April 7, 2020
by Susan McMahon, DMD; Joseph Zwickel
Social media has arguably become a global obsession. For teenagers and young adults, Facebook, Twitter, Instagram, and Snapchat have become the most common form of communication. Teens are increasingly posting photos of themselves and friends.
Beauty standards have changed significantly over the past several decades. As our social media and “selfie culture” continues to grow, an undeniable obsession to have the perfect appearance has emerged. Youtube, Instagram, Facebook, and Snapchat and other social media platforms facilitate comparison to others in many ways including appearance. Unfortunately, these comparisons are not completely accurate and can lead to “compare and despair” feelings. Editing applications and filters now allow people to digitally enhance their appearances (eg. smoother skin, whiter smiles, more contoured faces).
Appearance and self-esteem have long been intertwined. Self-esteem is considered to play an important role in psychological adjustment and educational success.”1 A new occurrence termed “Snapchat dysmorphia” is transpiring at an alarming rate. In an attempt to look more like the filtered versions of themselves, patients are seeking out more cosmetic procedures than ever.2
With this rising pressure to have the ideal esthetic appearance, teens and young adults are more commonly turning to cosmetic dentistry to help create an ideal looking version of themselves. As dentists, we can play a crucial role in their quest to have “social media worthy” smiles. Before we can provide these cosmetic services, we have to understand the patient’s desired outcome. A smile evaluation of the patient should be used to determine the most conservative methods, materials, and techniques to achieve the patient’s desired smile while considering the patients long term dental health. Enamel recontouring, direct composite bonding, minimal prep veneers, traditional veneers, full crowns, gingival recontouring, whitening, orthodontics and combinations of these are all possible treatments. Choosing the most conservative option is especially important for younger patients.
For a long time, the material of choice for cosmetic and conservative procedures was composite resin. However, the low durability of this material leads to esthetic damage due to color instability. In addition, its organic matrix degrades and it absorbs water; therefore, the material needs constant maintenance and polishing to prolong the duration of its useful life. Porcelain greatly mimics the natural structure of dental elements and is an excellent option to avoid the various deficiencies of composite resin.3 When preparation of tooth structure is necessary to achieve the desired results, restricting the preparation to enamel is considered to be a critical factor for a favorable bonding strength, thus more durable outcome. Additionally, preserving the interproximal contact is recommended in most of the literature and studies, this is due to preserving more enamel and tooth structure, allowing a positive seat for cementation in a conservative approach.4
The following case exemplifies a young man with a pleasing smile and attractive teeth who was not satisfied and sought cosmetic dentistry to idealize his smile.
Case Study: Minimal Prep Veneers, Whitening, Gingival Sculpting
This young man’s chief concern was, “I do not like the unevenness and color of my teeth. I hate the dark space between my front teeth too. I don’t like the shape of my two front teeth. I want veneers”. This patient had orthodontic treatment as an adolescent and teeth whitening several times. His dentition and periodontium were healthy. In order to ascertain the patient’s desired outcome and assess his clinical situation, a smile evaluation was performed. An ideal smile based on academic considerations may not be perceived as the most attractive by laypeople. Due to the variation in esthetic perception by each person, participation between providers and patients for decision-making and treatment planning is crucial to generate successful results.5 His smile evaluation revealed uneven gingival contours, asymmetric lengths of the lateral incisors, a small dark triangle between the central incisors, and banding of colors on his anterior teeth (Figs. 1 & 2). After smile evaluation and discussion with the patient, a plan was formed to idealize the smile with and reshape the anterior teeth with straighter incisal edges.
Pre-op Full Face.
To idealize the smile, the gingival heights would be addressed with gingival sculpting, the upper central and lateral incisors would be reshaped, and the remaining dentition would be whitened again. A conservative treatment option would be to use direct composite bonding to close the dark triangle, reshape the central incisors and lengthen the left lateral incisor. Direct composite bonding was ruled out because adding 2-3 mm of unsupported composite to the incisal edge of the left lateral incisor in composite would have compromised retention. The other restorative option would be porcelain veneers either traditional or minimal prep. The perfecting of current ceramic systems, especially pressed ceramics reinforced with lithium disilicate, has brought us back to the idea of no-prep veneers. Although these veneers achieve thicknesses similar to those of feldspathic ceramics, lithium disilicate ceramics allow for restorations of up to 0.2 mm in thickness with greater clinical and laboratory ease. Because of their better mechanical properties, these restorations can be made, finished, tested, and cemented more safely.6 Minimal prep lithium disilicate veneers were chosen to enhance this smile along with gingival sculpting for symmetry, preceded by whitening.
Records were taken and a mockup was waxed. Combination whitening was performed and then ten days allotted for shade stabilization (Fig. 3).
In-office whitening followed by take home whitening.
Preparation day consisted of the following:
Shade Mapping post whitening, pre-prepping.
Gingival sculpting with diode laser.
Minimally prepared teeth.
Digitally scanning with Trios Scanner.
Provisionalization for prototype.
The restorations were fabricated to the size and shape of the approved provisional prototype. When the patient returned, the provisionals were removed and the restorations were loaded with try in paste and placed for review (Figs. 9 & 10). The patient approved the restorations (Fig. 11) and signed a consent to insert the final. The final restorations were bonded with a light cured adhesive resin cement, Choice 2, Bisco (Fig. 12). Figures 13 and 14 show the post-op results. The patient feels more confident with his smile and is pleased with the results.
Provisionals being removed
Try in paste with restorations.
Patient approving insert of restorations.
Adhesive resin cement bonding restorations in place.
Post-op full Face.
As dentists, conservation of tooth structure is of utmost importance. This is especially true for the increasing younger patient population interested in cosmetic dentistry. Minimal or no-prep veneers, like the ones used in the case study, are an esthetic, yet conservative, option for many patients. Due to their versatility and natural appearance, porcelain veneers are regarded as the gold standard for cosmetic dentistry. These veneers can typically resolve complaints of open spaces, alignment of rotated teeth, enamel pathologies, and stain and color issues. New developments in ceramics allow very thin materials to be very durable. Because these veneers bond the strongest to enamel, minimum preparation are desirable for both bond strength and for longterm dental health of our patients.
In conclusion, the ultimate goal in dentistry is to restore health and function, as well as esthetics, using the most conservative method possible. This is becoming more and more relevant to dentists as the younger population, driven by social media, yearns for ideal and confident smiles.
Oral Health welcomes this original article.
About the Author
Susan McMahon has enjoyed a successful career for over 25 years in the dental industry. Dr McMahon is an accomplished Cosmetic Dentist, national Key Opinion Leader in the dental industry, educator, and author. She is an entrepreneur with 25 successful years in small business. Developing systems and teams for consistency, providing excellent products and offering unparalleled customer service are the hallmarks of the brands she has created. Dr. McMahon has restaurant experience and understands the process of managing a successful small business.
Joseph Zwickel is the President of the Academy of General Dentistry at his dental school and was instrumental in the development of an implant fellowship track program.
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The idea of placing porcelain veneers on a person in their 20s is a bit brave for someone like this whose teeth are very decent too begin with. Composite can be placed and if done properly and well will look good for many years. Microfils like Cosmodent’s Renamel is highly polishable and has a luster to rival porcelain. I have a problem when a person has decent looking teeth that are forever altered with a dental drill!! These veneers will need to be redone at some point in this young man’s life since nothing you place in the mouth is forever!!!
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