The New Skin of Your Teeth
By Justine De Lacy
Irwin Smigel has no trouble making people smile. The problem, he says, is getting them to close their mouths at all: "They laugh, they chew gum, anything to show off their teeth." Dr. Smigel, a Manhattan dentist, specializes in bonding, a procedure that is revolutionizing dentistry by making available to the average person cosmetic improvements that once only models and movie stars could afford.
Bonding involves no grinding or drilling, no needles or costly porcelain and gold crowns. Instead, a synthetic, tooth-colored material the consistency of dough is chemically fused onto stained, chipped, widely spaced, or misshapen teeth and molded into whatever new shape is desired.
"From an aesthetic point of view." says Dr. Smigel, "bonding is the greatest thing that has happened to dentistry. It is less expensive than caps, more aesthetic, painless, and easier to fix. A broken tooth used to require three or four visits to the dentist. With bonding, it can be fixed in a sitting."
While bonding is used mainly for cosmetic improvements today, generally on front and side teeth, dentists say that it is only a matter of time until sturdier materials are developed that can withstand the chewing pressure on back teeth. When this happens, they say, silver fillings and gold inlays will become obsolete. "I used to say that 90 percent of all fillings would be bonded by the year 2000," says Dr. Smigel. "Now I think it will be by 1985."
The procedure is simple. First the tooth is "bonded." It is etched with a buffered acid solution and then painted with a liquid acrylic that 'Edheres to the microscopically scored enamel. Next, the filling material, a composite resin, is patted onto the tooth in thin layers and shaped. Each layer is hardened for twenty seconds with a beam of either white or ultraviolet light from a "light-activating" machine. Once the desired shape and color are obtained, the tooth is polished. (Since the resin compound adheres only to enamel, people with caps cannot have their teeth bonded.)
Composite-resin filling material has been used in dentistry for about twenty years, but the real breakthrough came eleven years ago, when an ultraviolet-light-activated catalyst was added to it, giving dentists more time to shape the teeth. "For the first time, dentists have all the time they need to sculpt teeth to perfection," says Dr. Smigel. "Bonding has made dentistry a true art form."
One reason for the procedure's increasing popularity with dentists is that instead of harming the teeth, as do many cosmetic processes, it is good for them. The first two steps-acid etching and the acrylic sea - were devised to prevent decay in children's teeth, and, according to Dr. Martin Blitzer, head of the dental clinic at Mount Sinai Hospital, the evidence is "overwhelming" that bonding does prevent decay, and unlike caps, it does not require that an often healthy tooth be ground down to a stump. It is part of a new trend in dentistry. the main tenet of which is "Don't grind if you don't have to." "The beauty of bonding is that it is reversible." says Dr. Brian Pollack, who is currently testing bonding techniques at Mount Sinai and using them in his private practice. You can take it off and the etched enamel re-mineralizes. You haven't destroyed the tooth. That's why, in many cases, it's preferable to crowns."
Yet, some dentists, among them many who specialize in crowns, tell their patients that bonding can damage teeth. They warn that bonded teeth are not as strong as crowns, that they crack and chip and stain, and. worst of all, that your own tooth. tucked away out of sight- beneath its shining new veneer may actually be rotting away.
What of these claims? When the process was first introduced. people's teeth did rot beneath the plastic. The problem was that, since plastic expands and contracts, bacteria and debris could slip under the plastic and attack the tooth. But, says Dr. Blitzer, "this is no longer true, except in isolated cases." The resins used now are "filled" with minuscule specks of other materials-often quartz -that minimize expansion, and the tooth itself is protected by its acrylicseal undercoat.
Other complaints dwindle too when placed in the proper perspective. Should a bonded tooth chip, as it may, it can be patched with fresh resin and be as good as new. Should it stain, simply polishing off its top layer will restore its original shade. Staining of this layer can occur as early as during the first two weeks, and the number of polishings is obviously limited, but bonding still proves to be a wiser investment than crowns.
"If I were to have something break," says Dr. Bruce Larrick, former head of the audiovisual program at the University of Florida Dental School, "I'd rather have a bonding break than a crown break. People think that once they have a crown,that's it,but the average crown has a life of only ten years."
As Dr. Pollack points out, crowns, though stronger, are more brittle and are also more expensive and more difficult to make and repair. A crown requires three or four visits to a dentist's office; bonding is often completed in one visit. (Many dentists prefer a protracted single sitting in order to mix the color only once and thus get a much better match).
Some prosthodontists dismiss bonding as a "patchwork". "How can bonding be a temporary procedure", counters Dr. Smigel, "when we have documented cases that have lasted aesthetically and functionally for eleven years?"
Perhaps the real issue is one of professional rather than dental hazards. "People are getting the idea that bonding is better than crowns," objects a prosthodontist who practices in New York, reflecting the view of many cap and bridge specialists. "They make us look as if we're not up on things, as if we continue to do crowns just for the money. If we aren't doing bonding, it's because we don't feel it's ideal. Caps may not be ideal either, but at the moment they are the best we have."
"No one is saying that caps are obsolete," replies Dr. Smigel, pointing out that many cases necessitate crowns. "When the enamel has worn away or the tooth has been ground down, if the tooth has been fractured and there's not enough of it left to bond to, you have to do crowns. The best in restorative dentistry in many cases is still a well-made crown. All we're saying is "Why grind if you don't have to?"
Because porcelain crowns can be ground to a very fine finish, they trap fewer bacteria and generate less plaque than the rougher, porous surface of bonded teeth. But, because they are fitted snugly up under the gum, they are more likely to cause gum disease. Dr. Ronald Goldstein, a pioneer of bonding, who taught the first university course on dental aesthetics at Emory University, in Atlanta, says, "Studies have shown that, no matter how you brush, you can't get plaque off the part of the crown that's up under the gum."
Is there absolutely nothing wrong with bonding? One dentist who understandably prefers to remain anonymous says, "The only dentists who are against bonding are the ones who make money on caps." Dr. Goldstein's opinion is that "there is virtually no risk if bonding is done correctly. This is not true with crowns. Anytime you grind the tooth there is a possibility of damage to the nerve. necessitating a root canal." Still, the question of what is meant by "done correctly" is a delicate one.
The bonding procedure, though quite simple on paper, involves an intricate interplay among skill, materials, and time. Dr. Smigel gets calls from dentists all over the country asking, "What do I do now?" One had the resin fully in place in the patient's mouth, but, said Dr. Smigel, "he had forgotten to put spacers in between her teeth."
According to Dr. Pollack, susceptibility to stains varies greatly depending on the brand of material used-there are many on the market. In many cases, he says, the substances that stain bonding material are not always those that stain teeth. "We're testing the ultraviolet in sunlight, and red wine because of the tannin," he reports. The companies that make the filling material are putting more money into research, and products are getting better. New technology is increasing stain resistance dramatically, and Dr. Smigel is using a material that requires no final sealer, acquires an even more toothlike gleam, and withstands stains to a greater extent.
Dr. Smigel was one of the first to enlarge the scope of bonding by using it to close spaces between teeth, to lengthen teeth, and to re-contour the entire mouth instead of using crowns. Known as the "James Bond of bonding," he has done more experimental and more extensive work using the process than almost any other dentist. He frequently lectures to dentists at hospitals and universities. demonstrating the bonding techniques he has developed over the last eleven years. Determined to reach a broader audience, however, in 1979 he published a guide for laymen to the newer dental techniques - including implantology, root-canal techniques, and periodontics, as well as bonding-called Dental Health, Dental Beauty. He stresses that "people's self-image depends on their teeth more than they realize. The eyes may be the soul of the face, but the mouth is the first thing people look at. Now bonding has given us the possibility of instant transformation, since it can be done in a matter of hours, not days and years. <[>"Novocaine took the torture out of dentistry, and the X-ray took us out of the dark ages. But nothing will have the emotional impact on the public that bonding will."
Besieged by requests from dentists for more information on bonding, he founded, in 1978, the American Society for Dental Aesthetics, which now has 100 members. (Dentists must submit five examples of their work in order to be accepted for membership.)
Several dentists I spoke to said that without Dr. Smigel's lectures and demonstrations they never would have attempted bonding. "The hardest thing about it is deciding you can do it," explains Dr. Larrick. "Dr. Smigel inspired me to do that. I've seen half a dozen men lecture on bonding. The others are just dentists. Smigel's more. He inspires you to go back to your office and help people.
Getting Bonded: That Certain Smile
By the time I heard about bonding, I had practically given up hope of ever having a "come hither" smile. I was a dentist’s daughter with a black front tooth.
My shadowy, charcoal gray incisor was the result of root-canal work at age twelve. Then, too, there were the eight small but noticeable pussy-willow gray fillings in my front teeth.
In addition, I had what is known as a "severe cross bite." My semi-recumbent bicuspids and incisors four teeth on the upper right side sloped inward at almost a
45-degree angle were the result of sixteen years of joyful sucking on my two middle fingers.
For years, my mother had nagged me to have the root canal capped. But when I finally inquired about it, I was told that porcelain caps built out far enough to make my bite normal would be too heavy and break off. Braces were a possibility, but they would take two years, and who wants to hit the singles bars wearing braces at 31? Eventually, I became resigned to my Muppet-like smile, the left side of my mouth always making a heroic attempt to compensate for the dark, dented teeth on the right.
Then, at an encounter group in California about which I was writing an article, it became apparent that I was self-conscious about my teeth. The group leader, who had the most beautiful smile I had ever seen, informed me that there was a man in New York who could "transform" my mouth. I was skeptical. During most of our conversation, my eyes were riveted on her teeth. "They’re plastic" she said. She added that the New York dentist had lengthened her teeth to make her look younger. "He feels that worn teeth are a sign of age."
Fascinated, I went to see Dr. Smigel when I returned to New York. He warmed to me immediately. It turned out I reminded him of another cross bite he knew. "Your right side slopes," he said as I sat down. (All the time you think he is looking you in the eye, Dr. Smigel’s actually looking you in the mouth. Checking out the cheekbones. Scanning the facial muscles for signs of collapse.) "The teeth must be dented in," he pursued. Dutifully, I opened my mouth. He beamed at my concave right side. "A cross bite," he said. "Excellent for bonding." (Bonding is a building-up process, he explained, so teeth that point inward lend themselves to the procedure more than those that protrude.)
What would have taken two years of orthodontia to correct could now be repaired with bonding in a six-hour sitting, he said. The process takes about an hour a tooth and I was to have six teeth restructured.
Dr. Smigel has been referred to as a man of "evangelical zeal." Zeal is an understatement. The moment I sat down in the chair, I realized I was in the hands of a "relentless improver." Dr. Smigel doesn’t want you just to undergo dentistry, you see. He wants you to enjoy it. Painless dentistry through comic relief. Two index fingers, three cotton swabs, a tongue depressor, and three plastic lip grips in my mouth, and he said, "Mind if I ask you a personal question?"
He was starting the acid phase, doing for my incisor what Andre Malraux did for Notre Dame etching its façade, making it porous and white. "No," I grunted. Silence. "It’s no fun if you’re not embarrassed," he said.
Cotton balls were inserted under my lip until I felt like a boll weevil. (Once the teeth are acid etched, they must be kept completely dry.) "Don’t talk," he said, dabbing on the plastic sealant. Fat chance. "Is she hurting you?" he asked a minute later. A nurse, Susan, was propping up my lips with her index fingers. "Uh-uh," I mumbled. "You talked!" he shrieked. I was incredulous. A dentist who makes you laugh instead of cry. Chez Daddy it was never like this
"Next time you talk," he said, "I’m going to hit one of the nurses. Susan, when I hit you, you’ll know it’s her fault, not mine." Susan nodded.
"Open, bube," he said, beginning to pat the resin onto the teeth and mold it into shape with his little finger as we headed into the second round. The acid etching and plastic sealing were finished. Every so often there was a flash of purple light as he set each resinous layer.
"I like this girl," he pronounced. "I may be wrong. Look at my track record. But I like her. People say, ‘Look at the black tooth. That’s her bad character showing through.’ ‘No’ I say. ‘That’s just her old root canal.’ They say I’m defending her."
"Stand, bube," he said, checking the bite at eye level, the angle from which most people look at your mouth. Suddenly a yellow No. 2 Mongol was coming at me. He was drawing on my new teeth!
He sat me down and beveled along the pencil lines, checking and rechecking the bite. Finally, he was satisfied. Susan led me to the mirror. I smiled, taking it in from all sides. The charcoal-gray root canal, the gray fillings had all been magically erased. My uppers now extended proudly over my lowers. The right side no longer sloped!
In the weeks that followed, I found I was smiling more. In airports. In bakeries. Buying ceci beans. Just as the man said, anything to show off my teeth. The odd thing is that since bonding is so natural-looking, few people associate the dramatic change in your appearance with your teeth. "You look so relaxed," they say instead. "Did you take a vacation?" "Have you lost weight?"
"Why, no," I say smiling. - J.D.