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Robert Elsenpeter is a freelance writer and frequent contributor to Dental Products Report and Dental Lab Products. He is also the author of 18 technology books, including the award-winning Green IT: Reduce Your Information System's Environmental Impact While Adding to the Bottom Line. As such, he’s particularly interested in the technological side of dentistry.
Ask any cosmetic dentist that’s been around for awhile, and he or she will tell you a lot of the most popular treatments are now done in fresh and exciting ways. And while there are new, cutting-edge procedures, there are still a number of mainstays that provide the majority of their work.
Back to basics
The basics-the standards, if you will-of cosmetic dentistry are still the core of the profession. But the way those services are delivered tends to be different than they were 10 or 20 years ago.
“Whitening and full-mouth restorations make up about 70 percent of my work,” observes Dr. Richard Marques, BDS, of Wimpole St. Dental in London. “However, I also do facial esthetics (botox and fillers), gum treatments, dental implants (placement and restoration) and emergency dentistry.”
When patients come in to address one complaint, they must be assessed as a whole. That is, simply bonding or whitening teeth may not be enough to get them to their goal. The doctor must look at the big picture.
“Every patient that I see, we look at comprehensively, from a biological need and the cosmetic stuff,” says Dr. Jack Ringer, DDS, a general and cosmetic dentist at Advanced Smile Design in Anaheim Hills, Calif. “Any patient that is a candidate for bleaching, we’ll recommend it. Bleaching is a harmless, wonderful procedure; it’s better than doing restorations if it’s going to generate the same results.”
Today, more than ever, patients expect a higher standard and know what they want.
“The Internet has opened up a whole new world for people,” says Dr. Sam Simos, DDS, a cosmetic dentist at Allstar Smiles in Bolingbrook, Ill. “Back in the day of the Extreme Makeover, when Bill Dorfman introduced the veneer to the world, it seemed like it was only attainable for the very rich and the very famous, and now those are commonplace. We are doing veneers every day. We are doing them on people who are soccer moms and warehouse workers. It’s wonderful because it’s attainable.
Procedures, techniques and, as a result, outcomes have all improved over the years.
For Dr. Ringer, the whole process involves a well-planned design based on modern versions of classic techniques.
“Everything boils down to the evolution of cosmetics over the years,” he says. “Right now, it seems like it’s all focusing on first starting off with an accurate design. Whether you’re going to do something very elementary or very sophisticated with a patient, the ideal thing to do is to have a model dental design for the patient, and we have tons of tools nowadays to develop that. We always start off by looking at their face, seeing how their teeth fit in their face, then creating a design for that and working the steps as what could be done to achieve that.”
Those advancements are due, largely, to material improvements.
“It’s dictated by the materials we have available,” Dr. Simos says. “It used to be that if we were doing a crown in the front, we would have to take down two thirds of the tooth. Today, because of the materials and how thin they are, we can engineer a crown or a veneer that’s so fingernail-thin and have it be so predictable and bondable that it’s amazing.”
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The products and materials available to cosmetic dentists have helped deliver better results for patients.
“There are so many great products out there, and the manufacturers are doing a great job of keeping us very product-heavy,” Dr. Simos says. “Sometimes that’s a problem because sometimes these great products come out and you don’t know how to use them. You don’t know what to use them for.”
“At Wimpole Street Dental, we like to evolve using evidence-based research (EBR) to stay up to date with the latest techniques,” Dr. Marques says. “I have been a practicing dentist for 10 years, and things have changed immensely during this period. One such advancement is the introduction of Icon (microfilling material) by DMG for reduction/removal of white spots for fluorosis or calcification. Another is the improvement in bonding techniques, and we use Adhese Universal. The alginate Hydrogum is incredibly dimensionally stable and an excellent product (also flavored nicely). Temporary materials have also improved with Quicktemp by Schottlander and Luxatemp by DMG-two of the leading products. These come in a full range of shades from dark (A3.5) to bleaching (HBO). When polished and glazed, they look fantastic and can give the patients an idea of the color and shape of the final teeth.”
Without the advancements of new products, cosmetic dentistry would not have developed as fully as it has.
“It all goes back to manufacturers,” Dr. Ringer says. “It’s a business. They want to compete so they want you to buy their products. Somebody always comes up with something that they claim is bigger and better, but you never know.”
The world of composites has certainly grown, but doctors must know how to use the new materials.
“The composites have changed dramatically over the years,” Dr. Simos says. “It used to be at that they weren’t very wear-resistant. Now they are extremely wear-resistant, and they’re wonderfully polishable, and we can make them look like an exact match to the tooth. We don’t have to settle for decreased results. You can expect really great things.”
But it isn’t solely in the hands of the materials. Doctors must know the proper ways to use those products.
“That’s all technique-driven, too,” Dr. Simos says. “You can’t just expect to open it up, take it out of the package and get those results. You have to get the education and know how to use those materials competently and predictively so the patient can benefit from it. I think that’s the key.”
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veneers have also undergone an evolution during their existence in the cosmetic dentistry world.
“Initially, when veneers first started, there was a lot of skepticism of, ‘Are they going to work?’” Dr. Ringer says. “In those days, we only had techniques of bonding onto enamel so we were very, very cautious in our preparations and being very, very conservative. We didn’t have the plethora of ceramics that we do today but still there was some phenomenal stuff done.”
Materials have been a huge boon for veneers, and recent innovations make them better than ever.
“One of the biggest things that’s helped is the advent of some other better ceramics. In particular, I like lithium disilicate,” Dr. Ringer says. “The trade name is (IPS) e.max, which has kind of taken the world by storm because it’s beautiful, it’s bondable, you can mill it, you can press it, you can cut back and layer it and you can almost do anything with it other than posterior bridges.”
Bonding agents continue to evolve and improve the process of restoration adhesion.
“Some of the products I love out there now are the self-adhesive, resin cements,” Dr. Simos says. “We use them for bonding our crowns, but we don’t really need to treat the tooth. We can put these bondable cements into the crowns, and they work beautifully. It’s very simple and very easy.”
Bonding agents have developed to the point where they are easier to use and can do more.
“They’re getting a little bit more sophisticated with these one-bottle systems that have everything but the kitchen sink in them,” Dr. Ringer says. “There’s one called Universal that has everything you can find in it. And they’ve been showing really promising results. Same thing with some of the cementing agents. They are having everything in one cylinder so it bonds, it etches, it makes things a little bit more predictable for the dentist with fewer post-operative problems.”
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A doctor can examine the patient and figure out what he or she needs. However, successfully communicating that plan to the patient in a way that is receptive to them is critical.
“A lot of people, when they come to you, they say something like they’d like a nice smile, but that can mean a lot of different things to different people,” Dr. Ringer says. “The way I like to present it is to firstly sit with a patient with a photograph of their face and their smile and have them point out where they feel things are deficient and then for me to also point out things that I may see as deficient.”
From there, Dr. Ringer utilizes digital photography and 3D computer modeling before constructing custom provisional restorations.
“I kind of call them prototypes,” Dr. Ringer says. “They are based off of the original design, and those can be modified because they are resin, but the whole key with all of this is before the ceramist actually makes the final restoration, the patient has lived with, seen and approved a shape, design, size and position of whatever they’re going to have.”
It is a lot of work, but it takes the surprise and the uncertainty out of the work.
“What this does is it helps both the dentist, the lab and the patient understand everything so that at the end of the day, there are no surprises,” Dr. Ringer says. “The patient doesn’t say, ‘Oh, you promised me this,’ or ‘I thought I was going to get that.’ It is much more predictable and seamless.”
Dr. Marques utilizes the skills of other professionals in developing his treatment plan.
“A truly personalized treatment plan is key to making a fully informed decision,” Dr. Marques says. “I create a bespoke dental treatment plan that differs for every patient. Pre-assessment of the case and staying within your limits are important. I recommend the use of specialists (endodontic, orthodontic, periodontic) and imaging techniques (CT scans) to provide the best treatment. In the Harley Street area, I am fortunate enough to work with some of the best dental (and health) specialists in the world. This is why I trust them with my own teeth as well as that of my patients.”
For Dr. Simos, having a regular plan is important, but one must also be able to tweak the plan based on the patient.
“What you have to do first is have a system in place, and I don’t think any one system is the magic bullet to treatment plan explanation,” Dr. Simos says. “What I try to do is you have to have a complete system that everyone in your office is aware of and everyone works on so everyone is on the same page-from front desk to the doctor to the hygienists. Everyone has got to be on the same page when you’re presenting a treatment plan.”
“The next thing is you have to be able to read the patient and ask him or her what it is that he or she wants, and then you can talk to that,” Dr. Simos adds. “You have to listen. You have to get out of the one-size-fits-all mentality because everyone is different and has different needs.”
As cosmetic dentistry evolves, so, too, must the doctors. To stay on top of their industry, they must seek out and embrace learning opportunities.
“Constant learning is the key to a successful and fulfilling career in dentistry,” Dr. Marques says. “My upcoming training includes further implant facial esthetic training.”
Also, seek education from a variety of sources to broaden your learning.
“I would strongly advise them to take continuing education courses from independent sources,” Dr. Ringer says. “In other words, not strictly manufacturer-sponsored programs. Education through Spear Education or Dawson, for example. These types of places that are giving really high end, quality education without it being driven by the manufacturer.”
Doctors who are not taking advantage of these opportunities are hurting themselves.
“There are so many continuing education opportunities out there, whether it be the state meetings, local meetings or study clubs,” Dr. Simos says. “Dentists just aren’t taking advantage of those opportunities. The big problem is just getting doctors in the chairs to get this done because they are really busy. My biggest suggestion to doctors would be take the continuing ed. Take as much as you can. You can’t get enough of it because even if you take one pearl away from an hour or two-hour lecture, it’s worth it.”
The standards in cosmetic dentistry look like they will continue to be the bread and butter of the industry, and keeping up on their evolution, as well as being able to communicate their usefulness to patients, will continue to be important.