Written by Ross W. Nash, DDS Monday, 14 October 2013 09:44
In today’s practice, patients are looking for affordable options for smile enhancement that can be achieved quickly. In this article, I will discuss 3 modalities that fit in this category and that have positively impacted my practice in the past few years. These are Snap-On Smile (DenMat), Componeers (Coltène) and the Inman Aligner (Inman Aligner).
A number of my patients have been searching for an immediate solution to smile enhancement. While most communicate that they intend to acquire long-term solutions when they can, they want something quick and affordable for now. One of my patients was applying for a management position in the construction industry and wanted to look better for his interview. Another patient had excellent dental health, but very small teeth due to genetic development and wanted to look “normal.” Yet another is planning to have veneers and crowns placed when his finances will allow, but wanted an immediate an improvement for business reasons. These stories are routine in today’s economy.
Snap-On Smile, developed by New York dentist Dr. Marc Leichtung, provides the answer for many of these patients. While a number of acrylic and copolymers have been tried, he discovered that acetyl resin, a homopolymer used in other industries, has the strength and flexibility to work.
In my practice, we quote the manufacturer (DenMat) that the Snap-On Smile doesn’t actually fix any dental problems or permanently make over a smile. It is a unique, temporary cosmetic device that instantly improves the appearance of teeth and smiles. Conditions that can be improved with this device are diastemas between teeth, abnormally small teeth, crowded teeth, badly stained or discolored teeth, teeth that are worn, missing teeth, the appearance of a “gummy” smile and provisional replacements for implant restorations (Snap It [DenMat]). I have used Snap-On Smile to increase vertical dimension prior to full dental reconstruction. I have also used a Snap-On Smile for an opposing arch against a full arch of new restorations in order to stage treatment for the patients benefit.
We do not offer the Snap-On Smile to patients who cannot or will not address ongoing dental disease. A thorough exam and diagnosis is performed for candidates and recommendations for treatment are given. Any active disease is arrested and home care is emphasized before impressions are taken for the appliance. We encourage the patient to expect one to 3 years of service with the appliance and emphasize that a Snap-On Smile is “additive” and will feel more full than their natural teeth alone. Some patients can eat with the device in place and we recommend that it is not worn while sleeping and that it is thoroughly cleaned each day in conjunction with oral hygiene procedures for the patient’s teeth and supporting tissues.
Accurate impressions (usually using a vinyl polysiloxane [VPS]) and an occlusal bite registration are taken. We send digital images of the patient’s preoperative teeth and smile, and choose from a number of available shades. At the delivery appointment, the appliance is tried-in, and the occlusion is evaluated and adjusted, if needed. The Snap-On Smile actually “snaps” over the heights of contour of the natural teeth due its flexibility and is retained by engaging undercuts. It can, however, because it is made of a resilient material, be easily removed.
The patient shown here (Figure 1), the owner of a restaurant, wanted a better smile. His examination revealed good periodontal health and no active caries. As can be seen in the occlusal/incisal view in Figure 2, he had missing maxillary second premolars and his first premolars were restored with amalgam. Composite resin had been previously used to restore the centrals and laterals, and all 4 molars had PFM crowns in place. The canine teeth were unrestored and exhibited only slight wear at the incisal edges. He wanted a complete treatment plan that included implants to replace his missing premolars, crowns for his centrals and laterals, inlays for his first premolars, and veneers for his canines. The cost of this treatment plan was prohibitive for him at the time, so he asked for a transitional option until he could afford a more permanent solution. A Snap-On Smile appliance (Figure 3) was chosen to provide with the immediate aesthetics that he desired.
|Figure 1. The patient’s smile before Snap-On Smile (DenMat).||Figure 2. Occlusal/incisal view of the patient’s smile before Snap-On Smile.|
|Figure 3. Snap-On Smile as delivered from the |
|Figure 4. Occlusal/Incisal view with Snap-On Smile in place.|
|Figure 5. The patient’s smile with Snap-On Smile in place.|
Figure 4 shows the appliance in place. A slight increase in vertical dimension was accomplished by overlying all of the teeth. He reported that he could actually eat with it in place. He was very pleased with the appearance of his smile (Figure 5) and, in fact, told us later that he receives compliments from his customers. This patient was so happy with the results he ordered a second Snap-On Smile to have in case he lost the first one!
My fee for a porcelain veneer in today’s economy is 25% less than I was receiving 10 years ago when patients were investing in ceramic smile makeovers routinely. Even at lower fees, fewer patients are willing to make the investment for laboratory-fabricated veneers today. Many of my patients are choosing direct composite resin veneers because of their more affordable cost. In my own experience, a well-placed direct composite resin veneer can be expected to last 10 years or more; when provided in the appropriate clinical situations and properly maintained by the patient. Most dentists can master the clinical technique of composite bonding, but some have more artistic ability than others. Therefore, the aesthetic result can differ from dentist to dentist. About 2 years ago, I was introduced to a technique for direct veneers invented by Dr. Mario Besek of Zurich, Switzerland. I believe this technique can “level the playing field,” so to speak.
A Componeer is a prefabricated, enamel-shaded composite laminate designed to simplify the freehand technique of direct composite veneer placement. Componeers are intended for use where direct composite veneers are indicated. The composite resin material is Synergy D6, a nanohybrid (Coltène). It is light-cured under pressure but not heat processed, so it has the same physical properties as the direct light-cured material it is made of. The pressure curing, however, significantly reduces porosity, and I believe the surface is more stain resistant and possibly more wear resistant. The Componeer is used in conjunction with Synergy D6 dentin shaded light-cured composite resin.
I have found that I can place a Componeer in nearly half the time it takes me to place a similar direct veneer with a total freehand technique. The enamel-shaded Componeer blends seamlessly with the dentin shade underneath and can be altered in contour where desired. When adjusted, it can be polished to a high sheen. I have noted that the margins are often imperceptible, the surface is absent of voids, and the polish is excellent. My fee is less than half of that for a porcelain veneer, so many patients have chosen this alternative in my practice. In many clinical conditions where I would place a conventional hand-layered direct composite veneer, I can now use a Componeer.
In the clinical case shown (Figure 6), the patient wanted to revitalize her smile with veneers. She illustrated excellent periodontal dental health and only minimal caries in a few proximal areas. In the incisal view in Figure 7, we can see that she had some slight incisal wear and a previous composite resin restoration in one of the central incisors. She chose Componeers because they were affordable and within her budget.
|Figure 6. Facial view of the patient’s smile before Componeers (Coltène).||Figure 7. Incisal view before Componeers.|
|Figure 8. Componeers tried-in.||Figure 9. Bonding agent was applied to internal surface of Componeer.|
|Figure 10. Dentin shaded composite added to tooth surface.||Figure 11. Componeer placed.|
|Figure 12. Aluminum oxide polishing strip used to polish proximal surface of Componeer.||Figure 13. Incisal view of Componeers in place.|
|Figure 14. Facial view of Componeers in place.|
After minimal preparation, the Componeers were tried-in (Figure 8) and adjusted as needed. The prepared teeth were etched with 35% phosphoric acid gel for 10 seconds, thoroughly rinsed, and left slightly moist for wet bonding. A bonding agent (One Coat Bond [Coltène]) was liberally applied; air-dried and light-cured for 10 seconds with an LED curing light (SPEC 3 [Coltène]). The bonding agent was applied to the internal surface of the Componeer (Figure 9) and blown thin. A dentin-shaded nanohybrid composite resin (Synergy D6) was spread evenly on the internal surface of the Componeer. The dentin-shaded composite was also applied to the prepared tooth using a composite spatula (Figure 10). The Componeer was gently pressed to place (Figure 11) using a special placement instrument (Placer [Coltène]). The excess dentin-shaded composite was removed with a composite instrument and blended into the tooth structure. The composite was light-cured for 20 seconds on the facial and lingual surfaces with the LED curing light. Flowable composite resin (Synergy D6 Flow) was used to seal the incisal and gingival margins and light-cured. Margins and contours were refined with carbide finishing burs, sandpaper discs and strips (Figure 12), and polishing points. A high sheen was accomplished with a composite polishing brush. (In this case, all burs, discs, strips, polishing points, and brushes were by Alpen [Coltène].)
Figure 13 shows the finished result from the incisal view. Note the exquisite margins. The final appearance from the facial view is shown in Figure 14. The patient was very pleased with the aesthetics, function, and the affordable cost of her new Componeer smile.
THE INMAN ALIGNER
In the last 2 years, I have incorporated a remarkable orthodontic device in my aesthetic treatment plans. The Inman Aligner, invented by Donal P. Inman, CDT, of Inman Orthodontic Laboratory, can be used to align anterior teeth in many clinical situations in only a matter of weeks. This ingenious appliance is completely removable. It should be worn for 16 to 20 hours a day and removed for a minimum of 4 hours a day.
The Inman Aligner was designed to straighten anterior teeth with no more than 3.0 mm of crowding. Interproximal reduction (IPR) is used to create space to “unlock” the teeth and allow them room to move. All that is needed are full-arch accurate impressions with a stable and repourable material (such as a VPS), and an occlusal registration. The dental laboratory team sets the teeth to the desired positions (either manually or digitally) and then designs the appliance around this ideal curve. There is a face-bow to bring the teeth lingually and a lingual bow to push the teeth facially. Proximal contact adjustments are made slowly every 2 weeks as the teeth begin to align. When alignment is achieved, a fixed or removable retainer is placed.
There are innumerable patients in our existing practices that have moderate anterior malalignment. Many of these patients would be very grateful to have a simple and affordable treatment to correct the problem. Aligning teeth prior to placing restorations has allowed me to be more conservative with tooth preparation. In some patients, we find no need for further dentistry after alignment is achieved. Alignment, bleaching, and bonding have taken the place of more aggressive treatment for some of my patients.
While more drastic cases of anterior crowding are achievable with this appliance, the case shown here illustrates a common occurrence of minimal malalignment. The patient in Figure 15 had a beautiful smile, but she felt that the crowded mandibular central incisor detracted from it. A close-up preoperative view can be seen in Figure 16. She was happy to hear that a simple solution to correct the crowding was available for less than the cost of 2 porcelain veneers in our office.
|Figure 15. Patient’s smile before alignment of mandibular incisor.||Figure 16. Close-up view of crowded mandibular anterior teeth.|
|Figure 17. Incisal view of Inman Aligner (Inman Aligner) in place at delivery.||Figure 18. Incisal view, at 6 weeks.|
|Figure 19. Close-up view of aligned incisors.||Figure 20. Patient’s smile, after alignment.|
After impressions and occlusal registration were taken, and digital photography was performed, a lab prescription was written and the case was sent to the dental laboratory team for the fabrication of an Inman Aligner. At the delivery appointment, minimal IPR was performed with diamond-coated strips and the appliance was delivered. The aligner is shown at initial placement in Figure 17. The patient returned every 2 weeks for fine adjustments to the interproximal contacts, and, at the third appointment, the alignment was complete. Figure 18 shows the aligner in place at 6 weeks, and the result can be seen in the close-up view in Figure 19. Figure 20 shows the patient’s smile after treatment. Upon her 6-month recare appointment, she told me that she is an “Inman Aligner believer” and feels that it was one of the best things she has done for herself.
In today’s economy, many patients are looking for more cost-effective ways to improve their smiles through dental treatment. Three practical and affordable solutions were demonstrated and discussed in this article.
Dr. Nash maintains a private practice in Huntersville, NC, where he focuses on aesthetic and cosmetic dental treatment. He is an accredited Fellow in the American Academy of Cosmetic Dentistry and a Diplomate for the American Board of Dental Aesthetics. He lectures internationally on subjects in aesthetic dentistry and has authored chapters in 2 dental textbooks. He can be reached at (704) 904-3458, at email@example.com, or at cosmeticdentistryofthecarolinas.com.
Disclosure: Dr. Nash reports no disclosures.
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