May 2013, Volume 9, Issue 5
Published by AEGIS Communications
Cosmetic Dentistry: Options for the Youngest Patients
Treating children has always been a complicated part of practicing dentistry. The still-developing anatomy of younger patients presents a clinical challenge, because in many cases, treatment options must be adapted from procedures typically performed on adults. It can be difficult to determine the best course of treatment for a patient who is still changing and growing, making clinicians hesitant to perform normally common procedures, especially in the cosmetic arena.
Some consider cosmetic dentistry for young people taboo both clinically and ethically, as interfering with a child’s changing tooth anatomy may cause more harm than good in the long term. With the recent trend towards minimally invasive dentistry, however, new methods and materials are being developed that can make a significant difference in the lives of young patients, even those who are not yet in their teens. If these methods are applied properly, many experts believe that minimally invasive, non-permanent cosmetic procedures will become commonplace, among even very young patients.
A Moving Target
Clinicians may decline to perform cosmetic procedures on children and young adults because it does not seem appropriate. Permanent procedures, such as implants, are almost never performed on still-growing patients, for example. Veneers that require extensive preparation and deep tooth bleaching are also considered too extreme for a younger patient base.
According to Cherilyn Sheets, DDS, who has a private practice in California and is the co-executive director of the Newport Coast Oral Facial Institute, as well as a clinical professor of restorative dentistry at the USC School of Dentistry, one of the worst things a clinician could do is prescribe adult treatment for a child. “Working with a child is like aiming at a moving target,” she says. “As a child’s structure matures, the teeth show more enamel, the alveolar ridges grow, and tissue changes height. Permanent procedures are not ideal in that type of situation. You want to have something that could be reversible if you need it to be.”
Another reason that clinicians should take pause when considering cosmetic procedures for young patients is that field of dentistry is rapidly evolving. Thomas Trinkner, DDS, an accredited member of the American Academy of Cosmetic Dentistry with a private practice in South Carolina, believes that cases with children should always be treated as conservatively as possible because not only will the child’s facial structure grow and change, but so will the field of dentistry. “When treating young patients, clinicians should think of themselves as buying that patient time. A better option may be just 5 years ahead in the pipeline, and performing an invasive procedure on someone too young might cause that patient severe issues in the future,” he explains.
The Value of Minimally Invasive Procedures
Although permanent procedures may not be suitable for a very young patient, there are still situations where cosmetic dentistry may be necessary. Both Trinkner and Sheets are strong proponents of minimally invasive dentistry, which allows clinicians to make a difference for young patients without altering their tooth structure or making permanent changes to their mouth.
Sheets explains that minimally invasive dentistry is the best option for most patients when considering the long-term effects of treatment. “When one takes into account the structural stability of teeth, it is important to note that a tooth’s enamel covering provides tremendous strength to not only the tooth, but also to its underlying dentin and cementum. The more the clinician can preserve that uninterrupted enamel shell over the top portion of the tooth, the stronger that tooth is going to remain,” she says. Sheets encourages clinicians to choose restorative options that will promote the longevity of the patient’s natural tooth, regardless of the patient’s age. “Removing tooth enamel to get an esthetic change can be effective. However, sacrificing strength to achieve those heightened esthetics may not be worth it a few years down the road,” she says.
Trinkner has been using minimally invasive methods to treat young patients for many years. “There are procedures that can be done with adhesive dentistry and composite that do no harm to the tooth, and can give the patient the same results as veneers and ceramics in the short term,” says Trinkner. These are the procedures that Trinkner recommends for his youngest patients. He gives an example, “If I have a very young patient, as young as 9 or 10 years old, come in with missing teeth, I have two options. The first is to create a flipper with little fake teeth to fill in the gaps. This can be expensive and the appliance may not fit properly, causing the child even more embarrassment if it pops out during school or affects his or her speech. The other option, which I much prefer, is to create a bonded false tooth with composites. It looks better, it holds the tooth in position better, and can be buffed right off with a rubber wheel if we need to remove it.”
These temporary, low-preparation, conservative options allow clinicians to start offering cosmetic options to their youngest patients if they wish. Sheets elaborates, “There’s some wonderful things that can be done with no-prep composite veneers, chairside bonding, and light bleaching that are appropriate for children. ”
Making a Difference
Sheets and Trinkner both emphasize that while there are conservative treatments available for children, clinicians must still take into account whether the patient truly desires a change in his or her appearance.
“If the patient is psychologically comfortable with how she looks, then she probably won’t really value the changes that cosmetic interventions could create for her. In that case, we shouldn’t encourage her, or her parents, to pursue cosmetic procedures,” says Sheets. “That said, when a child desires to make a change, we should not be dismissive of those needs just because of the patient’s age.”
Trinkner concurs, and finds that many of the young people he treats, even those younger than 10 years old, are hyper-aware of appearances. “Children can be extremely self-conscious if their teeth are not perfect. If there is any way I can help a child improve his or her confidence without damaging tooth structure, there is no reason not to,” explains Trinkner. Clinicians should be sensitive to hearing the cosmetic needs of all of their patients, as they can truly make a difference in their lives.
Esthetic procedures can be a phenomenal boost for patients who feel insecure about their appearance. With this opportunity comes responsibility, however.
“As clinicians, we need to be able to work with our patients to not only give them a beautiful smile, but ensure that the work we do lasts for as long as possible,” says Sheets. “This is true in adult patients, but this must especially be considered in children. Even our finest work will not last a 15-year-old until he or she is 80 or 90.”
A wealth of options exists for clinicians who wish to perform cosmetic procedures on young patients, but those procedures should always be done with the long-term oral health of the patient in mind. Permanent procedures should not be performed unless the patient’s future oral health is at risk, and the more natural tooth structure that remains, the better. If these guidelines are followed, clinicians can start positively affecting their patient’s lives at younger ages than ever before.
When to consider more invasive procedures
In most instances, clinicians should avoid permanent, anatomy-changing procedures in children. There are unique cases, however, that do require that the clinician take a firmer hand and recommend a more aggressive course of treatment.
Thomas Trinkner, DDS, cites an example: “If I encounter a young patient whose front teeth jut way out, I would strongly encourage his or her parents to immediately take action to correct the issue. While straightening jutting teeth could be considered a cosmetic procedure, there are many clinical reasons to fix those teeth as well.”
Trinkner describes that teeth that jut out are much more prone to injury, and a cracked or broken tooth could cause issues for the rest of the patient’s life. “I would tell the parents that in the case, the child requires more aggressive treatment to ensure that he won’t have some sort of irreversible trauma in the future,” he says.
In these extreme cases, clinicians must be willing to think outside of the box and consider treatments that would normally not be on the table. Sometimes cosmetic procedures have a functional purpose that can make a major difference in the patient’s future oral health.