Transforming Smiles: The Art and Science of Modern Cosmetic Dentistry

Defining Cosmetic Dentistry

Dr. Gary Glassman: Cosmetic dentistry is a wide range of different things. Can you tell the audience what different things are involved?

Dr. Sol Weiss: Cosmetic dentistry encompasses anything that will change or improve your smile [1]. This ranges from simple bonding procedures when a tooth is chipped, to teeth whitening, to replacing lost teeth [1]. Everything, including implants and veneers, falls into the category of cosmetic dentistry [1].

Innovations in Tooth Replacement: All-on-Four Implants

Dr. Gary Glassman: Many industry publications have been reporting that dentures have now become the last resort in dentistry [1]. How do innovations like All-on-Four dental implants or other solutions help older patients avoid dentures?

Dr. Sol Weiss: Dentures were always the last option before the advent of implants [2]. Today, we really say that you shouldn't have to have dentures [2]. Implants can be used to replace a single tooth, multiple teeth, or, for people who have lost all their teeth and previously wore full dentures, we offer the All-on-Four or "teeth in a day" scenario [2]. Patients come in, get the implants placed, and have teeth secured onto the implants that same day [2].

Expectations, Guarantees, and Maintenance

Dr. Gary Glassman: How do you manage patient expectations regarding guarantees, given it’s a biological procedure involving significant expense?

Dr. Sol Weiss: Expectations are a big deal [3]. Implants are a very good treatment plan, but they do fail and they do fail for many different reasons [3]. We have to be very upfront with patients, telling them how long they can last and how they can fail, especially if they don't take care of them [3]. Implants must be treated the same way as natural teeth [3].

A big part of implant placement is the maintenance after care [3]. Patients need to come in regularly [22]. We unscrew the bridge, clean the heads of the implants, and then put them back in [22, 23]. This retraining for proper oral hygiene is a challenge for people who lost their teeth due to decay or periodontal disease [4, 22].

All-on-Fours are not for everybody [4]. The design was specifically for people who have only bone in the front of their mouth [4]. Doing an All-on-Four in a 40-year-old is not a good treatment because they will have that appliance for a very long time, and there is always bone loss around implants [24].

Modern Orthodontics: Clear Aligners

Dr. Gary Glassman: Clear aligners offer a discreet alternative for adults seeking orthodontic care. Who are the best candidates?

Dr. Sol Weiss: The original design of clear aligners was for adults who had ortho when they were younger but had some crowding later on in life because they didn't wear their retainers [5]. Aligners are an unobtrusive way to move simple cases back into position [5]. Attempting to do it with kids and teenagers poses problems because you really need to know about growth and development and have a good background in ortho to manage the issues that come around [6].

Risks and Management

Dr. Gary Glassman: What risk should dentists be aware of when they recommend clear aligners?

Dr. Sol Weiss: The biggest issue is that they have to manage the bite in the posterior [7]. If you start to expand the anterior teeth to correct crowding, you risk creating open bites [7]. Dentists doing this need to be really aware of that and manage the posterior bite as well as the anterior bite [7].

Black Triangles Remedy

Dr. Gary Glassman: After Invisalign, some patients will develop black triangles between their teeth. How do you remedy that situation?

Dr. Sol Weiss: The first remedy is to go back to the aligner treatment and do some interproximal reduction (IPR) to squeeze the teeth together a little bit and reduce the black triangle [8]. If that fails, Bioclear is a technique developed specifically for these areas, allowing the dentist to add material to cover those triangles up [8, 9]. Another option would be doing veneers, but for proper veneers, you often have to do a slice prep between the contacts, leading to much more significant tooth reduction [9].

Veneers, Aging, and the "Dental Facelift"

Dr. Gary Glassman: GQ magazine recently observed that veneers were once a "dirty secret" but are now the "new luxury status symbol" [25]. Has this increased demand given rise to more professionals offering cosmetic dentistry?

Dr. Sol Weiss: Everybody offers cosmetic dentistry now because everybody is coming in and asking for it [25]. People are coming in and asking for natural white, which doesn't exactly go together [26]. We go over colors, as whiter is better; whiter is considered to be more aesthetic and more pleasing [26].

One of the things I'm dealing with now is that older people are coming in, unhappy with how their teeth have discolored and worn down. As we age, we lose tone in our facial musculature, and things are hanging a little bit [27]. I call the correction the dental facelift [28]. We recover the amount of tooth loss, open the bite, and increase the lower face height, which automatically makes people look younger by stretching the face [28].

Non-Prep Veneers and Preservation

Dr. Sol Weiss: To open the bite, we use a new technique, which is non-prep veneers [29]. This means there is no filing of the teeth [29]. We place these onlays over the existing teeth, elevating the bite [29].

One of the biggest concerns with veneers is filing your teeth down, or what they call "turkey teeth" or "shark teeth" on Tik Tok [30]. Non-prep veneers provide a huge service because they address this concern [29]. The patient can wear an acrylic impression of the planned wax-up for a day or two to test the function before committing to the permanent restoration [31].

Dr. Gary Glassman: If someone doesn't need their bite to be open, how do you balance aesthetics with tooth preservation?

Dr. Sol Weiss: If the patient requires preparation to achieve the desired result, I will tell them, and I have no problem prepping into "virgin teeth" [10]. However, if I am prepping virgin teeth, the patient must be at least over the age of 30 and clearly understand what I'm doing [10]. For younger people needing cosmetic work, I would do non-prep veneers or full tooth bonding [8].

The Social Media Impact on Whitening

Dr. Gary Glassman: Teeth whitening procedures have become the latest trend among Tik Tok and YouTube content creators [11]. How has the rise of social media influencer culture changed whitening expectations?

Dr. Sol Weiss: Social media has changed all the expectations [11]. People have the expectation of intense whiteness [11]. Whitening results vary; it doesn't work on everybody [12]. Zoom whitening in the office works the best, and we give them trays afterwards to boost the result [12]. If teeth are great shape and position, but suffer from intense discoloration like tetracycline staining, they may require a prep veneer that is thicker to opaque out the intense color [13].

Professional vs. DIY Whitening

Dr. Gary Glassman: What advice would you give to dentists on how they can demonstrate the superiority of professional treatments over do-it-yourself ones?

Dr. Sol Weiss: I advise patients to go buy the Crest White Strips first [13, 14]. They'll get a result, which confirms their teeth *can* whiten [14]. I tell them that the strips will not get their teeth to the color they want, but using the professional whitening afterwards will yield a much stronger, better result [14].

The Dangers of Dental Tourism

Dr. Gary Glassman: What messages should dentists emphasize regarding the safety, quality, and value of domestic cosmetic treatments as opposed to dental tourism?

Dr. Sol Weiss: You get what you pay for is number one [15]. Number two is you don't have any idea of what the qualifications of the dentists or the materials they're using [15]. People are making their decisions based on Tik Tok and Instagram [15]. The major problem is the lack of local follow-up [16]. If you have a problem, you would have to fly back to Turkey or Colombia to take care of it [16]. If significant problems arise two years later, you face much more significant and costly dentistry [16]. Managing the risk is one of the major things [16]. Patients should come to a dentist that is locally trained or trained at least in North America, where regulations and material standards are consistent [17].

Ethical Dentistry and Unrealistic Expectations

Dr. Gary Glassman: How do you deal with the ethical considerations? Do you ever refuse certain treatments?

Dr. Sol Weiss: Yes, I will absolutely refuse working on a patient that has unrealistic expectations [17]. I will not try to see how close I can come if I know I can't successfully reach those expectations [17]. I also stay away from patients who are too vague and say, "No, doctor, you just do what you want to do" [18]. That's a red flag [18].

Dr. Gary Glassman: You're okay with telling patients, "I don't think I can manage your expectations?"

Dr. Sol Weiss: Oh, yes [18].

Guidance for Younger Clinicians

Dr. Gary Glassman: What strategies do you recommend to younger clinicians?

Dr. Sol Weiss: Education is really key [18]. Do simple, predictable cases first [19]. If a case involves high or unrealistic expectations, and your skill level doesn't fit into that yet, don't do it [19]. I considered myself as I went through my career as an apprentice [19]. I restored implants for about 10 years before I ever placed an implant [19]. You must challenge yourself, but you've got to go out of your comfort zone carefully, not indiscriminately or all at once [20].

The Importance of Continuous Education

Dr. Gary Glassman: What's your personal take on the whole educational process, for younger dentists and those that are experienced?

Dr. Sol Weiss: Education is the key to success [20]. Throughout my 42 years of being a dentist, I've taken extensive courses, including those on occlusion based on orthodontics, and cosmetic training from institutions like Spears, Dawson, and Pankey Institute [32]. Being part of a community with a robust education platform, like the DC Institute, is critical [32, 33]. Newer dentists are "sievs for information," and we older guys can share all of our expertise [32, 33].