Second Acts

If you didn’t have braces as a teenager, is it too late to get the smile you always dreamed of? Not by a longshot. Sandra Shelley explores the latest in cosmetic dentistry.

When i was a teenager in the ’80s, i wanted braces. Back then, they were big and silver and you had to wear them forever—or so it seemed. They required frequent visits to the orthodontist for wire adjustments (reported to be painful) and sometimes, it was rumored, outlandish headgear (like the nerd in Sixteen Candles wore the morning after his big date). I didn’t care. I longed for the transformation—the big reveal—when the braces finally came off.

I never did get those braces, and I have always wondered: “How would I look with straighter teeth?”

Apparently, I am not alone in my reverie. As it turns out, a growing number of adults who never had braces when they were young—or who had them, but their teeth have shifted over time—are now vying with teens for space in the waiting rooms of orthodontists. Over the years, I’ve noticed that the options in orthodontics have grown increasingly more appealing (no more metal mouth). With no wires or headgear in sight, progressive invisible aligners, which are made by a number of companies and fitted by dentists, are a major reason for the growing number of adults seeking straighter teeth.

“We get many more adult patients getting orthodontics done, especially with the advent of Invisalign and Clear Correct,” says Dr. Christopher Hooper, a cosmetic dentist from Virginia Beach and a popular national speaker on aesthetic dentistry. “They take them off when they go out to a cocktail party, they can slip them off when they’re going out to dinner .… they work beautifully.”

Cosmetic dentistry, which also includes procedures like whitening, crowns, veneers and implants, is on the rise. More than half of the patients electing for aesthetic procedures (56 percent) are between the ages of 31 and 60, according to the American Academy of Cosmetic Dentistry’s benchmarking survey in 2013.

“I think that’s linked to the fact that the public has been made more aware that there are cosmetic options out there, that dentistry just isn’t your old ‘go get a filling or a crown or a tooth pulled.’ There are multiple options now that we can use to change somebody’s smile,” explains Dr. Stephen Alouf, a dentist who shares the Alouf Aesthetics Medical Park facilities in Salem with his brother, a cosmetic surgeon. Alouf says he has experienced significant growth in his cosmetic and implant dentistry business since opening in 2004.

“We get a lot of people who have raised their children, they’ve taken care of their children’s needs, and they’re empty nesters, their children have gone off to college,” says Alouf, “and now it’s time for them to take care of themselves.”

With one of my own children leaving the nest for college this fall, this is beginning to sound familiar. But what is out there? To find out, I decided to visit dentists and orthodontists around the state, starting with Dr. Scott Berman, who shares two offices in Northern Virginia with his partner, Dr. Edwin Lee. The pair is known for cutting edge dentistry.

“Go ahead and open real big, we’ll start on the lower right,” says Dr. Berman. I follow his directions as I recline in a chair at the Falls Church office of Berman & Lee Orthodontics. I’m about to get scanned.

Berman’s hand-held iTero scanner beeps as he takes digital photographs of my teeth and gums. When he’s done, we look at a chairside computer screen, where the images have come together to create an incredibly detailed three-dimensional model of my teeth. I watch the model flip and rotate through space as he reviews it.

“There’s a little crowding down here,” he says, pointing to my bottom teeth. Lower anterior crowding is common as people age, he says. “As we get older, starting late teens and twenties, there’s a tendency for teeth to drift to the middle.” I also have some wear on my enamel, common in those who clench or grind their teeth over time.

In a high-tech leap from traditional dental impressions, Berman can send the digital image from his computer to San Jose, California-based Align Technology, manufacturer of the popular Invisalign braces. The company then returns an “outcome simulation”—a digital “after” photo—of what my teeth would look like following treatment. The custom-made aligners arrive at the dental office about four weeks after the initial consultation.

Patients wear the aligners for a few weeks, then they are replaced with another set. Treatment can take one to two years. The key is vigilance: Patients need to wear their aligners for 20 to 22 hours per day, but I think the ability to take braces off at all is remarkably freeing.

Overall, says Berman, “Invisalign is less noticeable than regular braces and more comfortable. It’s more hygienic because you can take them out [when you need] to brush and floss.”

While there are many other alternatives for re-aligning your teeth—from clear ceramic and metal braces (with much smaller brackets than the old days) to the ultra-discreet lingual braces like the kind Miley Cyrus wore behind her teeth a few years ago—invisible aligners are the biggest draw for adults.“

About 90 percent of our adult patients are Invisalign users,” says Berman—including him, I am surprised to learn. And the big reveal I hoped for as a teenager? Berman admits it’s somewhat anti-climactic because the invisibility of the braces means you can watch the gradual changes to your teeth. Though the “wow factor” at the end is somewhat muted, the aesthetics of invisible aligners are worth it.

There are, however, other opportunities for fairly quick dental transformations. As we age, our teeth are prone to yellowing, and are vulnerable to coffee and other staining. They can also darken as a result of childhood or prolonged adult use of tetracycline (a form of antibiotics). One-hour whitening is the answer.“

People are able to achieve anywhere from two to six shades difference in that one hour,” says Alouf, although it varies, depending upon the composition of the teeth. He uses Zoom! Whitening and explains the procedure begins with a dental cleaning. Then, he spreads a gel on the teeth and activates it using a high intensity light. The procedure includes portable trays for touch-ups at home. “We still have the patients who only do the at-home whitening, and that still works extremely well. But some people want an instant result, and that’s where the one-hour whitening can come in,” he says.

Cracked, badly shaped or discolored teeth can be fixed with same-day crowns. Dentists use Cerec and other in-house digital scanning and milling systems to create crowns and other restorations right in their own offices. According to Dr. Douglas Wright, a Harrisonburg dentist, the milling process takes about 25 minutes, and he can place the restoration that same day—as compared to a month later, when he used to send impressions to the lab.

In addition to offering convenience to patients, he appreciates the fit of the Cerec crowns: “The margin—where the crown meets the tooth—is almost undetectable.” Same-day crowns hold special appeal for his senior clients because “many have trouble getting back and forth to the dentist.”

According to Hooper, materials for crowns—which are placed right over teeth—are stronger today than when he first started practicing in 1990 (followed by a year of advanced training in 1991).

“The gold standard, when I graduated dental school, was to put gold crowns on the back teeth,” he says. This evolved to porcelain-fused metal, then porcelain jacket crowns. Today, says Hooper, the best crowns are made of full porcelain, porcelain bonded to zirconium oxide (in the same family as cubic zirconia), and full zirconium. These crowns appear much more translucent and natural than the old metal crowns. “They look a lot better, and they’re much stronger, and we have to take away a little bit less of the tooth,” he explains.

Bristol-based Dr. Scott Miller specializes in dentures and implants. Between Roanoke and Knoxville, Tennessee, he is one of only two prosthodontists, whose specialty—dental prostheses—requires an additional three years of training following dental school. Most of his denture clients arrive in his office wearing “a little horseshoe-shaped acrylic denture that sits on gum tissue” and presses the gums uncomfortably. In addition to the discomfort, while the top denture usually fits all right, the bottom one “really has no suction on the lower jaw, so it moves.”

Dental implants, made with small titanium posts, can be placed into the jaw to provide a retaining fixture for the dentures. “The oral surgeon places the implants,” says Miller, “and then the patients come to me and I hook the teeth to the implants the same day.” The appliance provides a more secure structure, he explains, and “it’s not touching the gum tissue anymore so it eliminates the pain.” Dentures also now come in a popular shade that gives the artificial teeth a bright white color, similar to natural teeth that have undergone a whitening process.

Says Miller of implants, “That’s God’s gift to dentistry right there.”

Back in Salem, Alouf tells me that improved, more natural-looking veneers are another way to achieve a smile makeover. A typical procedure involves eight to 10 veneers across the top front teeth.“

Veneers are an instant way to change your smile. And with the new porcelain technology, the veneers are extremely strong; they’re extremely lifelike. So we’re able to give you something that looks like nature itself put it in there,” says Alouf.

The veneers are thin—generally about one-half millimeter thick—and bonded on with dental cement, says Hooper. The first visit takes about two hours, during which the dentist will prepare the teeth by reshaping them and making impressions and temporary veneers. The next visit, when the dentist bonds on the permanent veneers, will take place about seven to 10 days later and last about 1½ to two hours. Generally, veneers cover just the front of the teeth, but three-fourths and full “jacket” veneers are also available.

Hooper generally recommends going with at least 10 veneers. “One of the biggest mistakes I see is when people get too few teeth done.”

Sometimes clients will seek a whole mouth restoration for functional or aesthetic reasons. The process can involve multiple products, including veneers, crowns, implants or fixed permanent bridges. Patients—including a growing number of men—begin to come in at early middle age, just as they are beginning to feel they look a little older, says Hooper. Life changes, such as divorces or the need to find a new job, “are generally the trigger points that will get patients to do things.”

Says Alouf, “We’ve had patients who are at a point in their life where they feel like their smile is holding them back, either in their career or their social lives. We’ve created new smiles for people that have allowed them to have the confidence to go out and get the job they’ve always wanted .… Those are the big warm fuzzies right there. When you do something for someone and they come back and they say, ‘Listen, I not only love my smile—my smile has changed my life, because I’m so much more confident. People treat me differently now. People used to stare at my mouth, and they wouldn’t look me in the eye when they would talk to me. Now they’re looking at me.’”

Hmm, maybe that’s just what I’ll be saying at my next high school reunion.

The Price of Beauty

Before electing a cosmetic procedure, it’s important to find the right dentist, says Hooper. Some things to look for include good referrals, before and after photos by the dentist, experience and a focus in cosmetic dentistry, professional memberships and a strong record with the Virginia Board of Dentistry. It’s always a good idea to meet with a dentist for a consultation first. “If the patient isn’t comfortable with that doctor or doesn’t get a good vibe, he should probably seek out a second opinion,” he says. “And be sure you don’t go to the cheapest one,” he says. “Generally, our patients really get what they pay for.”

Many insurance companies do not cover cosmetic dental procedures, except for some cases of restorative care. Here’s what Hooper says you can expect to pay for some of these services around the state:

  • Whitening $250-$750
  • Bonding $300-$500 for one front tooth
  • Invisalign $5,000-$6,000
  • Veneers $6,000-$12,000 for 8-10 veneers across the top front teeth
  • Complete smile makeover $25,000-$40,000
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