Modern Composites for Minimally Invasive Cosmetics

Dr. Todd Snyder

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INTRODUCTION
Enhancing one’s appearance is nothing new in our society. In fact, the popularity of cosmetic enhancements is growing more rapidly than ever,1,2 a trend that is clearly evident with related products such as over-the-counter teeth-whiteners.3 The many different social media platforms that are popular today are definitely increasing the awareness of cosmetic enhancement procedures by allowing our patients to see what types of work others are undergoing and spreading knowledge about the available options.4 The wonderful part about enhancing one’s appearance is that there are many different methods, including, but not limited to, modifying eye color, changing hair color or getting extensions, altering eyelashes or eyebrows, eliminating wrinkles, and making thin lips fuller. Various options exist for people to achieve their desired appearance, with alternatives and price points that can work for almost anyone. Of course, changing tooth shape and color is another way to enhance one’s appearance.

Social Media and Digital Technology Impact Cosmetic Dental Treatment
For those who choose to undergo cosmetic dental treatment, a complete smile makeover can transform their appearance, but often simple tooth modifications can achieve results that are just as incredible. Cosmetic dentistry can offer many patients the ability to see what is possible via the modification of their smiles—how it can alter their appearance, affect their vision of themselves, and even improve their overall confidence in social situations—and new technology is expanding the possibilities even further. Again, with the help of social media, people from anywhere on the planet can see the wide range of cosmetic possibilities available and connect with others who have considered and/or undergone various procedures.

Additionally, the ability for dentists to offer virtual smile consultations online (eg, smilevirtual.com/dr-todd-snyder) can create a significantly increased amount of new inquiries and opportunities. Digitally altering photographs to demonstrate what is possible allows the dentist to have a virtual discussion with the patient, during which they can not only create hope but also visualize opportunities.5 The digital mock-up can help the dentist bring in more new patients and offer more cosmetic dentistry than traditional marketing would yield. Patients who present to the office for a cosmetic consultation can have composite mockups performed on their teeth to instantly see what is possible as well as to highlight limitations that likely need to be addressed. A discussion can then ensue regarding which materials are most appropriate for each patient’s unique situation, time, and financial desires.

The Composite Resin Alternative
As much as these digital capabilities continue to drive cosmetic dentistry, modern composite materials are also constantly evolving.6 This provides amazing tools for the cosmetic dentist to become a true artist with the ability to provide minimally invasive alterations that can be life-changing for his or her patients.

Patients often want to enhance their smiles with simple cosmetic alterations or complete smile makeovers, and these modern composites have made the dental team’s cosmetic bonding capabilities better than ever in terms of natural appearance while, at the same time, providing improved strength properties. More stable, long-lasting polish can make these composites a good option in comparison to more expensive ceramic veneer alternatives.

CASE REPORTS
Case 1

The possibilities that modern composites open up were evident in a recent case involving an attractive young woman who was unhappy with the discoloration of her teeth over time, as well as the distractions in her smile caused by numerous old composite restorations that had become discolored (Figures 1 and 2). A large case such as this often involves restoring as many as 6 to 10 teeth, which may seem quite daunting for many dentists and patients. However, the ability to simplify the restorative process by using fewer layers of composites and working off a wax-up-derived template can reduce the invasiveness and treatment time required. In many cases, it is now possible for the dental team to deliver a whole new smile and appearance for a patient such as this one in as little as 2 to 3 hours.7

During the consultation appointment for this patient, photographs, diagnostic models, and a face-bow recording were taken. The patient’s models were then altered via the use of an additive wax-up technique that required no reduction to tooth structure. The additive process allows for enhanced lip support and minimally invasive dentistry as well as a potentially longer-lasting bond to enamel when compared to a process that involves tooth reduction into dentin. A template was derived from the diagnostic wax-up to allow for the incisal lingual aspect of the tooth and embrasure spaces to be created quickly.

Local anesthetic was administered, and the existing composite fillings and any caries were removed (Figure 3). A total-etch technique was done using a 35% phosphoric acid etch (Ultra-Etch [Ultradent Products]) for 20 seconds. The etchant gel was then suctioned off, and the teeth were rinsed with water for 5 seconds and then air-dried. A microbrush applicator was used to apply a universal adhesive (Peak Universal Bond [Ultradent Products]), scrubbing it on the surfaces for 10 seconds. Next, the bonding agent was lightly air-dried at a reduced pressure for 10 seconds and then light cured (VALO Grand [Ultradent Products]) for 10 seconds in standard mode. The small preparations into the dentin were filled with an A1 dentin shade of a nanohybrid composite (Mosaic [Ultradent Products]) and then light cured for 20 seconds (Figure 4). Next, enamel shade (BW) composite was placed in one large increment and then distributed across the tooth in order to avoid creating voids and porosities, utilizing an IPC-L Composite Instrument (Cosmedent) (Figure 5). A wetting resin was applied to a PKT #3 waxing instrument, and then it was placed slightly subgingivally, running it from mesial to distal to contour the gumline and to adapt the composite resin to the tooth. This increment was then light cured for 20 seconds (Figure 6). A small amount of contouring was then done to create space as well as some primary anatomy in the form of depressions. This was done so that a more translucent enamel layer of Mosaic could then be placed in the incisal half of the tooth. This second layer was cured for 20 seconds with the VALO Grand. Next, fine diamonds and cups were used to finesse the shape of the new restorations and to remove any scratches. Finally, all the composite surfaces were polished (Jiffy Polishers [Ultradent Products]) (Figure 7), and the patient was dismissed.

The patient was asked to return the next day to have the contours and final polish re-evaluated. Her excitement and appreciation of her smile makeover were then captured with photos of the new restorations. Her permission was secured to allow the use of her photos in subsequent social media marketing campaigns to create awareness for other potential patients with similar concerns and issues (Figures 8 and 9).

Additional Case Studies
Not all treatment plans need to be complex in order for the dentist to create dramatic results for patients. Some available modern composites can blend in seamlessly with the teeth without the need to perform any reduction to tooth structure.8 Minimally invasive dentistry and non-invasive dentistry are becoming easier every year with the continued improvements manufacturers are making in the colors, translucency, light reflectance, and shade ranges of their materials to mimic different aspects of natural tooth structure.

Case 2
A patient presented following orthodontic treatment, and she was still unhappy with the appearance of her teeth despite how well the orthodontist had symmetrically aligned them within her smile. When providing orthodontic therapy, the dentist should work to align the gum tissues rather than the incisal edges because, while the teeth can be altered at a later time, potentially needing to alter bone and gingival tissue is a much larger undertaking. Fortunately, in this case, the orthodontist had been able to align the teeth well at both the gingival tissue and the incisal edges. However, due to arch shape and tooth size, it had been decided to leave space bilaterally between the lateral and canines. The patient was unhappy with the appearance and wanted to do something conservative to close the spaces (Figures 10 and 11).

The patient first underwent tooth whitening (Opalescence Go [Ultradent Products]) prior to starting the restorative work, and the teeth were given a week for the color to stabilize.

A #00 retraction cord was placed in order to move the tissue out of the way slightly and to allow a mylar strip to be placed between the teeth. Air abrasion was used to remove salivary pellicle from the teeth and to create more surface area to adhere to. A 35% phosphoric acid (Ultra-Etch) was used, followed by rinsing the teeth with water and lightly drying them. The Peak Universal bonding agent was applied and then light cured. A single layer of Mosaic composite (shade EW) was then placed, contoured, and cured on each tooth to reduce the space.

The patient in this case was extremely happy with her new smile (Figures 12 and 13). This case shows the ability for dentists to alter the appearance of teeth in a relatively short amount of time with minimal reduction of the tooth structure, which undoubtedly contributed to the patient’s satisfaction as well.

Case 3
A patient presented with developmentally damaged enamel that was very white in appearance, desiring a smile that looked more realistic and believable (Figure 14). The damaged enamel was removed with an air abrasion unit (CrystalAir [CrystalMark Dental]). As in Case 2, a total-etch technique was done, a universal adhesive was applied, and one layer of Mosaic composite was placed (shade EN, along with a hint of shade EW on the distal edge of tooth No. 9). The results in this third case speak for themselves. This was an everyday case to replace damaged or missing enamel with a single layer of composite. A beautiful and natural-looking appearance, which in previous years would have required far more effort and time, was the outcome of a relatively fast and simple procedure (Figure 15).

CLOSING COMMENTS
Cases of varying levels of complexity can be made easier by utilizing modern composite materials that blend in easily with one to 2 shades, as has been demonstrated herein. Furthermore, minimal-to-no tooth reduction is necessary in order to achieve beautiful and believable results. This is a significant departure from the past, as materials from just a few years ago required far more tooth reduction to allow space for materials to blend with the tooth. With these capabilities, the dentist can save on both costs and time. However, and perhaps more importantly, these new materials and the techniques they facilitate make the process much more patient-friendly. This is keeping dentistry at the forefront of cosmetic enhancements at a time when such treatments are in more demand than ever before.


References

  1. American Society of Plastic Surgeons. New statistics reflect the changing face of plastic surgery [press release]. February 25, 2016. https://www.plasticsurgery.org/news/press-releases/new-statistics-reflect-the-changing-face-of-plastic-surgery. Accessed November 12, 2018.
  2. Grand View Research. Cosmetic dentistry market to reach $27.95 billion by 2024 [press release]. July 25, 2016. https://www.prnewswire.com/news-releases/cosmetic-dentistry-market-to-reach-2795-billion-by-2024-grand-view-research-inc-588104822.html. Accessed November 12, 2018.
  3. Carey CM. Tooth whitening: what we now know. J Evid Based Dent Pract. 2014;14(suppl):70-76.
  4. Gould DJ, Leland HA, Ho AL, et al. Emerging trends in social media and plastic surgery. Ann Transl Med. 2016;4:455.
  5. Santos FR, Kamarowski SF, Lopez CAV, et al. The use of the digital smile design concept as an auxiliary tool in periodontal plastic surgery. Dent Res J (Isfahan). 2017;14:158-161.
  6. Prieto LT, Araujo CT, de Oliveira DC, et al. Minimally invasive cosmetic dentistry: smile reconstruction using direct resin bonding. Gen Dent. 2014;62:e28-e31.
  7. Korkut B. Smile makeover with direct composite veneers: a two-year follow-up report. J Dent Res Dent Clin Dent Prospects. 2018;12:146-151.
  8. Qureshi T. Minimally invasive cosmetic dentistry: alignment, bleaching and bonding (ABB). Dent Update. 2011;38:586-592.

Dr. Snyder received his doctorate in dental surgery at the University of California, Los Angeles (UCLA) School of Dentistry and has trained at the F.A.C.E. institute. He is an Accredited Fellow of the American Academy of Cosmetic Dentistry and is a member of Catapult Education. Dr. Snyder was on the faculty at UCLA, where he created and co-directed the first 2-year graduate program in aesthetic and cosmetic restorative dentistry. In addition to lecturing internationally, he has co-authored 3 books and written numerous articles in publications around the world. He is the owner of Aesthetic Dental Designs in Laguna Niguel, Calif. He can be reached at the website drtoddsnyder.com.

Disclosure: Dr. Snyder reports no disclosures.

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