservative, and affordable methods to whiten, straighten, and restore smiles. I believe we need to address these patients’ desires for their self-esteem yet always be mindful of their best long-term dental health. This means doing the most conservative treatments while still attaining the smiles they desire. When considering treatment options, conservation of tooth structure should be paramount, especially with younger patients. Appearance and self-esteem have long been intertwined. Healthy self-esteem is feeling good about oneself and feeling worthwhile. Having a healthy, attractive smile can encourage a positive state of mind, inspiring confidence, and a willingness to smile more. Moreover, self-esteem is considered to play an important role in psychological adjustment and educational success.3 As evidenced with Snapchat Dysmorphia, more and more young people are seeking out cosmetic dentistry. For patients with unattractive, crowded, or spaced teeth, cosmetic dentistry can offer a solution that can be beneficial in many ways. We also have many younger patients who have what was once considered very nice teeth now seeking cosmetic dentistry to obtain “perfect selfie smiles.”

After thoroughly listening to the patient’s concerns and desires, a smile evaluation should be done. Treatment can then be determined based on smile design principles. Conservative procedures that deliver big results but, at the same time, require minimal or no natural tooth reduction should be considered: tooth whitening, gingival contouring, enamel contouring, microabrasion, resin infiltration, composite bonding, minimal-prep porcelain veneers, etc.

Tooth Whitening
Tooth whitening, accomplished by the application of peroxide-based materials, has become one of the most frequently requested dental procedures by the public. Many OTC products such as toothpastes, gels, and films contain various concentrations of peroxides. In contrast, in-office-based systems contain highly concentrated bleaching agents that are applied under professional supervision. The risks related to tooth whitening are increased tooth sensitivity, gingival irritation, increased potential for demineralization, tooth surface roughening and softening, degradation, and unacceptable color changes of dental restorations.

Gingival Contouring
Gingival contouring, also known as gingival sculpting, is the process of reshaping the gingival architecture around the teeth in the aesthetic zone. After assessing the biologic width and desired, idealized gingival zeniths, contours, and symmetry, the free gingiva can be reshaped with lasers or with traditional surgical techniques.

Enamel Contouring
Enamel contouring is a cosmetic dentistry technique that removes small amounts of tooth enamel in order to change the shape, length, or surface of one or more teeth. This is used for very fine adjustments and done with fine diamonds, discs, polishers, and abrasive strips.


Resin Infiltration
Microabrasion
Enamel microabrasion uses a combination of mechanical pumicing and chemical means to remove a small amount of tooth enamel (not more than a few tenths of a millimeter) to eliminate superficial discoloration. This technique is very effective in removing intrinsic brown lesions.

White spot lesions (WSLs), also defined as “white opacities,” occur due to subsurface enamel demineralization located on the smooth surfaces of teeth. Changes in the light-scattering optical properties of decalcified enamel are the reason for the white appearance. Various risk factors, such as acid-producing bacteria and fermentable carbohydrates, as well as many host factors, such as poor oral hygiene, low salivary volume, and a sugary diet, further the development of these incipient lesions.4 A low-viscosity resin infiltrant is used to minimize the appearance of white spotting caused by demineralized enamel on the facial surfaces of anterior teeth.

Composite Bonding
Bonding is the application of a tooth-colored resin to fix the shape or color of teeth. Composite bonding can easily repair chips, fractures, decay, and discolored teeth. Advanced adhesive materials and highly polishable composites often make this the technique of choice. Systems like Uveneer (Ultradent Products) provide templates and simplified techniques to help dentists give beautiful results.

Porcelain Veneers
Porcelain veneers are thin shells of ceramic material bonding to the facial surfaces of teeth in the aesthetic zone. They may be indicated for non-orthodontic closing of spaces, alignment of rotated teeth, enamel pathologies, severe staining issues, misshapen teeth, and more. Bonding to most or all enamel greatly increases the veneer’s success rate to almost 99% because bond strength to enamel is significantly higher than to dentin.5 If porcelain veneers are the chosen treatment, then minimal or no-prep techniques are preferable for teenagers and young adults.

A clinical exam revealed a 2- to 2.5-mm diastema between her upper right and upper left central incisors. She had a heavy labial maxillary frenum. The treatment decisions were to perform direct bonding of the diastema while still retaining an acceptable proportion of the central incisors. In addition, performing a frenectomy would prevent further separation of the central incisors.

CASE 1: DIRECT COMPOSITE, WHITENING, FRENECTOMY
A 14-year-old girl presented with an upper midline diastema. She stated that she felt very self-conscious about her “huge space” and was unhappy with her smile’s appearance. She had a Class 1 molar posterior relationship with upper anterior spacing and nice alignment on her lower anterior. Orthodontic treatment was ruled out by 2 orthodontists citing tooth size discrepancy of the upper anterior teeth.

An abnormal upper labial frenum is capable of retracting the gingival margin; creating a diastema; limiting lip movement; and, in cases of a high smile line, affecting aesthetics as well. When an abnormal frenum is present, a frenectomy is advised.6 This patient’s teeth would be whitened prior to the frenectomy (Figures 1 to 3).

Clinical Procedure
Whitening: A session of in-office whitening was performed, followed by at-home whitening. To minimize sensitivity, prophylactically, the patient used a desensitizer, UltraEZ (Ultradent Products), for the 3 days prior to the in-office procedure. The soft tissue was protected by isolation with retractors, cotton rolls, and OpalDam (Ultradent Products) for the in-office session. Opalescence Boost (Ultradent Products) was applied for two 20-minute sessions. The patient then followed up with home whitening using Opalescence Go 15% preloaded disposable trays (Ultradent Products) for 10 days, 30 minutes per day. Five shades of whitening were accomplished.

Frenectomy: The upper anterior labial mucosa around the maxillary frenum was anesthetized with infiltration of 4% Septocaine (1:100,000 epi) (Septodont). The frenum was removed with the dual-wavelength Gemini Laser (Ultradent Products). Postoperatively, the patient was instructed to rinse 4 times daily with chlorhexidine rinse (PerioGard [Colgate]) for 7 days. Ten days later, the diastema was closed.

Diastema Closure: The diastema was approximately 2.5 mm wide. Smile analysis indicated that the centrals could be widened with bonding, and the general proportions would still be aesthetic, and the smile would still be appealing. The mesial enamel of the upper right central incisor and upper left central incisor were etched with 37% phosphoric acid for 15 seconds, then rinsed. Universal adhesive was placed, and the solvent was air-dried and then cured with the VALO Grand curing light (Ultradent Products). Mosaic Shade A1 and Shade EW (Ultradent Products) were layered on each incisor and cured, closing the space. Finishing and polishing were done with fluted carbide burs and Sof-Lex finishing discs (3M). The final finish was with 0.5-µm Diamond Polishing Paste (Ultradent Products).

CASE 2: GINGIVAL SCULPTING, RESIN INFILTRATION, WHITENING
Post-orthodontic treatment, a 16-year-old was disappointed with the appearance of her teeth. Although her orthodontics resulted in good occlusion, she did not have confidence in the appearance of her teeth. Her smile was a bit gummy. WSLs were present, and she was not happy with their yellow shade (Figures 4 and 5).

Clinical Procedure
Resin infiltration was performed with Icon (DMG America) on the central incisors. The WSLs were gently abraded with a fine-grit diamond. Then Icon etchant was applied for 2 minutes, rinsed off, and dried. Icon-Dry was applied to assess if the resin would sufficiently infiltrate the lesion. This case required two additional 2-minute etching sessions. The Icon-Dry was applied for 30 seconds. Then the Icon-Infiltrant was applied for 3 minutes and cured.

Gingival sculpting was done on the upper anteriors using a Gemini Laser (Figure 5). The tissue healed for 2 weeks, and then the patient returned for an in-office whitening session with Opalescence Boost. Ten Opalescence Go disposable trays were dispensed for home use. A second session of in-office whitening was done (Figure 6).

CASE 3: FOUR VENEERS, GINGIVAL SCULPTING, WHITENING
Preparing for a career in performing arts, a 19-year-old wanted to have a stage-ready smile. She felt that her teeth were small, and she did not like the translucency of her central incisors (Figures 7 and 8).
Treatment: Gingival sculpting, whitening, and minimal-prep veneers were done on teeth Nos. 7 to 10 for the small laterals and the centrals with heavy translucency.

Clinical Procedure
Whitening in-office, followed by 10 days of at-home treatment, was done as in Case 1. Gingival sculpting on the lateral incisors was then performed with the Gemini Laser. After 2 weeks of healing, the central and lateral incisors were minimally prepared for IPS e.max veneers (Ivoclar Vivadent) (Figure 9). The veneers were placed 2 weeks later. The patient was very pleased with the results (Figure 10).

CASE 4: PRERESTORATIVE LIMITED ORTHODONTICS, MINIMAL-PREP VENEERS, WHITENING
This 28-year-old female patient’s chief complaint was the appearance of her smile—in particular, her upper anterior teeth. Her dentition was generally healthy with no restorations. Her periodontium was healthy. The teeth were misshapen and chipped, and the central incisors were rotated mesially (Figure 11). Treatment options included:

1. Orthodontic treatment alone. This option was ruled out because even if the alignment was corrected, veneers were indicated to improve proportion and restore wear to meet the patient’s aesthetic expectations.

2. Traditional veneer treatment of the upper anterior teeth with whitening of the other teeth.

3. Limited orthodontic treatment to improve alignment, then minimal-prep veneers on the upper anterior teeth and whitening of the other teeth.

The patient selected option number 3. The orthodontic goal was to level, align, and rotate the teeth into a position that will require the least amount of tooth reduction while still achieving optimal results. The treatment plan involved the use of Six Month Smiles, which is a short-term orthodontic regimen (Figure 12). Patients like this method because of the clear brackets and wires, making them less noticeable. I chose Six Month Smiles as opposed to clear aligners for this case because using brackets and wires ensures compliance and predictable timing on the orthodontic portion, which then allows the restorative portion of the treatment to be completed on schedule. With clear aligners, patient compliance can be inconsistent. The inconsistency can lead to delayed orthodontic movement, which in turn delays the restorative treatment. As is often the situation in cases such as these, patients frequently decide to undergo cosmetic treatment in anticipation of an important event, which necessitates completing treatment on a fixed timeline. This expectation must be met, or the patient will be extremely disappointed, regardless of the lack of compliance and responsibility. This patient wanted to have all treatment complete in preparation for a wedding.

Clinical Procedure
The patient underwent 4 months of orthodontic alignment with Six Month Smiles. She reported the treatment was very easy, and the brackets were hardly visible to others. Significant alignment was accomplished, and the brackets were removed. We should note that had the orthodontic treatment been extended, complete alignment could have been attained, but it was not necessary. The upper anterior centrals and laterals were very conservatively prepared for IPS e.max veneers. The other teeth were whitened with Opalescence Boost. The veneers were placed with the Variolink Esthetic LC System Kit (Ivoclar Vivadent). The post-op photo shows a well-proportioned smile meeting the patient’s aesthetic needs and was accomplished with very little tooth structure removal. The patient now has increased confidence (Figure 13). The veneers have an excellent prognosis for long-term success.

CASE 5: MINIMAL-PREP VENEERS, WHITENING, GINGIVAL SCULPTING
This young man stated, “I do not like the unevenness and color of my teeth. I hate the dark space between my front teeth, too. I want veneers.” As an adolescent, he had orthodontic treatment, and he has had tooth whitening several times and had good dental health. His smile would have been considered very attractive in the past, but standards have changed, so that is no longer the case today. He wanted a brighter, more ideal look (Figure 14).

Smile evaluation revealed uneven incisal edge lengths on the lateral incisors, varying gingival heights, a small dark triangle between the central incisors, and the banding of colors through all the anterior teeth. Direct bonding to close the dark triangle and lengthen the left lateral incisor was ruled out by the patient because he wanted to have brighter, denser-looking teeth. The treatment would be gingival sculpting for symmetry, then 8 minimal-prep veneers and whitening on his mandibular teeth.

Clinical Procedure
Whitening: In-office whitening was done, followed by at-home disposable tray whitening, then 10 days of shade stabilization.

Gingival sculpting: The 1.5 mm of free gingiva on the upper left lateral incisor were removed with the Gemini Laser. Because of the predictability of healing, the sculpting was done on the same day as the prep and impression.

Minimal veneer preparation: The upper 8 anterior teeth were minimally prepped for IPS e.max veneers. A very light chamfer was prepped on the gingival margin, creating a finish line for the ceramist (Figure 15). An impression was taken, and provisionals were fabricated. The provisionals were a prototype of the finals. The patient returned 2 days later for approval of the provisionals. The veneers were fabricated and tried in 10 days after prepping. Once approved, the veneers were inserted with Choice Cement 2 (BISCO Dental Products) (Figure 16).

IN SUMMARY
Cosmetic dentistry offers our younger patients a solution for unattractive, crowded, or spaced teeth or teeth that are just unacceptable to them. This can be beneficial in many ways, among them instilling greater confidence and self-esteem. But when considering treatment options, especially for younger patients, the conservation of tooth structure should be paramount. Our ultimate objective in any dental treatment should be restoring health and function, as well as aesthetics, using the most conservative method possible. Porcelain veneers are steadily increasing in popularity among today’s dental practitioners due to their ability to conservatively restore unaesthetic anterior teeth. As noted, the bond strengths of veneers are stronger when bonded to enamel than to dentin. If the teeth can be positioned into better alignment prior to prepping, it is a win-win for clinicians and patients. This saves significant tooth structure as minimally invasive preparation of just the enamel for restoration can raise the success rate for veneers.

Direct restorative techniques like direct composite veneering systems are also on the rise. Combining these indirect and direct restorative procedures with gingival sculpting, tooth whitening, and other enamel treatments allows us to conservatively deliver significant results to our patients.


References

  1. Schirripa J. How this generation’s obsession with selfies correlates with mental disorders. Elite Daily. January 19, 2015. https://www.elitedaily.com/life/selfies-self-love-surgeries/902152
  2. Nordqvist C. Beauty standards changing thanks to selfies and filters. Market Business News. August 3, 2018. https://marketbusinessnews.com/beauty-standards-selfies-filters/184184/
  3. DiBiase AT, Sandler PJ. Malocclusion, orthodontics and bullying. Dent Update. 2001;28(9):464–6. doi:10.12968/denu.2001.28.9.464
  4. Deveci C, Çinar C, Tirali RE. Chapter 6: Management of white spot lesions. In: Akarslan Z, eds. Dental Caries – Diagnosis, Prevention and Management. IntechOpen. 2015. doi:10.5772/intechopen.75312
  5. Gürel G. Minimally invasive veneers. Dental Industry Review. January 31, 2017. https://www.dentalreview.news/dentistry/20-cosmetic-
    dental-surgery/1834-minimally-invasive-veneers
  6. Bagga S, Bhat KM, Bhat GS, et al. Esthetic management of the upper labial frenum: a novel frenectomy technique. Quintessence Int. 2006;37(10):819–23.

SOURCE
Authored By: Dr. McMahon is a graduate of the University of Pittsburgh (Pitt) School of Dental Medicine. She maintains a private practice focused on cosmetic dentistry in Pittsburgh. Dr. McMahon is accredited by the American Academy of Cosmetic Dentistry (AACD) and is an invited Fellow of the prestigious American Society for Dental Aesthetics.
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