Smile Design Enhanced with Porcelain Veneers

Posted on May 7, 2012 by sfdentist

Porcelain laminate veneers are among the most esthetic means of creating a more pleasing and beautiful smile

Porcelain veneer.

Part 1 of this series on smile design gave an overview of the many facets involved in beautifying smiles by design and the many ways of interpreting what is normal or ideal. Our first article discussed the role of the dentist as diagnostician, artist and scientist in meeting you the patient to decide the best course of action for your particular situation. A detailed analysis of your smile is critical to the correct assessment and the appropriate procedures for change or enhancement.

Porcelain laminate veneers are among the most esthetic means of creating a more pleasing and beautiful smile. Porcelain veneers within reason allow for the alteration of tooth position, shape, size and color. They require a minimal amount of tooth preparation — in this case reduction (approximately 0.5 mm of surface enamel) — and are, therefore, a more conservative restoration than a crown, which requires significant removal of sound tooth structure. Although not the only alternative for all esthetic abnormalities, they are truly a remarkable restoration when they are the treatment of choice.

What is a Veneer?

Simply stated, a veneer is a thin covering over another surface. In dentistry a veneer is a thin layer of dental restorative material, usually porcelain that replaces enamel.

Porcelain was named after its resemblance to the white, shiny Venus-shell, called in Old Italian “porcella.” The curved shape of the upper surface of the Venus-shell resembles the curve of a pig’s back (from the Latin porcella – a little pig). Properties associated with porcelain are high strength, hardness, glassiness, high durability, translucence and high resistance to chemical attack.

Dental porcelain is a type used by dental technicians to create bio-compatible life-like crowns and bridges for dentistry. As you will note from the cases shown, dental porcelains in the right hands can make for spectacular tooth imitations by mimicking tooth enamel perfectly. This is also a testament to the artistic skill of the laboratory technicians with whom the dentist partners in producing life-like precision veneers to create your enhanced smile. The dentist will usually specify a shade of porcelain, corresponding to a set of mixtures of porcelain powder used in the laboratory. The powder corresponding to the basic tooth color is mixed with water, and then placed in an oven for “firing.” Further layers of porcelain are built up to mimic the natural translucency of the enamel of the tooth.


Figure 1: Original smile before veneers	Figure 4: Original smile showing worn teeth


Figure 2: Smile after “Hollywood White” veneers	Figure 5: Establishing normal tooth length with veneers


Figure 3: Portrait photo after “Hollywood White” veneers	Figure 6: Portrait photo showing “Enhanced White” veneers
Photos provided by Dr. Dean C. Vafiadis

A laminate is a material constructed by uniting two or more layers of material together in a process called lamination (in common parlance, lamination refers to sandwiching an object or material between layers of plastic and sealing them with heat and/or pressure, usually with an adhesive). The laminate structure refers to the combination of tooth, bonding interface and veneer complex. The veneer shell replacing the removed tooth enamel is chemically bonded to the underlying tooth surface with which it becomes part.

Before a patient can successfully receive veneer treatment, certain aspects related to his or her dental health and tooth structure must exist, verified by a smile analysis:

The teeth are in more or less normal position;
Sufficient tooth structure needed for veneers exists;
Symmetrical gingival (gum) contours are present, which allow for the proper “framing” of the teeth necessary for a beautiful cosmetic result [Fig. 1,2 and 3].

What veneers can do — porcelain veneers are an excellent solution for correcting small or medium spaces between teeth, imperfections in tooth position (e.g., slight rotations), poor color, poor shape or contours, as well as some minor occlusal (bite) related problems. Porcelain veneers can allow for dramatic improvements for patients who have worn their teeth by bruxism (grinding of one’s teeth through habit patterns) or fractured teeth [Fig. 4,5 and 6].

What veneers can’t do — in considering the limitations of porcelain veneers, we should be reminded of another important definition of “veneer” — a deceptive, superficial show or a fasade. So too, there are situations that the technique cannot correct, such as poor tooth position, large discrepancies in root position, poor bite relations and poor profile.

Many of these situations first require some form of orthodontics to move the teeth into proper position — for both function and esthetics. This important diagnostic determination is critical and defines the “brilliance” of your dentist. Porcelain veneers are an excellent form of tooth restoration, but as with any material used in the mouth, it does have limitations. There is no substitute for your dentist’s expertise and consideration of your specific needs obtained from his or her diagnostic evaluation — they are critical to assure the successful result of a beautiful smile.

Smile Analysis

After a traditional dental exam has verified the health of all underlying structures, the dentist begins a smile analysis, using facial measurement formulae relating teeth to the face and other techniques to customize the appropriate sized teeth to each specific individual.

Smile design has as much to consider as the designing and building of a home.

Figure 7: A mock-up smile of tooth colored (white) wax

A computer imaging process is used to digitally replicate the patient’s smile and then fabricate a mock-up smile made of tooth-colored (white) wax [Fig. 7]. This is used to make the provisional teeth after the diagnostic visit.

Provisional teeth are often used and are a benefit to patients because they can be worn for up to two weeks, creating, in effect, a “trial smile” — one of the rare instances in medicine or surgery where we can view and evaluate changes before the final result.

The provisional stage gives patients the exciting prospect of becoming full partners with their dentist in choosing from available colors and shapes. Patients interact with their dentists through feedback and information before deciding upon the final restorations that a gifted technician will exactly replicate in the porcelain veneers.


Figure 8: Original smile before veneers	Figure 9: Smile with “Natural Color” veneers


Figure 10: Smile with “Enhanced White” veneers	Figure 11: Smile with “Hollywood White” veneers


Figure 12: Portrait photo showing “Enhanced White” veneers
Photos provided by Dr. Dean C. Vafiadis

Now here’s where the art in dentistry is really important. Your dentist and dental technician must carefully choose the right color for the porcelain veneers, As you will note this is complex:

Typical colors of natural teeth have three basic dimensions:

hue, the color tone — red, blue or yellow;
chroma, the intensity of color or saturation of the hue; and
value, the relative darkness or lightness of the hue.

However, when looked at three-dimensionally, teeth have a variety of these combinations.

When changing people’s smiles, the patient has a choice of matching their existing tooth color known as “Natural Color.” Patients can enhance their tooth color in two more ways; a much brighter “Enhanced White” color; or, like some celebrities, a dazzling version known as a “Hollywood White” color. Each of these colors usually has the same chroma and hue chosen by the dentist and the laboratory technician. The difference between these three enhanced smiles is the value of that chroma [Fig. 8, 9, 10, 11 and 12].

With the different shade guides that are created by the porcelain companies, the dentist or the lab technician can blend the shade and color that best represents the patient’s expectations [Fig. 13]. The technician will choose several different colors and textures to mimic an existing tooth color or create a new brilliant color that the patient and the doctor have agreed on.

Since most of the tooth is still remaining after preparation, the veneer will act like a “contact lens” and transmit the original color of the tooth, and then be enhanced with the colors the technician baked into the porcelain.

Some facts you should know about Porcelain Veneers

Since they require approximately 0.5 mm of tooth reduction, porcelain veneers are not considered a reversible form of treatment.
Occasionally, the preparation of a porcelain laminate veneer does not necessitate the use of a local anesthetic. However, for those patients that are particularly sensitive or anxious, a local anesthetic is advisable.
The laboratory time required for the fabrication of a porcelain laminate veneer is approximately one week, although this may vary.

Figure 13: Dentists use a shade guide to determine the best veneer color for a patient’s teeth.

You can expect some sensitivity to hot and cold. This is normal and is due to the removal of a small portion of the tooth’s enamel covering. This sensitivity should disappear a few days after the placement of the veneers.
The insertion or cementation of your laminate veneers can be accomplished once again with or without local anesthetic. This visit is usually longer in length. The laminates are placed with a light-sensitive resin hardened with the use of a white light, effectively bonding them to your teeth.
Once placed, your laminate veneers are very strong and will resist most of the forces placed upon them by a normal diet. Porcelain is a glass and like glass it is strong, but brittle. Therefore, you should avoid anything that will tend to stress the laminate veneer. Opening pistachio nuts with your teeth, chewing on bones or candy apples is probably not a good idea. As with most things, common sense should prevail.

Maintenance of Your New Porcelain Veneers

The maintenance of your porcelain laminate veneers is relatively simple. Here are some recommendations:

Brush and floss as you normally would to prevent dental problems. Porcelain veneers are one of the kindest restorations to gum tissues that we currently have in dentistry. Don’t be afraid of damaging your laminates by either flossing or brushing. Any non-abrasive fluoride toothpaste is acceptable. A good home care regimen will insure the esthetic success of your laminate restorations for years to come.
If you are known to be a bruxer or clencher, i.e. you have a habit of grinding your teeth, please let your dentist know. He or she will fabricate a protective “occlusal” or bite guard for you to wear to minimize the stresses placed upon your teeth while you sleep.
Approximately one week after the placement of your laminates you will be asked to return to the office for a treatment evaluation. This visit is extremely important. It gives your dentist the opportunity to evaluate the placement of the laminates, the gum tissue response and to answer any questions you might have regarding your new smile. Regular maintenance and dental check ups are recommended so that your veneers and oral health can be reviewed periodically.

Frequently Asked Questions About Veneers

What happens to my teeth after veneers, and will I ever get cavities?The integrity of veneered teeth is only marginally compromised, and the veneer is bonded to the existing teeth. There is no higher incidence of decay provided the veneers are properly cared for as previously mentioned with regular flossing and brushing with toothpaste. In general, it is good dental advice to keep your sugar consumption low and confined to meal times to prevent decay.
How long will porcelain veneers last?They can last from seven to twenty years. While the veneer itself is inert and non-living, the tooth or teeth to which they are attached and the surrounding gum tissues are living and may change. For example, gum line shrinkage may expose or reveal root surfaces. If a veneer comes off it can generally be rebonded. If it chips it can sometimes be rebonded or otherwise replaced.
If I have my upper teeth treated with porcelain veneers, will my lower teeth still be a different color, or more yellow?This is certainly a factor that will be discussed during your evaluation and smile design so that everything matches and blends well. Most patients usually whiten the lower teeth with whitening (bleaching) procedures to ensure a good match.
Do porcelain veneers stain with normal things like tea, coffee and wine?Porcelain veneers should never stain; however; if your teeth have a propensity to stain you should try to avoid or minimize the behaviors that lead to staining and look after them as recommended above with normal hygiene and maintenance procedures.
Does dental insurance cover porcelain veneers?Some insurance companies will cover up to 50% of the fee they deem customary. However, it depends upon what your employer has contracted for with your insurance company rather than what your dentist is charging. Don’t forget your dentist also has to pay the dental technician who actually fabricates the veneers, a critical component in the fee.

Understanding Gum (Periodontal) Disease

Posted on April 30, 2012 by sfdentist

Periodontal disease affects millions of Americans. Are you one of them?

Understanding gum disease.

The mouth is a remarkable eco-system, studied closely by researchers for hundreds of years: your own oral tissues live alongside millions of bacterial organisms, most of the time in benign cooperation. Sometimes, however, that symbiosis erupts into an all-out war known as periodontal disease.

Periodontal disease refers to any disease (actually several) that affect the areas around the teeth (from the Latin “peri” – around and Greek “odont” – tooth). Periodontology is the corresponding specialty that studies these supporting structures of the teeth — including the gingival (gum) tissues, the periodontal ligament which suspends the tooth in its socket and the underlying bone to which it is attached. Periodontics is the dental specialty dedicated to the treatment and prevention of periodontal disease.

The periodontal tissues are arguably among the most highly researched tissues in the body. Contributions by researchers from many fields have greatly added to our knowledge of oral as well as general health and bodily functions. While periodontal diseases may be confined to the mouth, their effect may not be: research is beginning to uncover a relationship between periodontal health and general health. Known risk factors for periodontal disease include smoking and diabetes. Evidence is also suggesting a relationship between severe periodontal disease, cardiovascular disease (heart and stroke conditions) and mothers of preterm low birth weight babies.

Periodontists have developed several effective treatments to halt or eradicate many forms of periodontal disease. The most effective treatment, though, is preventive, performed by the patient. Good personal daily oral hygiene, which disrupts the growth of plaque, is the best defense against most forms of periodontal disease.

There are currently over six hundred species of bacteria known to exist in the mouth alone, with only about four hundred currently identified.

Dental Plaque: The Main Culprit in Periodontal Disease

Van Leeuwenhoek, a Dutch scientist of the 17th century and inventor of the first microscopes, was the first to observe living bacteria, which he called “animalcules.” He observed dental plaque to be bacterial in origin and made the connection between it, oral hygiene and gum disease.

Over the next four centuries, knowledge about the relationship between the bacteria-rich plaque and periodontal disease advanced steadily. Studies carried out in the 1950s and 1960s, contributed enormously to this understanding: by looking at large populations of different age groups over time, researchers found a clear but indirect association between mouth cleanliness, dental (bacterial) plaque deposits on teeth and the time that it was present. Most of the variation in disease levels could be accounted for by bacterial plaque alone, the rest attributed to other factors like diet, nutrition, bite factors and other variables. The association between smoking and periodontal disease also became apparent with smokers showing worse and more rapid bone loss than non-smokers.

Stages of Gum
(Periodontal) Disease

Stage 1: Gingivitis — inflammation of the gingiva (gums) without bone loss.

Stage 2: Early Periodontitis — inflammation of the gingiva (gums) and the surrounding tissues that results in early bone loss.

Stage 3: Moderate Periodontitis — inflammation of the gingiva (gums) and the surrounding tissues that results in moderate bone loss.

Stage 4: Advanced Periodontitis — inflammation of the gingiva (gums) and the surrounding tissues that results in severe bone loss.

The Immune System: Balance is Key

The immune system is the body’s way of protecting itself against disease. It is made up of a complex recognition and response system to bacteria or other pathogenic (disease-causing) organisms. Specific antibodies to these organisms enhance the effectiveness of the body’s defenses against these bacteria.

One of the major defensive responses mediated by the immune system is inflammation of the gums, usually the first tell tale sign of periodontal disease to be observed. This inflammation is actually the immune system at work, trying to isolate the disease-causing bacteria and prevent spread to other parts of the body. Defense cells get rid of the offending bacteria and promote the repair of damaged tissues.

Certain groups of people carry genes that may predispose them to periodontal and other inflammatory disease.

Unfortunately, the body’s immune system can be influenced by a number of factors, heredity being one of the most critical. Certain groups of people carry genes that may predispose them to periodontal and other inflammatory diseases. Family history of periodontal disease may be an important clue, since we inherit our genes from previous generations. Genetic testing has recently been developed that helps identify such people.

Another impediment to the immune system is stress, brought on by physical illness or severe emotional distress. Stress can affect the immune system by lowering resistance, which impedes the ability of the immune system to fight periodontal disease.

Signs and Symptoms of Periodontal Disease

As mentioned before, the first signs of periodontal disease usually begin with gingivitis; the gums appear reddened at the margins, slightly swollen and bleed when gently provoked by tooth brushing or flossing. It is often thought that brushing too hard causes bleeding gums — however, bleeding from the gum tissues is not normal and should be taken as a warning sign.

Bad breath and taste are also commonly associated with periodontal disease. As the disease progresses the gum tissues begin to recede, exposing root surfaces which may cause tooth sensitivity to temperature and pressure change. Gum tissues may start to lose their normally tight attachment to the tooth causing pocket formation, detectable by a dentist during periodontal probing. As pocket formation progresses, supporting bone loss may be noted around the teeth.

Abscess formation, the collection of pus pockets denoted by pain, swelling and discharge from the gum tissues is a later sign of disease. Ultimately looseness and drifting of teeth occur as bone is lost in more advanced degrees of disease and may also be apparent as eating becomes more difficult or uncomfortable.

Diagnosis

Early periodontal disease can be detected by your general dentist during routine and regular dental checkups. He or she can physically and visually evaluate the gingival tissues, probe to determine whether the attachment levels to the teeth are normal or abnormal, and evaluate bone health through dental radiographs (x-rays).

Depending on the findings, your dentist may also refer you to a periodontist, a dentist specializing in the diagnosis and treatment of periodontal diseases. A periodontist will interact with a general dentist and other dental specialists in planning and treating periodontal and bite problems to achieve optimum periodontal health and a functional and esthetic result.

Treating Periodontal Disease — What to Expect

Should you encounter periodontal disease, here are some of the aspects of treatment you should expect:

Behavior Change: One of the first things your dentist will recommend as a part of treatment for periodontal disease is a behavior change on your part. Since dental plaque is the main cause of periodontal disease, its removal on a daily basis is essential. For many patients this involves forming new oral hygiene habits, along with cessation of smoking and other lifestyle changes. Consistent behavior change is the most important element in maintaining long term periodontal health, since daily plaque removal in large part will set the stage for sustained, successful treatment.

Calculus (Tartar) Removal: Cleaning however, isn’t all on your shoulders — your dentist will also see that your teeth receive a thorough cleaning in his or her office to quickly remove the deposits of calcified plaque called calculus or tartar and other bacterial toxins which become ingrained into the root surfaces. This process of mechanical cleaning is generally known as scaling and root planing using ultrasonic and hand scaling instruments. It may be carried out by a hygienist, a dentist or a periodontist, and sometimes requires local anesthesia. Scaling usually results in little or no pain, although in rare instances a patient may need mild pain medication for a day or two.

Evaluation: After three or four weeks your dentist will evaluate the response of your gingival tissues to the initial therapy. In early or mild cases the healing response may be good enough to return an individual to periodontal health. Your dentist will probably recommend a regular schedule of office checkups and cleanings to maintain this healthy state.

Occlusal Bite Therapy: Generally, attention to the bite or bite disorders are treated during or after initial therapy once an inflammation free environment has been established. This phase of treatment addresses such issues as loose teeth, clenching or grinding habits, may include localized grinding of some tooth surfaces or even orthodontic (tooth movement) treatment.

Surgical Therapy: Surgical treatment may be needed in more severe cases of periodontal disease that do not respond adequately to non-surgical initial therapy. Periodontal surgical treatment today encompasses a variety of sophisticated plastic surgical procedures. These include techniques to repair and regenerate soft (gingival) and hard (bony) tissues and replace missing teeth with dental implants. They are usually performed by a periodontal specialist trained in these techniques. Most procedures are performed with local anesthesia (numbing of the gum/periodontal tissues), and sometimes with the use of intravenous or conscious sedation. The objective of surgery is generally to eliminate pockets, regenerate attachment and return the patient to more normal function and esthetics, while generally providing an environment more conducive to oral hygiene and maintenance care.

Vigilance Can Make the Difference

If you have periodontal disease all is not lost. Remember, your teeth were meant to last a life time. Early diagnosis and treatment of periodontal disease are also essential in keeping your teeth for life.

While periodontal disease is treatable, vigilance is necessary to prevent recurrence: institute daily plaque removal through brushing and flossing as a part of your oral hygiene; seek treatment to quit smoking; and establish a regular schedule of clinical cleanings and checkups.

In a nutshell, a familiar adage aptly describes your best defense against periodontal disease, “if you look after your teeth, they will look after you.”

The Impact of a Smile Makeover

Posted on April 18, 2012 by sfdentist

What does it really mean?

The subconscious yet contagious impact of a beautiful smile is radiant health, happiness, warmth and invitation. A “Smile Makeover,” a common household term for many Americans today, is designed to enhance the esthetic and functional aspects of teeth The impact of a smile makeover. through cosmetic and restorative dental procedures leaving one with a brighter, whiter, more youthful smile. In the overall context of the face, it’s the eyes and smile that speak to us. When you smile they both light up.

Americans are catching on to the emotional and social importance of a healthy, beautiful smile, and they’re seeking out ways to improve their smiles. It’s not only the rich and famous looking for a smile makeover. According to the largest organization devoted to smile enhancement dentistry, the American Academy of Cosmetic Dentistry, over 70% of clinical inquiries about cosmetic dentistry come from those in the 31-50 age group — including not only people in family situations and the workforce who want to improve their social and business interactions, but also individuals who just simply want to feel better about themselves.

First Impressions

First impressions are not only important; they often last the longest.

There is no doubt that among people suffering from poor self-image, dental concerns rank among the highest. Smiling, one of humanity’s most innate and in-borne natural expressions, is inhibited when it’s not all it can be. Raising the curtain on the theatre of a smile sets the stage before the show even starts. When the curtain goes up and teeth are discolored, missing, or misaligned, it may be a show stopper right there.

It really doesn’t matter if it is a serious defect or a slight imperfection — if a person is self-conscious about their smile, it can exact an emotional toll and adversely affect interactions with others.

The greatest effect, of course, is within the person himself or herself — YOU — and often it doesn’t end there. Far from being “just in your mind,” an inhibited smile may also affect others’ perceptions of you.

Couple smiling.

Self-expression is one of the basic freedoms that Americans enjoy. This begins with our ability to engage with others through smiling, laughing and a host of facial expressions. However, the inhibited feelings associated with an unattractive smile have a ripple effect:

Friendships and family relations can suffer; dental appearance can even determine who we allow ourselves to fall in love with.
Careers can be affected by dental imperfections; those interviewing for jobs and for those whose jobs depend on networking, the self-consciousness of a poor smile can limit a career.
Our own feelings of being free and outgoing become stifled. We become aware that we are not as happy as we could be. We then limit our possibilities we have in the world and our future does not look as rosy as it once did.

Perceptions of a Smile

Beall Research & Training, a marketing research firm recently conducted a study evaluating how individuals perceive others according to the quality of their smile. In the study, over five hundred people were shown photographs taken before and after treatment of several individuals who had undergone various degrees of cosmetic dentistry. Each picture was classified by the perception of change created by the “smile makeover.” The photographs were defined as mild, moderate and extreme in regards to the change in appearance (none of the subjects in the photos had catastrophic or grossly deformed smiles to begin with). They were asked to rate each individual they viewed on a scale of 1 to 10 (“1” equaling “no change at all” and “10” equaling “extreme change”) for ten different character traits including “intelligence,” “happiness” and “degree of success.”

While the amount of the cosmetic change between the two photos in each set may be viewed as “not dramatic,” the change in perceptions of those who viewed the photo sets made a definite impact on the measurements. Every category saw a significant improvement in scoring for each pictured individual when comparing the before photos to the photos after cosmetic dentistry. The most significant improvements in character traits occurred in the categories of “attractiveness,” “wealthy” and “popular with the opposite sex.”

Beyond personal and social perceptions, smiling is also viewed as a key component in gaining cooperation, especially among strangers, in a variety of human interactions and transactions. In other words, as the late Dale Carnegie might have put it, a smile is contagious. It can help you “win friends and influence people.”

In 1999, scientists from a variety of disciplines, including zoology and economics, put this idea to the test. Over one hundred subjects participated in a game with the object of making a simple “one-shot” bargaining deal (based on trust) with another participant whom they had not met. They had, however, seen photos of the other contestants — under controlled conditions — of either their bargaining partner smiling or not smiling. The results lent support to the idea that game partners previously viewed as smiling had a greater chance of eliciting trust and completing the bargain.


Wendy’s Makeover: Her beautiful smile was created using of a combination of porcelain veneers and crowns, as well as subtle changes in tooth size and position.

The Proof is in the Results

Take for example Wendy (pictured to the right). She had just suffered through the premature death of her husband and was getting back on her feet. She had always hated her short, small, mismatched teeth. She wanted a new look as she began to date again. After whitening, and the placement of upper porcelain crowns and lower porcelain veneers she immediately began to express more confidence and contentment in her interactions with men. This extended to all other areas of her life too.

“My smile makeover made a tremendous difference to me — I now have a beautiful smile. I love the way I look! I feel brighter, whiter and younger!!! I find myself laughing and smiling with ease and grace. I should have done this a long time ago!”

The makeover also re-ignited her professional confidence. “I’ve always been good at dealing with the public, but I noticed a definite boost in the harmony I now enjoy in my personal and professional relationships.” says Wendy. “I feel my current success is linked to the dental work I received. Even my kids are noticing the change in my self-expression. They say I am happier. I am!”

Wendy’s example underscores the true importance of a smile makeover: while cosmetic dentistry rarely corrects life-threatening conditions, its impact on emotional and social health can be exponential. A smile makeover truly can change your life for the better.


*Amy’s Makeover:** A subtle smile makeover changed the tooth position through the use of four porcelain veneers which eliminated her protruding front teeth (featured above). She also had tooth whitening which has brightened her beautiful smile.

Amy* (pictured to the right) was soon to be married. All her life she had hated her crowded, protruding front teeth. She could not imagine that on this day, the most important day of her life, she would have to hide her smile. In a very short period (3 weeks) she whitened her teeth and then had just four porcelain veneers placed on her front upper teeth. Amy could smile fully and happily for the first time in her life!

“I had the best wedding ever — I was beaming! You can see it in all my pictures. I felt like I was on top of the world. I wasn’t holding anything back! That full enjoyment was exactly what I was looking for and it was all so easy to obtain.”

Amy’s treatment was simple and easy to do. It only involved four teeth and four office visits. The first visit was for records, models and photographs. The second visit was for the treatment plan discussion and whitening. The third and fourth were for preparation and then cementation of the veneers.

An additional benefit of her smile makeover was the increased self-assurance Amy felt at work. In her profession as a psychologist, she was able to be a better therapist because she was not holding her self-expression back from her clients.

“My smile makeover was the best thing I ever did for myself. I noticed how much more fun I was having with my clients and what better results I was helping them gain. This gave me the confidence to start my own practice in a new city with my husband.”

You Have the Ability to Smile

We are not all born with a beautiful smile. Yet, we are all born with the ability to smile. If you are not projecting radiant health, contentment and cheerfulness through your smile, perhaps you should consider an enhancement, if not a makeover. Cosmetic and restorative dental procedures can do that for you. After all, smiling and laughing are contagious and this is a good way to infect someone!

Do You Need a Smile Makeover?

Use the following self-test to see whether you can benefit and improve your smile through cosmetic dentistry. If you answer yes to any of the following questions, it may be right for you.

Do you avoid smiling in photos?
Are you conscious about spaces and gaps in your teeth?
Are your teeth making you look older than you feel?
Have you held back a smile?
Do you feel that your teeth are stained or too yellow?
Do you hold your hand up in front of your mouth when speaking or laughing?
Do you notice areas of excessive tooth wear that make your smile look older?
Do you have little teeth and a gummy smile?
Are your teeth crooked, chipped or crowded?
Do you wish you had someone else’s smile?

Nutrition & Oral Health

Posted on April 11, 2012 by sfdentist

How Nutrition Impacts Oral and General Health

In Part 1 of this important series, we will focus on diet as it relates to dental/oral health. Be sure to look for upcoming topics in this series.

Can you imagine how many times a day a compliment is given to those with beautiful smiles? Most of the time, the compliment-giver is recognizing the beauty of a person’s teeth. After all, teeth are what we show to the world when we smile. Teeth affect our self-esteem and our ability to socialize, as well as our ability to enjoy food. Not to mention, the most important factor of all, the impact teeth have on our nutrition and health.

Nutrition and oral health.

In Part 1 of this series we will explore what we eat and how we eat… the variety of food in our diets… all of which contribute to the social experience and enjoyment of food. Further, we’ll discover just how oral health impacts our general health and well being. A sound and nutritionally adequate diet is not only vital for general health, but also for the proper formation of teeth and maintenance of oral health.^[1]

There are no ifs, ands, or buts, that oral health is a huge part of our general health. And a well balanced diet is essential to growth and health maintenance.

Diet, Nutrition and Teeth

Teeth live in an environment that is constantly changing throughout our lives, as do the teeth themselves. While they develop with strong and protective outer coatings of enamel (the hardest and most impervious structure produced in nature) teeth are not completely immune to the ravages of disease and wear.

Diet plays a major role in dental decay. It contributes to the healthy development of enamel and has a significant role in erosion caused by acids. Let’s take a look at some dental diseases:

Dental caries (decay)
Developmental defects of enamel
Dental erosion
Periodontal (gum) disease

Regarding periodontal disease, diet and nutrition seem to play a relatively minor role, especially in modern industrialized societies. However, dental research tells us that dental caries (decay) rates have gone down in the last three decades. That is largely due to improved prevention, especially incorporating the use of fluoride, which we’ll discuss later in this review.

Oral Conditions Change As We Age

Deciduous (baby) teeth are most susceptible to decay soon after they erupt from 3-6 months of age and so are permanent (adult) teeth which begin erupting from 6-7 years of age. Although what a pregnant woman consumes is important for tooth development, what the child eats is much more important immediately following eruption of the teeth, as we will see. With people now living longer, decay rates are likely to increase in older age groups. This is key in knowing that more attention needs to be paid to diet and dental care in our later years.

Keeping your natural teeth into later life is vitally important. Our natural teeth will enable us to enjoy food more, especially the nutritious diet of fruits, vegetables and fiber that provide us with a lifetime of general health.

Dental caries or tooth decay as it is commonly known is a disease process. Bacteria in your mouth produce organic acids from dietary sugars particularly sucrose (what is most commonly known as sugar), which concentrates in dental plaque, that sticky whitish film that collects on surfaces of our teeth. When sugars are ingested, an increase in acidity results which causes dissolution of the enamel and dentine of the teeth leading to cavities.

Cause of Tooth Decay
For tooth decay to occur, bacteria utilize the sugars in your diet to produce acids which demineralize the tooth surface.

Sugars: The Good & The Bad

We’ll see here that there are many forms and varieties of sugars. And in what form and frequency they are ingested is relevant for both oral and general health. Our modern diet contains a mix of sugars including sucrose (what we commonly know as sugar) glucose, lactose (milk sugar), fructose, maltose. Oral bacteria can ferment all these sugars with more or less equal facility, with the exception of lactose, milk sugar from which less acid is produced. The diet also contains glucose and high fructose corn syrups and other more complex sugars that can also be fermented.

Total Dietary Sources of Sugars

Both the World Health Organization and U.S. Drug Administration cite that “Free Sugars” should contribute no more than 10% to energy intake, approximately 50g/day.

Scientific evidence overwhelmingly tells us that sugars are the most important dietary factor in the development of dental decay. Soft drinks represent the single largest source of sugars consumption in the U.S.; in 2003, Americans drank an average of 52 gallons of soft drinks per capita. Average per capita consumption of all sugars in the U.S. was 141.5 pounds (64.3 kg) one of the highest levels in the world. In recent years, sugars intake has been implicated as a contributing factor in the worldwide epidemic of obesity in children.

Evidence does not support a role for fruit, vegetables, milk and starch rich staple foods in the development of dental decay as it does for “Free Sugars.” There is no evidence that sugars in whole grain foods, whole fruits and vegetables and in starch rich staple foods like bread, rice and potatoes are harmful to teeth. The distinction we have to make between “Other Sugars” and “Free Sugars” allows dietary guidelines for dental health to be integrated into those for general health.

Xylitol and to a lesser extent, sorbitol (which are chemically similar to sugar but do not cause decay), have been used as sugar substitutes for many years. Hence they are a useful part of decay control. We now have evidence that supports chewing xylitol-sweetened gum three to five times a day for a minimum of five minutes (after meals) stimulates saliva flow which helps protect against decay.

Oral Hygiene vs. Levels of Decay

Oral hygiene practices are important for oral health, particularly periodontal (gum) health, and everyone should brush twice a day with fluoride toothpaste. Brushing with fluoride toothpaste is the most important way of getting fluoride into the surfaces of teeth. Other methods of tooth cleaning such as eating fibrous foods, apples and carrots are ineffective in cleansing the tiny pits and fissures of teeth where decay begins.

Fluoride to the Rescue

The main protective effect of fluoride is topical, i.e. applied to the tooth surfaces after eruption (e.g. by using fluoride toothpaste). When fluoride is incorporated into tooth enamel, it makes the enamel more resistant to acid dissolution. It also promotes re-calcifying the tooth surfaces where calcium has been lost due to acid attack. However, let’s not ignore the relationship between sugars consumption and decay even when fluoride and other preventive measures are taken, though it’s to a lesser degree. In the modern age of fluoride exposure, we know that individuals with a high level of free sugars intake (>10% energy intake) and a high frequency of sugars consumption (>3 per day) have a moderate risk factor for decay, and which will be higher for those not exposed to fluoride.

Bowl of cereal.

Starches and Decay

Starches constitute a very diverse food group, which varies in botanical origin. These may be highly refined and consumed in their natural state, raw or cooked (peas, bananas and beans). Some starches may be broken down by the salivary enzymes that in turn release glucose and other simple sugars to produce acid. Cooked staple starchy foods such as rice, potatoes and bread have low decay producing potential as do uncooked starches. Finely ground and heat-treated starch can cause decay but the potential is much less than sugar. When sugars are added to already starchy foods, the potential for decay increases significantly (think biscuits, cakes, breakfast cereals).

Less refined starches (e.g. whole grains) have properties that protect teeth. They require more chewing and thereby stimulate secretion of protective saliva. There is also some evidence that unrefined plant foods (e.g. whole cereal grains) contain phosphates which may be protective.

Fruit.

Fruits and Decay

There is little evidence that fruit is an important factor in development of decay unless consumed excessively. Dried fruit, on the other hand, may be more cariogenic (decay causing) since the drying process releases free sugars. Fresh fruit appears to have low ability to promote decay and even citrus fruits have not been found to cause tooth decay (but may cause dental erosion, which we will cover in the next section). It’s important for us all to know that the more fresh fruit we consume instead of free sugars is likely to have a positive impact in decreasing decay.

Diet and Dental Erosion

Dental erosion is a progressive irreversible loss of tooth structure that is chemically etched (dissolved) away from the tooth surface by acid. This action does not involve bacteria. It is often associated with overzealous oral hygiene and grinding habits. Tooth erosion is caused by the over ingestion of acids (extrinsic acids) such as citric, phosphoric, ascorbic, malic, tartaric, and carbonic acids found in fruit juices, soft drinks (either carbonated or still) and some fruits if consumed frequently. Any acidic drink even if mildly acidic may initiate erosion. Intrinsic acids (those from inside the body), produce erosion following vomiting, regurgitation or reflux and can be extremely damaging to the teeth. A condition now known as GERD (gastro-esophageal reflux disease) is now a recognized cause of tooth erosion from stomach acids. One of the most potent and acidic of acids is hydrochloric acid from the stomach and it is responsible for the extensive erosion of teeth seen in conditions like bulimia and anorexia where reflux is common and constant.

Erosion is an ever-increasing problem in industrialized countries. The observed levels are thought to be largely due to increased drinking of acidic beverages — soft drinks. Brushing the teeth following consumption of an acidic product before the saliva has had a chance to buffer (or counteract) the acid, will enhance the removal of the softened enamel.

Recommendations to promote good oral and general health

Eat a healthy diet and follow the recommendations of the USDA (www.mypryamid.org).
Eat sugars in the form of fresh fruits & vegetables.
Limit free sugar intake to a maximum equivalent of 10 teaspoons per day (a can of soda contains over 6 teaspoons!).
Free sugars should be limited to a maximum of four times a day.
Don’t snack on sugars between meals.
Ensure optimal fluoride level in water supplies.
Promote adequate fluoride exposure via toothpaste, tablets or dentist recommended application.
Brush teeth with a fluoride toothpaste at least twice daily especially at night.
Do not eat for at least one hour before bedtime especially foods containing free sugars because low salivary flow rates during sleep reduce the ability to neutralize acid.
To minimize erosion limit the amount and frequency of soft drinks and juices.

Here are other factors that protect against decay:

Cheese: consuming cheese following a sugary snack virtually abolishes the increase in acidity. Cheese stimulates saliva and is rich in calcium influencing the balance of re-calcifying teeth and protecting against loss of calcium from teeth.

Cow’s Milk: contains lactose which is less acid producing than other sugars and therefore does not promote decay as readily. In addition, cow’s milk also contains calcium, phosphorus and casein all of which help stop decay. However the practice of bottle feeding milk at night may promote decay.

Human Breast Milk: contains 7% lactose and is lower in calcium and phosphate. It generally does not initiate much decay except in cases of very high frequency nighttime feeding and prolonged on demand feeding.

Plant Foods: are fibrous and protect teeth by mechanically stimulating saliva. Peanuts, hard cheeses and gum that contain sorbitol and xylitol can act the same way.

Black & Green Teas: are particularly rich in polyphenols and flavonoids which are complex antioxidant compounds found in many plant foods. The fluoride in black tea may also protect against decay.

Chocolate: there is some evidence that cocoa in an unrefined form (without added sugars) may have some anti-caries potential but processed chocolate is too high in sugars to be good for the teeth so there is little hope for chocolate lovers.

Looking after your teeth is important if you want them to last a lifetime! Sticking to a diet that is high in fruits and vegetables and starchy staple foods, drinking lots of water (preferably fluoridated) and limiting the intake of sugary foods and soft drinks will safeguard your dental as well as your general well being.

Oral Cancer – Diagnosis & Facts

Posted on April 4, 2012 by sfdentist

- Oral Cancer
- Oral Cancer Diagnosis
- Facts About Oral Cancer

Although this topic is scary, this article may just save your life

Cancer: Know All You Can About It

Cancer is one of the scariest words in our language. If you’re one of a growing

Woman breaking a cigarette.

number of people determined to take an active role in your health care now and in the future, you’ll want to learn what you can about one of the principal killers in developed nations today. Knowledge is power; let’s arm ourselves with as much knowledge as we can. We will begin with an overview then apply the information to a more specific type: oral cancer.

What is Cancer?

Cancers are a class of diseases characterized by the uncontrolled division of cells and the ability of these cancerous cells to spread. They can grow into nearby tissue through a process known as invasion, or they can be transported through the bloodstream or lymphatic system (a complex system of glands and ducts active in the body’s defense against disease), to distant areas by what is called metastasis. I’ll attempt to provide what we know today about this major threat.

The scary aspect of oral cancer is that it’s not usually detected until a late stage.

There are many types of cancers; how severe the symptoms are generally depends on the nature of the malignancy, which refers to cancerous cells that usually have the ability to spread, invade, and destroy tissue. Most cancers can be treated and some even cured, depending on the type, location in the body, and at what stage the cancer is diagnosed. However, once diagnosed, cancer is usually treated with a combination of surgery, “chemotherapy” (drugs which destroy cancerous cells) and “radiotherapy” (killing cancerous cells with radiation).

How is a Normal Cell Transformed?

The unregulated growth of cells that characterizes cancer is caused by damage to DNA — the stuff that genes are made of. The genes are the command machinery which informs the cells what to do. Mutations, changes to the DNA, alter and damage proper cell function. Many mutation events may take place to transform a normal cell into a malignant one. What causes these mutations to occur? They can be caused by radiation, chemicals or physical agents known as carcinogens, or by certain viruses that are able to insert their own genetic material into human cells. There are two alarming characteristics of mutations:

they can occur spontaneously, and
they may be passed down from one cell generation to the next.

Cancer: A “Multifactorial” Disease

There are many reasons or factors that cause normal cells to mutate into cancerous ones. Among the most important are:

predisposing factors — an innate capacity to develop disease that can be triggered under certain conditions, e.g. genetics (genes that are altered or mutate have a tendency to occur along family lines), and
risk factors — conditions or behaviors that increase the possibility of disease e.g. smoking, chewing tobacco and alcohol use, diets low in fruits and vegetables, viral infections — primarily the human papilloma virus “HPV 16” (the same one that’s been in the news lately which causes cervical cancer in women), and an immune (protective) system that is not functioning normally in response to infections or inherited disease.

Oral Cancer & Precancerous Conditions

Now that we have more of a background about cancer, its causes as well as its risk factors, let’s take that knowledge and apply it to a specific area, the mouth.

Oral cancer accounts for roughly 3% of all cancers in men and 2% in women. Men still outnumber women 2 to 1, but this is changing as women become more exposed to the same risk factors as men. Like all cancers, oral cancer is associated with aging. Did you know that more than 90% of all oral cancers occur in individuals over 40? We now know that African-Americans have a higher incidence than Caucasians and a disturbing number of cases in young people regardless of ethnicity, have been seen in recent years.

Just ponder this staggering statistic: in 2008, it is estimated that more than 34,000 cancers of the oropharynx (oro-mouth and pharynx-throat), will be diagnosed in the USA. Get familiar with the main areas where oral carcinomas (cancers) occur:

the oral cavity proper (the mouth),
the lip, tongue, and
the pharynx (back of the mouth and throat).

You might say that the mouth and lips are accessible for direct examination all the time by routine visits to the dentist. Thinking along those lines, it’s probably easy for a dentist to notice anything unusual in the mouth within a matter of months, right? Here’s the scary aspect of oral cancer: it is not usually detected until a late stage. So despite all the advances in treatment, survival is poor, with only 58% surviving 5 years after treatment.

Most oral cancers are “squamous” (small scale-shaped) cell carcinomas, occurring in the lining of the mouth and are often preceded by identifiable surface changes (lesions) of the oral membranes. White or red patches begin to form in the pre-cancerous stage, and as the cancer develops, a non-healing ulcer may appear.

Oral Cancer Diagnosis


Figure 1: Early cancer (squamous cell carcinoma) that was first thought to be a harmless sore (ulcer) caused by biting the tongue.	Figure 2: Early cancer (squamous cell carcinoma) that was first mistaken for a harmless white patch (benign leukoplakia).


Figure 3: Early cancer (squamous cell carcinoma) of the floor of the mouth was noticed for 2 weeks and at first was thought to be a canker sore.	Figure 4: Early cancer (squamous cell carcinoma) of the lip was noticed for 1 month and was at first thought to be a “cold sore.”

Stick Out Your Tongue

The tongue, particularly the sides are the most common sites for oral cancer [Figure 1 and 2], with the floor of the mouth (under the tongue) coming in second [Figure 3]. Lip cancers mostly affect the lower lip [Figure 4] and frequently there is a history of chronic sun exposure and preceding damage, which shows up as scaling and crusting at the site. The thing to remember here is that recurring ulcers in the lip area can also be mistaken for cold sores. Since the tongue has a rich blood supply and lymphatic drainage (the lymphatic system is a major component of our immune protection system) 30% of cancers have spread or metastasized by the time they are diagnosed. That’s a frightening fact. Now let’s take that fact a step further — up to 15% of people diagnosed with oral cancer are normally found to have a second primary cancer.

However, when detected early while a lesion is small, survival rate exceeds 80%. Bear in mind, early detection is key. If you notice any unusual lesions (sores or ulcers), or color changes (white or red patches), anywhere in your mouth that do not heal within two-three weeks get to your dentist or physician as soon as possible.

The Oral Cancer Exam

An oral cancer examination should be part of your dental check-up or regular cleaning appointment. The oral cancer examination consists of the following:

A visual inspection of your face, neck, lips, and mouth looking for any signs of cancer (such as red and/or white patches).
Your dentist will feel the floor of the mouth, sides of the neck, glands etc. for any lumps that may suggest cancer.
Using gauze your dentist will gently pull your tongue from side to side as well as examine the underside of it.
Your dentist will also ask you to say “Ahh” and will then place an instrument on top of your tongue to examine the back of your throat.

Diagnosis Can Be Complicated

Earlier we talked about the fact that oral cancers are most often detected when they are at a late stage, with early diagnosis only taking place in about one third of the cases. Unfortunately, recognition is complicated. Why? Because the early signs can mimic harmless sores that occur in the mouth such as canker sores, minor infections, or irritations that occur from biting or even certain foods. When we’re given a proper oral cancer exam which includes the oropharynx, the health care professional will feel the neck for lumps; inspect the lips and all inside surfaces of the mouth, including the tonsils at the back of the throat.

Further, we must remember that oral cancers can occur on any surface that lines the mouth and throat, with tongue being the most common site. These changes — as I mentioned earlier — can appear as white or red patches, ulcers and lumps that may or may not be associated with any discomfort or pain.

An appropriately trained dentist should evaluate any such changes that persist for more than two-three weeks. Definitive diagnosis requires the microscopic examination of a piece of the lesion (tissue biopsy). This is a procedure usually carried out with local anesthesia, numbing of the involved site with the removal of a sample or all of the abnormal tissue, if small enough. The tissue specimen is then sent to the lab for analysis where it undergoes microscopic evaluation for a more thorough diagnosis.

Facts About Oral Cancer

Treatment of Pre-Cancerous Conditions

Pre-cancerous lesions must be assessed by biopsy (tissue sampling for disease). If pre-cancerous changes disappear by removing irritants, e.g. tobacco, alcohol, biting, or other chemical or physical irritants, there is no need to biopsy. Follow up is necessary together with determining a frequency for continued monitoring and evaluation. This will, of course, depend upon the findings at the time of biopsy. The ultimate treatment of pre-cancerous lesions is surgical removal however the use of lasers has been very helpful. Diets, vitamins and other drug or chemical approaches have not been useful.

If there is some reason to delay biopsy, other techniques are available to help evaluate a suspicious lesion. While these non-invasive “adjunctive” techniques are helpful in shedding light on a suspicious lesion, they do not substitute for biopsy confirmation. These FDA-approved devices include the use of light reflections, tissue staining (tolonium chloride), cytology (brush biopsy), and fluorescence. These adjunctive techniques do not require anesthesia and are helpful in accelerating the need for further testing or referral. These techniques are available to general dental practitioners, however biopsy remains the gold standard.

The American Cancer Society recommends a cancer related check up annually for all individuals aged 40 and older and every three years for those between 20 and 29.

When Cancer is Diagnosed

Once the diagnosis is definitive, the extent of disease has to be determined so that a treatment plan and prognosis can be formed. Staging is the term used to describe the level a cancer has reached. Involved in staging are clinical, microscopic findings and imaging with techniques such as magnetic resonance imaging (MRI). Depending upon the stage, your health care professional will formulate a treatment plan that will most likely include considerations for surgery and/or radiation and/or chemotherapy. With all treatments, the teeth and membranes of the mouth must be protected from further incidence of decay, gum disease and other infections, dryness of the mouth, and other more subtle changes.

A treatment team is usually comprised of surgeons, radiation and medical oncologists (cancer specialists), dentists, dental hygienists, nurses, and other professional specialists.

In summary, as a health care professional, I hope you understand the importance of knowing all you can about one of the principal killers in developed nations today. Obviously, risk factors can and must be minimized wherever possible and proper periodic oral cancer screening exams should be a priority. Keep in mind, the more you know about this class of diseases, the more empowered you’ll be toward paving your road to victory.

Hard Facts About Oral Cancer

Aside from a genetic predisposition, the use of tobacco in any form and/or excessive use of alcohol increase risk for many diseases, including oral and pharyngeal cancer. Let’s take a look:

Chronic exposure to the sun is, without a doubt, associated with development of lip cancers
Moderate to heavy drinkers are at three to nine times greater risk than non-drinkers — obviously hard alcohol creates a much greater risk than beer or wine because of the higher alcohol content.
Tobacco smokers are at five to nine times greater risk than non-users
Snuff and chewing tobacco users are at roughly four times greater risk than non-users

How Thumb Sucking Affects The Bite

Posted on March 29, 2012 by sfdentist

“Tongue Thrust” Therapy Helps Ensure Successful Treatment

Dear Doctor,
My 10-year-old sucked his thumb from birth until age 8. I’m wondering if this habit affected his bite because now his teeth don’t come together in the front and every time he swallows, his tongue moves forward. What can be done?

An “open bite,” a space between the teeth, can be caused by prolonged thumb sucking, and then perpetuated by the presence of the tongue resting or thrusting between the teeth.

Dear Jackie,
It sounds like your son has two conditions that are sometimes related. The first is an “anterior open bite,” in which the upper and lower front (anterior) teeth do not meet; there is a space between them. The second is a tongue position problem; instead of the tongue lifting up against the palate (roof of the mouth) when swallowing, a “tongue thrust” occurs in which it moves into the space between the teeth. Prolonged thumb sucking may indeed have caused his open bite. However, there is treatment that can help.

How Thumb Sucking Can Affect Tooth Alignment

In a normal bite, the top teeth overlap the bottom teeth. In your son’s case, there is a gap between the teeth where the tongue now likely rests and then moves or thrusts forward into when he swallows.

All babies position their tongues forward and swallow with a tongue-thrusting motion, called an “infantile swallowing pattern” or primary tongue thrust, necessary to provide a seal with the lips. The transition to adult swallowing normally begins when most of the primary (baby) teeth are erupting. Once the tongue moves out of the way and the upper and lower front teeth contact, the teeth then support the lips, which seal together during swallowing.

It is believed that most open bites occur due to a failure in this swallowing transition, which leaves the tongue between the teeth and blocks their full eruption. However, a thumb constantly resting between the teeth can have the same effect.

Swallowing activity matures over time, and by around age 4 the infantile pattern is normally replaced by the adult pattern in which the tip of the tongue now contacts the roof of the mouth, just above the back of the front teeth. (Try swallowing right now and feel where the tip of your tongue is positioned.)

Given that your son sucked his thumb for so long, it likely interfered with the proper eruption and positioning of his front teeth. Even if he stopped the habit, his tongue’s resting position, if too far forward, may still be affecting the development of his bite. In other words, the constant (albeit light) pressure from the tongue resting in that gap between his teeth is enough to prevent his front teeth from coming into proper position.

The question is, did his thumb sucking cause all of this? Most likely, especially if he continues to suck his thumb even once in a while.

Thumb sucking can actually block the front teeth from erupting fully and can also push the teeth forward — sometimes more on the side where the thumb rested. How far out of position the teeth end up will depend on the number of hours per day his thumb was in his mouth and how much pressure was applied. That is why it’s so important to stop such habits before the permanent teeth start to come in. But all is not lost in your son’s case.

Closing An Open Bite

Diagnosis: The first step is to take him for a thorough evaluation by an orthodontist, a specialist in the diagnosis and treatment of malocclusions (“mal” – bad; “occlusion” – bite). The most important challenge is to figure out what is causing the open bite.

There are times when an open bite is caused by factors other than thumb sucking. “Skeletal factors” include too much vertical growth of the jaws, or the way the upper and lower jaws grow in relation to one another. When open bites are skeletal or jaw-related they can be difficult to close and tend to relapse.

Causes not related to skeletal growth are grouped under the heading of “dental factors.” Since your son sucked his thumb at an age when his permanent (adult) teeth were coming in, he probably has a dental open bite and not a skeletal one. However, when the pressure exerted by the thumb in the mouth is particularly strong and occurs over a long period of time, the forces can potentially influence growth of the jaws.

Treatment: When an open bite is a result of thumb sucking, which essentially creates a “secondary tongue thrust” to seal the gap between the teeth when swallowing, it can often be treated successfully with orthodontics (“ortho” – to straighten; “dont” – tooth). One approach involves placing a thin metal “tongue crib” behind the upper and lower incisors. The aim of this appliance is to discourage thumb or finger sucking. It also acts to retrain the tongue, stopping it from going between the upper and lower teeth where it doesn’t belong. If that habit is not eliminated, orthodontic treatment may not be successful, or the teeth may eventually relapse into the open bite position.

My research has shown that orofacial myofunctional therapy (OMT) can be highly effective in treating tongue thrusts and preventing open bite relapses. OMT involves individualized exercise routines to retrain specific oral and facial muscles, particularly those of the tongue and lips. The exercises help correct tongue resting positions, create good chewing and swallowing patterns, and may improve speech sounds. The group of patients my colleague and I studied benefited greatly from having up to 14 half-hour OMT sessions, with the number of sessions determined by how fast progress was made.

The results of my research and other studies show the benefits of collaboration between orthodontists and myofunctional therapists. Your son may benefit from both types of treatment to make sure that his teeth move into — and stay — in a new and improved position.

How Sun Damage Ages Your Skin

Posted on March 21, 2012 by sfdentist

Warning Signs Of Too Much Exposure Tips For Prevention And Treatment

How sun damage ages your skin.

Awareness of the sun’s power to harm skin has made a constantly cultivated suntan less desirable than it used to be. However, even if your sun-worshipping days are long over, you may notice that the older you get, the more brown marks and darker patches you have on your skin. What you are seeing is the effect of your prior sun exposure. And the most constantly exposed skin you have is on your face. It’s important to keep an eye on these changes — they may be cause for concern.

Sun exposure is the major cause of damage to your skin. In the short term, too much sun will cause a burn, sunburn, and in the longer term, chronic exposure to the sun will cause photo-aging (“photo” – sunlight; “aging” – deterioration).

Basically, the more sun exposure you get, the more damage your skin will sustain. And some skin types do worse than others, for example, thin skin versus thicker skin types, fairer types versus darker types. Sun damage is cumulative and begins at an early age. Skin changes in response to sun damage determine the onset and extent of photo-aging; its effects may appear as long as 20 to 30 years after sun damage first occurs. It is not uncommon to see signs of early to moderate photo-aging (brown spots, dryness, wrinkles) in your 40′s — even if you used sunscreen in recent years.

The Truth About Sunscreens And SPF — FDA update!

Sun Protective Factor, SPF measures a sunscreen’s ability to delay (not prevent) sunburn, which is an indication of injury to the living cells beneath the skin’s surface. SPF 30 means that it takes 30 times longer to burn with sunscreen than without it. SPF is the most popular reference used when selecting a product. The higher SPFs offer superior protection to lower SPFs. SPF 30 or higher is recommended for daily use, and SPF 50 for more intense sun exposure, for both adults and children. Although SPF is based mainly on exposure to the type of ultraviolet light known as UVB, both UVA and UVB cause solar damage. The best sunscreens, which are labeled “broad spectrum,” protect against both.

But while choosing the right sunscreen matters, a layer of sunscreen less than one millimeter thick is no match for the rays emanating from that great ball of fire in the sky — the sun. So re-apply often and thickly, the more the better. But remember you can still burn.

How to Treat Sunburn

Is a suntan protective against sunburn or skin damage? NO — A tan is evidence that you already have sun damage, whether you realize it or not! Sorry — Myth busted!

An example of sun burning of the facial skin.

Several hours after sun burn, fluid filled blisters can appear on the skin surface.

The damaged skin from sun burn peels off.

Skin damage starts with exposure to the sun’s ultraviolet (UV) radiation. Even though you use sunscreen, you can still burn. Most people have experienced sunburn; within a few hours of sun exposure the skin becomes red, itchy, even painful and hot to the touch. Intense sun exposure results in sunburn increasing your risk of skin diseases and complications.

If you do get sunburn, several home remedies and treatments can relieve the discomfort and speed the healing of your skin. However, even effective sunburn treatment only helps ease the symptoms:

Keep sunburned areas cool: Apply cold compresses dampened with cool water or take a cool bath.
Keep the affected areas moist: Apply aloe or moisturizing cream to the affected skin. Avoid products containing alcohol, which dry out skin.
If your skin blisters: Leave blisters intact, don’t burst them, it will slow healing and increase the risk of infection. Cooling compresses soaked in milk are helpful. If blisters burst, blister adhesives or wound dressings from your local pharmacy or drugstore may be helpful.
Take non-steroidal anti-inflammatory medication: If needed, take anti-inflammatory medication — such as aspirin or ibuprofen. This will help control discomfort and swelling. Avoid aspirin for children or teenagers — it may cause Reye’s syndrome, a rare but potentially fatal disease.
If your skin peels: This is the sloughing of the top layer of damaged skin. While your skin is peeling, continue to use moisturizing cream.

Photo-aging

Photo-aging is truly the crux of the matter. Frequent and repeated sun exposure and sunburns accelerate aging of the skin making you look older than you are. Common associated skin changes include:

Freckles especially on the face
Dry and rough skin
Reduction and weakening of the elastic fibers, reducing strength and resilience
Damage and weakening of the connective tissues in the skin’s substructure
Thinning of the skin making it more translucent or see-through
Deep wrinkling
Fine red blood vessels appearing on the cheeks, nose and ears
Large brown macules (flattened spots) on the face, and solar lentigines (liver spots)

Darkening patches of facial skin giving the skin a mottled, spotty look.

A liver spot or solar lentigine is named because its size and appearance resemble a lentil bean.

Actinic keratosis is a rough, scaly patch that develops on your skin from years of exposure to the sun. Doctors consider it to be precancerous because it may evolve into skin cancer.

Results Of Chronic Sun Exposure And Aging

Sun damage takes many forms, some more serious than others. What follows is a brief overview of some of the most common conditions caused by photo-aging.

While your dentist or physician might notice changes associated with photo-aging when you are in their offices, it is best left to a dermatologist (skin specialist) to diagnose a particular mark or marks on your skin. Here are some of the things you may notice if you have sustained sun damage:

Uneven pigmentation: To protect itself from the damaging effects of the sun, the skin makes the dark brown pigment melanin, which is produced by melanocytes (“melano” melanin-producing; “cyte” cell). Melanin makes your skin look darker or “tanned.” With age, the sun causes an uneven increase in melanin production and/or in the number of melanocytes, giving rise to irregular pigmentation or blotching. The sun can also cause a permanent stretching of small blood vessels, giving the skin a mottled, reddish look. This can manifest as:

Darkening patches: Brown, darkening patches of facial skin form as a result of a combination of factors, including sun and an increase in female hormones. Known as melasma (“melasma” – from Greek, black spot), this condition tends to affect women with dark skin and who take oral contraceptives or hormone therapy, or who are pregnant. Appearing with pregnancy, it is also referred to as chloasma or “mask of pregnancy.” The dark patches usually occur on the cheeks, forehead, nose and chin.
Age spots: Sometimes called “liver spots,” they are also known as solar lentigines (“lentigo” – lentil bean) because of their appearance. They tend to be darker than the usual freckle and do not fade in winter. They vary in size and usually appear in areas most exposed to the sun such as the face and hands. Although they are more common in older people, they also occur in younger adults and even in children who spend too much time in the sun.
Lip spots: If you have a single dark brown spot on the lower lip, it could be a labial lentigo — from labial, meaning lip. Labial lentigos tend to develop after repeated sun exposure.

Most of these conditions can be treated with the medication hydroquinone available over-the-counter or by physician prescription, which is used to bleach abnormal pigment. In-office dermatologic treatment using laser therapy or chemical peels can also help remove unsightly staining and visible discoloration. But beware, to protect your skin from recurrent staining, avoid more sun exposure.

Skin Cancer And Precancer

Sun exposure that damages the DNA of skin cells, the genetic material that controls cell functions and multiplication, can predispose the skin to become cancerous. Skin cancer develops mainly on areas of skin exposed most to sunlight, including the scalp, face, lips, ears, neck, chest, arms and hands, and on the legs in women.

The appearance of basal cell carcinoma, the most common type of skin cancer.

The appearance of melanoma which is very dangerous and the leading cause of of death from skin cancer.

Sandpaper spots: These precancerous changes appear as rough, scaly areas as a result of chronic sun exposure and are definite cause for concern. Called actinic keratoses (“acktis” – ray; “kerat” – hornlike; “osis” – overgrowth) or solar (sun) keratoses, these patches vary in color from whitish, to pink or flesh-colored, to brown/dark brown. They’re most commonly found on the face, ears, lower arms and backs of the hands of fair-skinned people whose skin has been damaged by the sun. Actinic keratoses are considered precancerous, and may evolve into skin cancer. They are easily recognized and successfully treated by freezing with liquid nitrogen and/or painless topical (locally applied) anti-cancer drugs — chemotherapy.

There are many forms of skin cancer:

Basal cell carcinoma, also known as a rodent ulcer, develops from abnormal growth of the cells in the lowest layer of the epidermis (“epi” – cover; “dermis” – skin), the outermost or top skin layer, and is the most common type of skin cancer.
Squamous cell carcinoma involves changes in the squamous (pavement – shaped) cells of the top layer of the epidermis caused directly by sun damage.
Melanoma occurs in the melanocytes and is less common than squamous or basal cell carcinoma, but more dangerous. It is the leading cause of death from skin disease.

Some types of skin cancer appear as small growths or as sores that bleed, crust over, partially heal and then reopen. In the case of melanoma, an existing mole may change or a new, suspicious-looking mole may develop. Other types of melanoma develop in areas of long-term sun exposure and start as dark flat spots that slowly darken and enlarge. In melanomas, dermatologists look for the “ABCD” characteristics: A – Asymmetry, e.g. one side smaller or more raised than the other; B – Border, an irregular border (scallop-shaped or indistinct); C – Color, changing color, multiple colors, or jet black; lastly D – Diameter, rapidly increasing in size or bigger than the head of a pencil eraser on presentation. All are all ominous signs.

A biopsy remains the gold standard for diagnosing exactly what type of abnormal skin condition you have, especially if it is cancerous. This involves the removal of a small portion of abnormal tissue under local anesthesia (numbing the area) and having it examined microscopically to confirm a diagnosis, following which appropriate treatment decisions can be made. Once diagnosed and the type of cancer specified, they are removed by simple and complete excision. Rarely is systemic (general body) chemotherapy or radiation necessary. The exception to this is melanoma, which can be more rapidly aggressive and in some cases fatal — early diagnosis is mandatory, it can be life-saving.

Sun Damage Assessing Danger

See your doctor if you notice any new skin change or growth, including a bothersome change in your skin, a change in the appearance or texture of a mole, or a sore that doesn’t heal. While not all of the conditions listed above are dangerous, i.e. precancerous or cancerous, do not try to recognize, diagnose or treat them yourself — see a dermatologist or a physician.

Don’t forget, sun protection still helps, even for older skin. And as they say, “chance favors a trained eye.” Chances are, a dermatologist will intuitively know when something looks ominous, especially if it’s a melanoma. Most conditions are treatable, especially if caught early and monitored by a dermatologist.

Overcoming Dental Fear & Anxiety

Posted on March 15, 2012 by sfdentist

Comfortable Dentistry in the 21st Century.

Overcoming dental fear and anxiety.

Do you feel relatively calm before your dental appointment or are you a little nervous about a visit to the dental office? Do you worry about it days or weeks before the appointment? Are you someone who is actually terrified about dental treatment and worries about it all the time? Do even those things that are supposed to make visits more comfortable just seem to increase the apprehension or feeling of anxiety and being out of control — like anti-anxiety medication, nitrous oxide (laughing gas) or local anesthesia — numbing the treatment area (injections, needles, shots)? Whichever end of this spectrum you might be on, it may be helpful to know that you are not alone.

Actually, having a little or even a lot of nervousness about dental visits is common. Some studies have concluded that up to 75% of people surveyed have at least a little fear about dental visits. In addition it appears that 10%-15% of people have a great deal of fear — so much so, that it prevents them from having any dental treatment at all. There are people who have frequent dreams about dental treatment; some will only eat soft foods because they are afraid that they might chip a tooth and then need dental treatment. As a consequence these individuals who put off having dental treatment suffer for years with toothaches, infections and poor appearance.

It’s possible, even for those people who are the most fearful, to reduce their fear and to learn to have dental treatment in a way that feels calm and safe.

While dental fear can result in stress and avoidance of care, it can also have more wide-reaching consequences. For some it affects their whole identity and sense of self worth. They may see other people who don’t seem to have the same reactions to dental treatment and begin to feel that something is wrong with them. “Why can’t I do this thing that other people seem to do so easily?” In fact, untreated oral conditions may result in even worse general health complications.

In the end, it’s in everyone’s interest to find ways to overcome dental fear and make dental treatment a calm and safe experience.

Good News

Now for the good news! First, it’s helpful for many people who are fearful to know that they are not alone. It’s also important to realize that help is available. Actually, experience has shown that even people who have extreme fear about dental procedures can get over their fears and learn to have dental treatment in a manner that feels calm and safe. If you have been afraid for a long time you may have difficulty believing this, but even people with long standing fear can be helped. Before we describe how it’s possible to get over dental fear, let’s first review some things about what makes people fearful.

Nervous woman. How do people become afraid of dental visits?

No one is born being afraid of dental visits. So everyone who is afraid has learned somewhere that dental treatment is something to fear. Some people learn this because they’ve had previous bad dental experiences. The sense of loss of control in the dental environment may be enough to avoid dental treatment forever. And still others may be afraid due to stories they have heard, movies they saw or other indirect experiences. The message conveyed to a child from a scared parent might be that going to see a dentist is something to be afraid of. Such messages may cause individuals to avoid treatment and not have any opportunity to learn that things can be different.

Fear and anxiety can also be reinforced inadvertently. Think about it this way; try to remember a time when you were really afraid of something, do you remember how your body felt? Was your heart beating quickly, palms sweaty, stomach in a knot? Those and other symptoms of being afraid are all unpleasant feelings. So, if someone who is already afraid forces themselves to go have dental treatment and re-experiences those same bad feelings during the appointment, then what they will remember afterward is those same unpleasant feelings. It doesn’t matter how friendly the dentist is or how pain free and pleasant the treatment is. What you remember is the feeling of being afraid, thus reinforcing the idea that there is something to be afraid of.

In fact, dental fear begins at the subconscious level. People have what we call an “automatic fear response.” Jane says “I feel like something just takes over and I begin to sweat and my stomach tightens up. I don’t really have any control over it.” Since this automatic fear response is subconscious, you can’t make it go away using logic or reason. Telling Jane that “there is nothing to be afraid of” won’t help. In fact it might make things worse because it could sound like you are saying there is something wrong with her. So, how do we change this pattern of fear and reinforcement? Let’s find out.

Getting to Calm and Safe

As we said earlier, it’s possible, even for those people who are the most fearful, to reduce their fear and to learn to have dental treatment in a way that feels calm and safe. The basic idea is really very simple. In order to counteract past bad experiences you need to have new positive experiences which lead to the development of improved feelings and attitudes. The more bad experiences you have had or the longer they have gone on, the more good experiences you need before you will have different reactions to the same situation. Dental health professionals know that your mouth is a very personal place and trust is a big part of allowing us to partner in your care.

Patient Profile

Jane is 33 years old. She hasn’t had any dental treatment in 10 years. She is worried that she has dental problems and should have them taken care of. She has even made some dental appointments in the past decade. She cancelled or just didn’t show up to most of them. Twice she did go and have an examination, but didn’t go back to have any treatment performed. She changes the channel on the TV if a show has any dental treatment in it and she won’t go to movies that show anything about dentistry. Her smile embarrasses her and has led to poor self-esteem. Jane feels bad about herself. She wants to change both the way she feels and reacts to dental treatment but she doesn’t know how.

If you are very fearful, how do you have a “good experience” with dental care?

Tell your dentist you are afraid, even when setting up an appointment and make sure the dentist is prepared to listen. If you can’t talk about it you can’t get over it.I am very careful to listen to what Jane says and try to understand her “story.” I ask Jane to tell me about her fear of dental treatment. “I’m glad you asked” she says. “I always felt that dentists didn’t really want to know.”
The dentist must listen carefully to you in an accepting and non-judgmental way.I avoid telling Jane that things will be different, that there is nothing to worry about, or that there is anything wrong with her being afraid. I also avoid any explanations about dental disease or dental procedures until I’m sure that Jane knows that I understand her fear and am committed to working with her to help her overcome it. I know that the best way for me to convey that I care is to listen, not to provide explanations. Jane should feel confident that she is not being judged.Of course, some people are better at this than others. If you are afraid, find a dentist who listens to you and who cares about working with you to get over your fear. Some dentists have made themselves quite expert in this area. If you start your work with a psychologist, make a transition from working with the psychologist to working with a dentist who understands and can follow the principles involved in reducing dental fear.
When working to reduce fear, only do things that you can do with mild or no anxiety.I reassure Jane that she is in control of the situation at all times. I need Jane to tell me exactly what she is afraid of since it’s different for everyone. It’s critical that I understand what brings on her particular fear reactions. We will start by having Jane try to do those things that she feels she can do fairly easily. The idea is for her to have the goal of being able to leave each visit saying “that was OK; I could certainly do that again if I needed to.”
Set up an agreement so you can take whatever time you need to get over your fear and not be rushed to do things you are not ready to do.Let’s stop to emphasize the last point, since this can be a significant shift in expectations. In order to help someone get over their fear of dental procedures, the goal for each visit is for you to have a good experience rather than getting a particular procedure finished. Remember, if you push yourself to do something you are really afraid of, you will remember how unpleasant your fear is and reinforce the fear rather than diminish it.
If you are afraid, work with your dentist and make a specific plan to reduce your fear. Don’t just concentrate on “fixing your teeth!”It’s critical that both the dentist and patient agree that becoming comfortable with dental procedures is something that they are going to work on. Understand that you and your dentist must consider your internal anxiety feelings by working at a pace where you will be more comfortable and trusting. Set up an agreement with your dentist to talk about the time and fees associated with treatment so you can comfortably overcome your fear and not be rushed to do things you are not ready to do. This may result in a procedure taking a little longer than usual to complete or spreading out appointments over the course of time.

Imagine a relationship with your dentist where you feel you have the time you need to go at your own pace, the listening relationship that you need to feel safe, and the sense of control you need to reduce any automatic anxiety responses. It might take some faith in the beginning to realize that this is possible, but you really do have the opportunity to have a “Lifetime of Dental Health.”

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San Francisco Dentist

Flossing – A Different Approach

Posted on March 8, 2012 by sfdentist

Flossing is important but challenging for some — This approach may make your life easier.

Flossing QUESTION:

I have struggled with flossing for years, strangling my fingers and not really getting all the plaque off from between my teeth. Is there an easier way?

ANSWER:
Thanks for your question — you are not alone in your frustration and I would like to suggest an alternative and simpler technique that I teach to many people. It takes a little practice, but I can virtually guarantee that once you get it down your attitude will be a lot more positive.

Research suggests that while most people will habitually brush their teeth, developing a flossing habit is still a bit more difficult. Flossing however, remains the best method for most effectively removing plaque from between the teeth where the brush won’t reach.

Flossing remains the best method for most effectively removing plaque from between the teeth where the brush won’t reach.

There are also a couple of other obstacles that we need to overcome to make flossing easier. In addition to the problems you have encountered, in my clinical experience, I find that the floss technique itself is frustrating for too many people. There is also a tendency for people to tighten their cheeks making it even more difficult to get their fingers into their mouths to floss effectively. The techniques used should be easier and more relaxing; you shouldn’t need to be tense therefore “getting in your own way.”

I would like to introduce you to another technique that has helped many people floss more comfortably and efficiently. So remember to keep your facial muscles relaxed and try this new method that I like to call the “ring of floss” where the hardest part is just like life itself for some people — tying the knot! You’ll see what I mean.

Below is a variation on flossing technique; it still requires a degree of dexterity and importantly practice and perseverance to become comfortable and efficient.

A step by step look at this approach to flossing:

Step 1: Take a length of your favorite type of floss (waxed, un-waxed, tape, etc) about 10 – 12 inches. Make the floss into a circle that will allow all your fingers to just fit within it, excluding your thumbs.	Step 2: Double knot the floss in a circle — this is the hardest part of the exercise — the double knot is to stop the knot from slipping. The knots must be in the same place — an old seamstress technique.	Step 3: Now you’re ready — the difficult part is over and this technique makes flossing much easier — no more fingers turning blue.


Step 4: To floss your upper teeth — place all fingers in the ring, with floss over the left thumb and right index finger — floss upper left teeth. For the upper right teeth, use the right thumb and left index finger.	Step 5: Keep the floss taut at all times, no more than 1/2 – 1 inch between the thumb and index fingers, (or index fingers only for the lower teeth).	Step 6: “C” wrap the floss to curve around the shape of each tooth. Move the floss vertically, curving it gently up and down 3 – 6 times until the tooth feels “squeaky” clean, being careful that the floss goes just below the gum tissue without hurting or damaging the gums.


Step 7: Move around the floss circle using a clean area of it for each tooth or few teeth.	Step 8: Using both index fingers — floss all lower teeth. If you are too quick and/or vigorous the floss can cut into the gum tissue — this technique should not cause the slightest discomfort.	Step 9: Flossing thoroughly once a day before or after brushing should be enough to keep your gums healthy. Practice makes perfect — this technique requires a degree of dexterity and importantly practice and perseverance to master it.

San Francisco Dentist

Wedding Day Smiles -you deserve it

Posted on March 2, 2012 by sfdentist

Wedding day smiles.

A wedding is a ceremony that celebrates the beginning of a marriage. Wedding traditions and customs vary greatly between cultures, ethnic groups, religions, countries and even social classes. A wedding is one of life’s major events, an opportunity to celebrate with friends and family.

One tradition that has become almost universal is photographing the event, recording forever the magic of a wedding day. Photographs are keepsakes, souvenirs for capturing and reliving memories; allowing us to immortalize and forever freeze in time these peak moments. After all, life is not just longevity or how long you live, but how you live it and the extraordinary moments that make memories unique.

Modern day dentistry can help ensure that your wedding day smile will make you look and feel your best, and not just for the pictures, but for your overall health and well being in the years to come.

21st Century Wedding Day Smiles

Three decades after the cosmetic dentistry revolution, the American public, and more specifically engaged couples themselves, are demanding more effective smile enhancement solutions for their special day. This has created momentum in a movement for wedding day preparation. The crux of this reform is mostly due to the importance that the public places on first impressions; appearance and beautiful smiles in particular. With the many cosmetic dental services available in the 21st century, a wedding day smile may be nearer than you think.

Let’s examine what really constitutes a great smile. Perhaps the first hint of a smile is in the eyes, but a smile is reflected in your whole face; eyes, clear skin, complexion, and more. The lips are the curtains hiding the smile, and when they part — the true revelation — your teeth become the main show taking center stage. So let’s face it — it really is the smile that lights up your face. Without a beautiful smile, first impressions may not be all they could and should be. And when the curtain goes up on an unattractive smile it’s noticed immediately. If teeth are discolored, misaligned, misshapen, or missing — it’s a show stopper right then and there.

Besides, a perfect smile doesn’t only include pearly white, straight teeth. You should be concerned about the health and functionality of your teeth, not for just the wedding day, but always.

Creating Your Wedding Day Smile

Your dentist is a good place to start to consider the best overall approach to aesthetic enhancement and dental health. Even something quite simple like tooth whitening or tooth bonding can create even a subtle improvement. An ideal full aesthetic makeover or enhancement may require the expertise of a team of dental specialists to create optimal results.

The following stories of one bride and one groom will illustrate how modern dentistry helped make each of their wedding days everything they dreamed it should be. In addition, this investment provided better function for ensuring long-term oral health.

The Story of Suzanne’s Wedding Day Smile

Suzanne. Patient History

Suzanne, a 31 year-old, attractive, fun-loving woman, had been busy building her business for many years. These hard-working efforts had resulted in the creation a very successful high-end clothing boutique. She had found the man of her dreams to whom she was now engaged. With all this and a wedding imminent, she realized she had left very little time to focus on her appearance, particularly her teeth. The future looked bright, but her smile didn’t.

Patient’s Concerns

She was unhappy with the color of her teeth and felt they were quite yellow. She was also upset with the crowding of her teeth as well. She had attempted tooth whitening in the past with some over-the-counter bleaching products with unsatisfactory results. She wanted something dramatically different and yet she also wanted something that would appear natural and aesthetically pleasing in the end.

As a young child she had not had the opportunity to undergo orthodontic treatment and had been troubled with the crowding of her teeth and a bad bite all her life.

Findings & Diagnosis

Dr. Paquette’s examination revealed that, medically, Suzanne was healthy and that her dental health was also generally good. An aesthetic evaluation revealed that crowding of her teeth was not very pleasing or functionally optimal. Suzanne was the perfect candidate for orthodontic treatment to correct her bite and to improve the appearance of her smile by correcting the alignment of her teeth. Because of a discrepancy in the size of the “dental arches” (between her upper and lower jaws), the removal of a lower front tooth would allow for:

The creation of a more functional bite
Placement of the teeth in more perfect position to facilitate aesthetic change with restorative techniques

Treatment Planning


Figure 1: Photograph at the completion of orthodontics of Suzanne’s right side showing increased space between her teeth. She wanted a larger tooth size to match her facial features.	Figure 2: Photograph after orthodontics of Suzanne’s right side showing increased space between teeth in preparation for the porcelain veneers to be placed.


Figure 3: Photograph during orthodontic treatment of Suzanne’s left side.	Figure 4: Photograph after orthodontics of Suzanne’s left side showing increased space between teeth in preparation for the porcelain veneers to be placed.


Figure 5: Photograph after orthodontics of Suzanne’s front teeth showing increased space between teeth. Notice the beautiful alignment of her teeth.	Figure 6: Photograph showing the use of a diagnostic wax up indicating the proposed tooth size and shape for Suzanne’s porcelain veneers.


Figure 7: Photograph of Suzanne’s new veneers and her beautiful smile. Notice how natural the increased tooth size looks.
Photos provided by Dr. Jacinthe M. Paquette

As part of the design of Suzanne’s new smile, orthodontic treatment was planned to re-space the upper and lower front teeth more evenly for restorative treatment (Figures 1 and 3). Once her orthodontic treatment was complete, the teeth and gum lines were more perfectly positioned to facilitate ideal tooth contouring, shape and color change (Figures 2,4 and 5). The final restorative plan was to place porcelain laminate veneers to create a nicer, larger tooth size to better match the shape and size of Suzanne’s facial features. The porcelain veneers would also dramatically lighten the color of her teeth. This was to be what Suzanne had always wished for, a more dramatic, brighter smile.

A diagnostic “wax-up” was made to first assess the proposed restorative plan. This actually amounts to the artistic creation of the new teeth in wax. This excellent technique can serve as a “blueprint” for both the patient and the doctor to not only predict, but also clearly determine whether their aesthetic goals are possible and the final outcome will be satisfactory. It is especially helpful for both the dentist and patient to be able to visualize the planned outcome before more permanent changes are made. Once accepted, the blueprint can become a reality in the fabrication of the final porcelain laminate veneers for the 6 upper front teeth and 5 lower front teeth.

Once the teeth were prepared for the veneers, by removal of the most minimal shell of outer enamel, the temporary restorations were placed to serve not only as the aesthetic template of the teeth but also for thermal protection. The “temporary” veneers are derived from the wax “blueprint,” and the final porcelain veneers will be an exact replica of the temporary veneers (Figures 6). This is a very effective way of making certain that Suzanne’s aesthetic goals are being met before the final porcelain veneers are created.

Final Result

Suzanne after smile makeover.

The final result was not only amazing, but a truly dramatic yet perfectly natural looking change (Figures 7). Suzanne felt confident and beautiful on her wedding day. Suzanne’s treatment including orthodontics took almost two years to complete. She continues to benefit from the decision she made back then to improve her appearance through her smile. Most importantly though, now many years later, Suzanne has the opportunity to reflect back on that special time through her wedding day pictures that showed her wonderful smile. People now often compliment Suzanne on how beautiful her smile is. Suzanne says, “It was the best decision I ever made.”

The Story of Steve’s Wedding Day Smile

Steve.

Patient History

Steve, a 30 year old marketing director of a large business had been working very diligently to get himself established in business. Life was going well for Steve. His business was going well, and with his professional goals on track, he was happily engaged to a beautiful woman. With the wedding not too far off, Steve decided to address some nagging issues he had about his smile so that he could truly shine on his wedding day.

Patient’s Concerns

Steve presented with some staining and white marks on his teeth and was in need of orthodontic treatment. After completing orthodontic treatment his previous dentist treated him with composite veneers to mask the stains and white marks. While this treatment was successful for many years, Steve noticed that the composite veneers had started to stain and discolor over time (Figure 8). Steve was happy with the overall alignment of his teeth but wanted a more natural looking smile reflective of the excitement and happiness he was feeling for his new bride. For Steve, that meant a brighter, stain-free smile.


Figure 8: Photograph showing Steve’s smile before teeth whitening and veneers.
Photos provided by Dr. Jacinthe M. Paquette

Findings & Diagnosis

Steve is a very healthy individual, except for a smoking habit of half a pack a day for the last five years which contributed to the staining and discoloration of his teeth. An aesthetic evaluation revealed good positioning of his two front teeth but needed to be lengthened to more naturally follow his lower lip contour. All the teeth were well aligned and positioned. Steve also presented with some isolated periodontal (gum) disease with early pocket formation (a condition in which the gum tissues become detached from the teeth leading to loss of supporting bone), that needed to be addressed before any restoration of his teeth could be completed.

Treatment Planning

The first phase of treatment included coordinating Steve’s periodontal work with our dental hygienist. During his care with the hygienist, Steve also learned how to take care of his mouth and teeth through better homecare maintenance. This involved instruction in daily plaque control, scaling and root planing (deep cleaning) of the affected teeth. The deepened pockets were re-evaluated to see if any resolution had been achieved. Sure enough, Steve’s gums responded positively to the periodontal treatment. His periodontal condition had healed and stabilized; he was now ready for final restorative treatment to improve his smile.


Figure 9: Photograph showing teeth whitening performed with light activation to reestablish Steve’s natural color.
Photos provided by Dr. Jacinthe M. Paquette

The first step in the cosmetic treatment was to bleach his teeth in order to whiten them by trying to remove some of the stain which occurred over the years from smoking (Figure 9). The old composite veneers were then removed from the upper 6 front teeth and they were prepared for porcelain laminate veneers. Similarly to Suzanne’s case, both the new aesthetic outcome and the shade were tested in the temporary veneers allowing the patient to actually see what the final result would look like.

The talented dental team, Dr. Devin Stewart and dental laboratory technicians, worked hard to complete the final veneers before the wedding. In fact, the final veneers were delivered in the nick of time, one day before he left for his wedding in Australia! This makes the point to plan well ahead for dental treatment of this nature — dentistry is an art as well as a science, and takes time. His treatment took about two months to complete.


Figure 10: Photograph showing Steve’s smile before teeth whitening and veneers.	Figure 11: Photograph of Steve’s new veneers and teeth color after teeth whitening.
Photos provided by Dr. Jacinthe M. PaquetteFinal Result

Steve is extremely happy with his decision to go through with the treatment. When you compare his before (Figure 10) and his after (Figure 11), you can see why his internal confidence and happiness shine through his smile in all of his wedding pictures. He will cherish his new smile for the rest of his life.

A Successful Ending for a Beautiful Beginning

Dentistry has made a very visible contribution to the appearance of Suzanne’s and Steve’s smiles. You could say that the “proof of the pudding is in the eating,” no pun intended, but it’s not just all about looks. Our bride and groom not only look better, they feel better about themselves. Part of being a dental professional is to improve and maintain health and psychological well-being. So behind the scenes, your dentist is not only creating visible art, but also incorporating professional know-how to provide improved function, health and longevity.

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San Francisco Dentist