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Winter 2009, Aesthetic Trends & Technologies


As a cosmetic dentist practicing in Manhattan, the majority of new patients I see inquire about cosmetic dentistry, mainly tooth bleaching and porcelain veneers. With the economic woes facing our world, one would think cosmetic dentistry would be the first thing to vanish from the discretionary spending wallets of Americans. I, however, am seeing the exact opposite in my practices.
Our procedure revenues for 2009 Q1 and Q2 are at record high levels, up 15% from 2008. This is highly due to the fact that executives and professionals are continuing to enhance their appearance to remain favorable and attractive in the workplace where any and all edges matter.
Laid-off executives and workhungry professionals seem to have more free time on their hands now that the business world's pace is a little slower.
A common thread I see with these patients is the age group of the baby boomers. This segment of the population represents over 75% of patients seeking cosmetic dentistry in my practice. From my experience, I have subdivided baby boomers into two different groups:

Group A
Patients who have average looking teeth. Their teeth are not an ''appearance nuisance'' but are also not their strong feature. They present discoloration issues, misalignment, size, shape, and/or length irregularities.

Group B
Patients who have a severe smile problem. These patients have been self-conscious of their smile their entire life and have learned to smile and communicate without exposing their teeth. These patients have been aware of their problem for decades.
The economy has had very little impact on Group B. These patients have been planning, saving, and researching cosmetic dentistry for decades and are motivated and determined to change their lives by correcting their smiles, i.e. we have not seen a drop in these patient demands.
The change we see is the dynamics and motivating factors for Group A. We see less patients looking for a smile enhancement or smile makeover because they want to look like a ''movie star'' and have perfect teeth. An analogy: a patient with minor wrinkles putting off a facelift. This procedure can be put off since it is considered elective to this group. Conversely, we see a different portion of Group A increasing cosmetic dentistry demands for new reasons: ''I have lost my job and now I have some time to get my teeth fixed,'' or, ''I'm looking for a job and I want to make the best impression I can.''
With all the information (and sometimes misinformation) we are bombarded with in the media and on the web, I wanted to review some basic concepts in cosmetic dentistry that have survived the technology era, and also touch on some of the newer techniques that may or may not be a good cosmetic option. Whether one is in Group A or Group B, this review can help one stay on top of the latest, greatest, and not so greatest techniques we are commonly using.

Porcelain Veneers
All dentists are not created equally. Many people grace our lives with bad veneer makeovers (chicklet teeth), and the dentalcrown- smiles with black lines showing thru the gums. A big part of these dental nightmares is determined by the ceramist with whom the dentist works.
Dentists can use small ''boutique'' style ceramists who create each tooth like a sculpture, or they can opt for a veneer from a national chain type laboratory that spits veneers out of a machine for sometimes 90% less cost!
In 2002 I founded Oral Design Boston, a ceramics laboratory, on Newbury Street in Boston, MA with world-renowned ceramist Yasu Kawabe from Japan. From importing rare porcelain vacuumed furnaces from Germany and Hawaii, to testing microscopes and elaborate porcelain combinations, I was involved extensively in developing the technical and laboratory portion of high-end porcelain veneer fabrication.
Understanding and managing every step in the process is vital to ensure superb porcelain aesthetics when dealing with high-level cosmetic dentistry. Some of the most published cosmetic dentists do not understand the technical aspect of veneer fabrication and proper material specifications.
Critical information is frequently skipped or omitted in the dental veneering process simply because dentists have been able to ''get by'' without truly understanding each and every step. This is just one of the many aspects of cosmetic dentistry that people need to investigate when choosing their cosmetic dentist, who is their dentist's ceramist, and how involved is your dentist going to be in the laboratory process.''
Truly beautiful veneers are interpreted as beautiful teeth. These veneers are stealth to everyone's eyes and subconscious. The optical properties of the porcelain are the key. When I write ''optical properties,'' what I am saying is the way human eyes perceive light reflecting and passing through the veneers.

Here are facts I must elaborate on and simplify before I continue:
• White is actually the absence of color.
• Something that is white is reflecting light back at the person looking at it.
• Conversely, black is absorbing all light and reflecting none.
• All colors in between white and black absorb and reflect light in different amounts, giving that object a ''color.''
• A ceramic toilet, a piece of Chicklet gum, a white piece of paper, and a white sock all reflect, scatter, and absorb light completely differently - yet they are all white.

When we are creating porcelain veneers, we want to use a porcelain that reflects light, in the same manner and degree as human enamel reflects light. We also want the structure of the material (the lattice work, framing, building blocks) of the veneer to be assembled similarly to human enamel. Otherwise, even though a material may be white, as we see above, it doesn't necessarily mean it will look like a tooth.
Dentists have choices when they decide which technician will make your porcelain veneers. Dentists can choose veneers milled by a machine from a block of engineered solid glass Lucite, or can choose veneers made by hand, layer after layer, by a trained artist out of feldspathic porcelain. There are many laboratories, material, and technicians; and it is very important for you to understand this process so you can be a part of the decision making when your dentist sends your work to be fabricated.

We use hand stacked, feldspathic porcelain by Jason Kim, Oral Design New York. The type of porcelain powder Jason uses is somewhat of a secret formula. It is believed to be a mixture of Creation porcelain (by Wille Gellar) and old school Ceramco porcelain powder. The mixture and ratio of these powders is a mystery, a formula that Mr. Kim and his closest ceramist apprentices keep as a trade secret!
Dental Bleaching/ Whitening
I am bombarded daily with questions about tooth whitening.
• What is the best kind to buy in the store?
• Does that place in the mall do a good job?
• Do you have a laser?
• Do lasers work better?

After whitening a few thousand smiles, I have put together this summary about my personal clinical experiences as of early 2009 (technology changes so rapidly, this article may be out of date in 6 months). I have broken this summary into the different categories of whitening commonly available either at a dental office or drug store.

In-Office Bleaching (any type of laser assisted procedure, high intensity light, blue light)
The claim: Significant color change in a short period of time is the major benefit of in-office whitening. This protocol involves the carefully controlled use of a relatively high-concentration peroxide gel, applied to the teeth by a trained technician after the gums have been protected with a paint-on rubber dam. Generally, the peroxide remains on the teeth for several 15- to 20-minute intervals that add up to an hour (at most). Those with particularly stubborn staining may be advised to return for one or more additional bleaching sessions, or may be asked to continue with a home-use whitening system. Inoffice teeth whitening costs about $1000.

The reality: This method works only if the proper steps are taken beforehand and if a longterm maintenance plan is established. A close colleague of mine, Dr. Irwin Smigel, has perfected this procedure with his line of Supersmile products. The teeth must be stripped of the protein pellicle before the inoffice ''power bleaching'' procedure, and a long-term maintenance protocol needs to be followed. The active ingredient in Supersmile, Calprox, effectively manages the long-term care without any harsh abrasives. The Supersmile line of products, coupled with a thorough in-office whitening treatment, can be very profound and immediate!

Professionally Dispensed Take-Home Bleaching Kits
The Claim: Take-home kits incorporate an easy-to-use lowerconcentration peroxide gel that remains on the teeth for an hour or longer (sometimes overnight). The lower the peroxide percentage, the longer it may safely remain on the teeth. The gel is applied to the teeth using custom-made bleaching trays that resemble mouth guards. Takehome teeth whitening costs about $500 to $700.

The Reality: If this is done properly over the course of 4-6 weeks, 95% of people can achieve bleached, beautiful white teeth. Unfortunately about 5% of the people I see are resistant to any form of whitening. Typically a dentist will hand you a kit with 2-4 syringes of whitening gel, and then you are on your own. This is marginally effective.

I have devised a method where I (not my assistant) see the patient every 2 to 3 weeks for about 5 minutes. I assess the patient's progress and sensitivity and change the solutions accordingly. On average I start people with a 15% carbamide peroxide solution, then 22% carbamide peroxide solution, then a 6% Hydrogen peroxide solution.

These all work 4-6 hours while sleeping. What makes this method effective is the ''sleeping'' part. At night while sleeping your salivary glands shut down. This lack of salivary flow permits the solution to work on a dry tooth structure without the saliva buffering and rinsing the solution form the teeth.
This method is time consuming, cumbersome, and difficult to stick with. Sleeping with trays can be difficult for many.
Over-the-Counter Bleaching

The Claim: The cheapest and most convenient of the teeth whitening options, over-thecounter bleaching involves the use of a store-bought whitening kit featuring a bleaching gel with a concentration lower than that of the professionally dispensed takehome whiteners. The gel is applied to the teeth via one-sizefits- all trays, whitening strips, or paint-on applicators. In many cases this may only whiten a few of the front teeth unlike custom trays that can whiten the entire smile. Over-thecounter teeth whitening costs around $40.

The Reality: This method works on about 50% of the people who try it. If you only have minor discoloration, and no crowns or filling in/on your front teeth, this is the easiest and least expensive way to get whiter teeth. You will not achieve the same results as a dentist dispensed take-home kit, but you will see some improvements!

About the Author
Dr. Thomas Connelly is a New York City Cosmetic Dentist whose work spans many generations and walks of life. Moms, corporate executives, celebrities, professional athletes, runway models, and high profile clientele from all over the world, Dr. Connelly has built his reputation by inviting everyone into his practice.

Bringing over a decade of experience to his cosmetic practices spanning the Northeast, Dr. Connelly received his dental training at the Mayo Clinic, the University of Detroit Mercy, and Louisiana State University. He has also served as clinical instructor at Harvard University dental school in Boston. Aside from general dentistry, Dr. Connelly also provides extensive cosmetic services including full-mouth reconstruction which includes full-smile makeovers and fullmouth porcelain veneers.

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