THE CHANGING FACE OF AESTHETIC DENTISTRY

INTRODUCTION
In an age driven largely by social media and photography, more young men are seeking to
improve their smiles. Cosmetic procedures, once the nearly exclusive domain of women,
are increasingly being requested by male patients. Whether surgical or non-surgical, the
percentage of men seeking cosmetic and aesthetic procedures to retain or improve their
appearance is on the rise.1,2 Recent research reveals that the percentage of men seeking non-
surgical cosmetic treatments increased by 6% from 2018 to 2019 and that men requesting
surgical treatments increased by 4%.2 Among all consumers researching cosmetic
treatments online, interest in cosmetic procedures is highest among adults under the age of
45.2,3 In the United States, nearly 50% of this age group plans to seek treatment in the next
12 months, compared to 28% of those over the age of 45.2,3
Of all the cosmetic treatments being researched by consumers, the 2 areas of the body that
individuals would most like to change in the next 12 months are their teeth and their
midsections.3 For men, the top researched cosmetic procedures in 2019 were dental crowns,
Invisalign, and dental implants, which ranked Nos. 1, 2, and 5, respectively, outpacing such
procedures as Botox (No. 10), hair transplants (No. 6), and liposuction (No. 8).3
The underlying motivations for an individual seeking to improve his or her appearance are
many; however, the main reasons behind enhancing attractiveness are to boost self-
confidence and self-esteem.4,5 It is significant to note that a 2017 survey conducted by the
American Academy of Cosmetic Dentistry reported that the average amount patients spend
on cosmetic procedures was $5,477, with 5% of patients spending $20,000 or more.6
The 2 cases presented here are both of men under the age of 30 who recognized that
enhancing the appearance of their smiles would help them gain confidence socially as well
as improve the success of their careers.
CASE REPORT 1
Background and Clinical Exam
A 27-year-old male presented to the practice with significant damage to his teeth, including
severe enamel loss due to past drug use and a smokeless tobacco habit. He was concerned
that if he did not immediately act to protect his teeth, he would lose them prematurely. He
also expressed embarrassment when he smiled, which had, in turn, caused a loss of self-
confidence socially and concern that success in his career may be hampered. A full-face
photo and retracted views were taken (Canon EOS 40D) showing the patient’s existing
dentition (Figures 1 and 2).
Upon the initial clinical exam, it was noted that his maxillary teeth were undersized with
thin enamel. Both arches demonstrated gross, generalized decay and wear from
parafunction and chemical erosion, as well as gingival recession due to his previous
tobacco habit. A slight discrepancy in gingival height between teeth Nos. 8 and 9 was also
evident (Figure 2).
Treatment Plan
The treatment plan discussed with and accepted by the patient called for reconstructing the
maxillary and mandibular arches with fixed crown and bridge restorations. The gingival
margin on tooth No. 9 would be heightened by 1 mm to improve the gingival architecture
and symmetry of his central incisors. To achieve the aesthetic outcome desired by the
patient, the dental team selected a combination of zirconia and lithium disilicate materials.
A full-contour crown and bridge restoration (IPS e.max ZirCAD Prime [Ivoclar Vivadent])
was chosen to restore teeth Nos. 2 to 5. This material was strong enough for the bridge Nos.
3 to 5 yet still aesthetic, whereas tooth No. 2 had subgingival margins and thus presented
the inability to predictably bond to lithium disilicate. On teeth Nos. 6 to 13 in the maxillary
arch and teeth Nos. 18 to 31 in the mandibular arch, lithium disilicate was selected for the
full-contour crowns (IPS e.max CAD [Ivoclar Vivadent]). The lithium disilicate crowns on
teeth Nos. 7 to 10 would be cut back for porcelain layering to ensure optimal aesthetics.
Prior to treatment, the patient had his teeth cleaned to remove any plaque or calculus. His
periodontal status was evaluated and deemed healthy.
Digital Design and Provisional Matrix Fabrication
Intraoral digital impressions (TRIOS [3Shape]) of the patient’s preoperative maxillary and
mandibular arches were performed, along with a scan of the patient’s maximum
intercuspation occlusion. The pre-op digital scans were used by the laboratory to virtually
create the smile design proposal according to the prescription (Figure 3). A 3D printed
model of the design and a putty matrix (Sil-Tech Plus [Ivoclar Vivadent]) were then made,
which allowed for the transfer of the smile design to the mouth and was used to fabricate
the provisional restorations chairside.
Gingival Recontouring and Tooth Preparation
Once the smile design was approved and the putty matrix (Sil-Tech Plus) was delivered, the
patient returned to the practice for gingival recontouring and tooth preparation. The upper
arch was fully anesthetized. Prior to tooth preparation, a soft-tissue diode laser (Picasso
Lite [AMD LASERS]) was used to heighten the gingival architecture of tooth No. 9 by 1
mm. Tooth preparations were performed on the maxillary arch, and the preparations were
scanned using an intraoral scanner (TRIOS). A prep shade tab that best matched the shade
of the preparations was placed next to the prepared teeth and photographed. The patient
returned one week later for tooth preparation and a digital scan of the mandibular arch. The
digital bite was also captured at this appointment. Both the digital intraoral scans of the
prepped arches and the photographs of the selected stump shades were sent to the
laboratory to assist the dental technician in selecting the correct shade of the final lithium
disilicate restorations (IPS e.max CAD).
Provisionalization
The provisional restorations were fabricated chairside using the putty matrix (Sil-Tech
Plus) and bis-acryl material (Integrity Temporary Crown and Bridge with Fluorescence
[Dentsply Sirona]). The mandibular provisionals were sectioned in segments distal to the
cuspids to allow removal for maintaining vertical dimension of occlusion while capturing
the digital bite using the intraoral scanner (TRIOS). The provisionals were tried in for
patient approval of tooth shape, form, and shade (Figure 4). The provisional restorations
were then checked in vivo for overall aesthetics, phonetics, centric relation, and anterior
guidance and were seated using temporary cement (TempBond NE [Kerr]).
Collecting Information for Final Crowns
After a 2-week period, the patient returned to the practice for a postoperative check. Minor
adjustments were made to the occlusion, and the patient also expressed that he would like
the cuspids to have more of a point. These changes were made, the pre-op photo series was
retaken with the provisionals, and a new intraoral scan was captured (TRIOS). The
laboratory then used this patient-approved provisional scan to duplicate and create his
ceramic restorations. Utilizing 3-point alignment, the full-face provisional photo was used
to align the digital scan in the computer software (Figure 5).
Delivery
The final restorations were delivered to the practice, and the patient returned for seating of
the final restorations. The lithium disilicate restorations were tried in with try-in paste
(Variolink Esthetic Try-In [Ivoclar Vivadent]). The bonding surface of each restoration was
treated with a cleaning agent (Ivoclean [Ivoclar Vivadent]), followed by a universal primer
(Monobond Plus [Ivoclar Vivadent]). Due to the severe erosion and loss of enamel, the
lithium disilicate crowns were bonded using an adhesive luting system (Multilink Automix
[Ivoclar Vivadent]) that demonstrates a high-strength bond to dentin (Figure 6). A resin-
modified glass ionomer cement (RelyX Luting Plus Cement [3M]) was used to seat the
zirconia restorations.
The patient was thrilled with his new appearance (Figures 7 to 9) and said he was especially
pleased with how his family and friends commented on the natural appearance of his
restorations. He felt that he finally had his original, healthy teeth back.
CASE REPORT 2
Background and Clinical Exam
A 22-year-old patient presented to the practice missing central incisor No. 8 and with the
chief complaint of being unhappy with his smile. Tooth No. 8 was avulsed after a fall at age
10 and never replaced (Figure 10). An old composite restoration on tooth No. 9 was
discolored, adding to his discontent. He stated that, due to the appearance of his teeth, his
self-confidence had suffered dramatically over the years.
The patient had a thorough comprehensive exam and an aesthetic consult. It was noted that
there was a loss of facial bone at tooth site No. 8 due to years of missing a tooth and that
the lateral incisors were undersized. The gingival height of tooth No. 9 did not exhibit an
ideal height compared to the lateral incisors, and teeth Nos. 7 and 10 had an unfavorable
peg lateral shape (Figure 11).

Treatment Plan
The treatment plan discussed with and accepted by the patient was to place a dental implant
at tooth site No. 8, increase the gingival height of tooth No. 9 to bring it into symmetry,
crown tooth No. 9, and place aesthetic composite bonding on teeth Nos. 7 and 10 to
improve their shape. The patient’s smile architecture and symmetry would also be corrected
by adding length to teeth Nos. 7 and 9 so that they would more aesthetically follow the lip-
line (Figure 12).
Implant Planning and Placement
A CBCT scan of the patient was performed for the purposes of implant planning at tooth
site No. 8 and also for the fabrication of a surgical guide. It was determined the patient
would need a block bone graft to repair the Class III alveolar ridge deficiency at tooth site
No. 8. This grafting procedure was completed during the same surgical appointment as the
patient’s third molar removal. Because the patient did not want a non-autogenous graft
material, the oral surgeon harvested a ramus graft from the oblique ridge of the left
mandible where tooth No. 18 was absent. In addition, 30 cc of blood was taken from the
patient and separated in a centrifuge. The graft was 20 mm × 10 mm × 4 mm and was
affixed to site No. 8 using 9-mm fixation screws. Bone shavings from the harvest site were
mixed with platelet-rich plasma and used to augment the graft. A membrane, created from a
fibrin clot from the patient’s blood products, was placed over the bone graft, and the site
was closed. After a 5-month healing period, the patient returned for another CBCT scan as
well as an intraoral scan (TRIOS) to evaluate and plan the optimal implant position. A
surgical guide was fabricated to aid in ideal implant positioning and used by the oral
surgeon to place the implant (TSV 3.7 × 11.5 mm [Zimmer Biomet]) at tooth site No. 8
(Figure 13).
Digital Design and Provisional Matrix Fabrication
The laboratory created 2 separate digital CAD designs (TRIOS Design Studio [3Shape])
utilizing 3-point alignment of the patient’s full-face photo and intraoral scan. The first
digital design was used to create a model and a silicone index (Sil-Tech Plus) for the
chairside composite reconstruction of teeth Nos. 7 and 10 peg laterals. The second digital
CAD design was used to create a model and silicone index (Sil-Tech Plus) of the final
outcome of the case from which a splinted provisional full-contour crown for tooth No. 9
and a provisional implant crown for tooth No. 8 would be fabricated.
Direct Bonding, Gingival Recontouring, and Tooth Preparation and
Provisionalization
Teeth Nos. 7 and 10 were acid-etched. A single component adhesive was applied (Adhese
Universal VivaPen [Ivoclar Vivadent]), and an aesthetic light-cured direct composite (IPS
Empress Direct A2 Dentin and Enamel [Ivoclar Vivadent]) was chosen for enhancing the
laterals. At the same appointment, 2 mm of gingiva was removed from the facial of tooth
No. 9 with a 12-blade, and tooth No. 9 was prepped for a full-contour crown. A scan flag
was placed in implant site No. 8, and the final intraoral scan (TRIOS) was captured to send
to the laboratory, along with a shade-mapping photograph to help the laboratory select the
appropriate shade for the full-contour and implant restorations for teeth Nos. 8 and 9. The
splinted provisional restorations were made (Integrity Temporary Crown and Bridge with
Fluorescence) utilizing the second silicone index. The provisional for tooth No. 8 was lined
with flowable composite (LuxaFlow [DMG America]) and was seated as the implant
temporary was screwed into place. The screw access hole was filled with Teflon tape and
flowable composite (LuxaFlow).
Collecting Information for Final Crowns
When the patient returned for his one-week post-op check, the decision was made to add 1
mm of length to teeth Nos. 8 and 9 (Adhese Universal [Ivoclar Vivadent] and LuxaFlow).
A new full-mouth digital scan (TRIOS) was taken so that the laboratory could duplicate the
patient-approved provisionals in the final restorations. Photographs, paired with the “final
impression” prep scan of tooth No. 9, were used to design (TRIOS Design Studio, Implant
Studio [3Shape]) an implant abutment shape for site No. 8 that would replicate that of the
natural tooth preparation. This allowed for similar optics and ceramic thickness of the final
restorations (Figure 14). Based on the clinical prescription, the laboratory chose an HTA1
ingot of lithium disilicate with A2 shading and slight amber effects in the incisal one-third
for the full-contour crowns on teeth Nos. 8 and 9.
Delivery
The zirconia abutment screw was torqued to place at 30 Ncm, and Teflon tape was placed
in the screw access hole. The intaglio surfaces of the 2 crowns were treated with a cleaning
agent (Ivoclean) as well as a universal primer (Monobond Plus). Both crowns were bonded
with an adhesive luting system (Multilink Automix Transparent [Ivoclar Vivadent]). These
final restorations beautifully restored the symmetry and aesthetically pleasing qualities of
the patient’s smile (Figures 15 to 17).
CONCLUSION
Physical appearance is an important aspect of one’s personal identity and self-perception.
In a socially driven culture where physical attractiveness seems to be a priority, many
patients often have the desire to improve their appearance. Whether the goal is to be more
competitive in the workplace or live up to perceived social standards, enhancing physical
attractiveness by improving one’s smile to boost self-confidence and self-esteem is on the
rise.7
Acknowledgments:
The author would like to thank the following for their collaboration: in Case 1, Michael
Roberts, CMR Dental Lab, Idaho Falls, Id, and in Case 2, Dr. Edward Wise, Oral Surgeon,
Lexington, SC; Brit Schiner, CMR Dental Lab; and Pavlo Ryabokon, CMR Dental Lab.

References

1. Frucht CS, Ortiz AE. Nonsurgical cosmetic proce dures for men: trends and technique
considerations. J Clin Aesthet Dermatol. 2016;9:33-43.
2. PR Newswire. Male interest in nonsurgical cosmetic procedures increases 6% on
RealSelf; skin resurfacing treatments and injectables top list of fastest-growing
procedures. June 12, 2019. https://www.prnewswire.com/news-releases/male-interest-
in-nonsurgical-cosmetic-procedures-increases-6-on-realself-skin-resurfacing-
treatments-and-injectables-top-list-of-fastest-growing-procedures-300866059.html.
Accessed February 13, 2020.
3. PR Newswire. More than 1 in 3 U.S. adults are considering a nonsurgical or surgical
cosmetic treatment in the next 12 months, according to new RealSelf Aesthetics Interest
 Survey. September 26, 2018. https://www.prnewswire.com/news-releases/more-than-1-
in-3-us-adults-are-considering-a-nonsurgical-or-surgical-cosmetic-treatment-in-the-
next-12-months-according-to-new-realself-aesthetics-interest-survey-300719146.html.
Accessed February 13, 2020.
4. PR Newswire. More than four in five U.S. adults want to improve their personal well-
being or appearance in 2019 and 36 percent are considering cosmetic treatments,
according to new RealSelf Survey. January 17,
2019. https://www.prnewswire.com/news-releases/more-than-four-in-five-us-adults-
want-to-improve-their-personal-well-being-or-appearance-in-2019-and-36-percent-are-
considering-cosmetic-treatments-according-to-new-realself-survey-300779900.html.
Accessed February 13, 2020.
5. Huff M, Kinion E, Kendra MA, et al. Self-esteem: a hidden concern in oral health. J
Community Health Nurs. 2006;23:245-255.
6. American Academy of Cosmetic Dentistry. State of the Cosmetic Dentistry Industry:
2017 Survey Report. Madison, WI: American Academy of Cosmetic Dentistry;
2017. https://aacd.com/cmsproxy/236/files/2017_State_of_the_Cosmetic_Dentistry_Ind
ustry_Report.pdf. Accessed February 13, 2020.
7. Globe Newswire. North America Restorative Dentistry Market Projected to cross $9.27
Billion by 2027. September 3, 2019. https://finance.yahoo.com/news/north-america-
restorative-dentistry-market-082053686.html. Accessed February 13, 2020.

Dr. Thomas maintains a comprehensive, aesthetics-driven private practice in Lexington,

SC. Following dental school at the Medical University of South Carolina, she completed an
AEGD residency in St. Petersburg, Fla. Dr. Thomas has achieved Fellowship in the
International College of Oral Implantologists and the AGD. Dr. Thomas is a member of the
Academy of Cosmetic Dentistry, the ADA, the AGD, and the American Academy of Facial
Esthetics and and is teaching faculty for the American Academy of Facial Esthetics. She
can be reached via the Instagram handle @doctor.caro.thomas.
Disclosure: Dr. Thomas reports no disclosures.
 
REPORT
 Using what we just saw in class, write 1 paragraph per each one of the next
aspects.
1. What is your opinion about the case in general?
2. What would you have done with those cases?
3. What is your opinion on how the dentist handle the cases?