Received: 15 September 2023 Revised: 19 October 2023 Accepted: 20 October 2023

DOI: 10.1111/jerd.13162

CLINICAL ARTICLE

Quo vadis, esthetic dentistry? Part II: Composite resin

overtreatment and social media appeal

Ronaldo Hirata DDS, MS, PhD 1 | Leandro Augusto Hilgert DDS, MS, PhD 2 |
3
Camila S. Sampaio DDS, MS, PhD | Oswaldo Scopin de Andrade DDS, MS, PhD 4 |
Ginger Melo DDS, MS 5 | André V. Ritter DDS, MS, MBA, PhD 6

1
Department of Biomaterials and Biomimetics,
New York University College of Dentistry, Abstract
New York City, New York, USA
Objectives: This article presents case reports highlighting over-treatments with resin
2
Department of Operative Dentistry, School of
Health Sciences, University of Brasília, Brasilia, composites, often misconceived as minimally invasive procedures.
Brazil Clinical Considerations: Tooth-colored restorative materials, such as ceramics and
3
Advanced Clinical Fellowship Programs in
composites, have found widespread application to correct problems related to tooth
Esthetic, and Operative and Digital Dentistry,
New York University College of Dentistry, color, shape, and alignment. When composite resin is used, these procedures can be
New York City, New York, USA
done in a very conservative, cost-effective, and timely fashion. However, it is note-
4
Advanced Program in Esthetic Dentistry,
Senac University, São Paulo, Brazil
worthy that contemporary dental esthetic expectations are based on standards prop-
5
Anatomy and Sculpture and Restorative agated by social media and other marketing and communications platforms. The
Dentistry of UNIVAG, Várzea Grande, MT, abuse of and addiction to social media impacts can lead to unrealistic esthetic expec-
Brazil
6
tations and standards for both patients and dentists.
University of Washington School of
Dentistry, Seattle, Washington, USA Conclusions: After a critical discussion on ceramic veneers published in part I of this
2-part series, this article directs attention towards what has become a trendy fashion,
Correspondence
Camila S. Sampaio, Advanced Clinical i.e., the use of direct composite resins as “non-prep” veneers in clinical situations that
Fellowship Programs in Esthetic and
arguably required no restorative intervention at all. We further explore how social
Comprehensive Dentistry, New York
University College of Dentistry, New York media influences the decision-making processes of both professionals and patients.
City, NY, USA.
Email: css458@nyu.edu
KEYWORDS
dental esthetics, composite resins, esthetic dentistry, esthetics, minimally invasive dentistry,
overtreatment, veneers

1 | I N T RO DU CT I O N population, who are incessantly exposed to esthetic and beauty stan-

dards through several media platforms.1
The introduction of the term “esthetic dentistry” several decades ago The evolution of dental materials and technologies has fueled this
has broadened the scope of practice for dentistry and allied profes- increased interest in esthetic dentistry and cosmetic procedures.
sions to include “cosmetic procedures.” Although one could argue Remarkable progress in composite resins, adhesives, and dental
that esthetic and cosmetic dentistry can carry different connotations ceramics, in particular, has enabled dentists to be more conservative
for different people, it is undeniable that the scope of the dental pro- (and creative) than ever before when approaching dental esthetic
fession has expanded from diagnosis and management of oral and cra- challenges.2,3
niofacial diseases and conditions to encompass aspects related to Since their introduction, ceramic veneers have been used to
appearance, perception, self-esteem, as well as the pursuit of beauty. address issues related to tooth color, enamel imperfections, tooth
It would not be an overstatement to assert that esthetic dentistry, position, and anatomy challenges.4,5 Notably, ceramic veneers offer
while not officially recognized as a dental specialty, has gained distinct advantages over, for example, full-coverage conventional
increased attention from both dental professionals and the general crowns, including their ability to bond to the tooth structure

J Esthet Restor Dent. 2023;1–5. wileyonlinelibrary.com/journal/jerd © 2023 Wiley Periodicals LLC. 1

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2 HIRATA ET AL.

(particularly to enamel),6,7 as well as the possibility of avoiding addi- utilization of direct composite resins for veneers on anterior teeth.
tional preparations, often employed in the context of “non-prep” The clinical cases showcased serve to illuminate situations where
4,8
veneers. However, it is also essential to recognize that ceramic composite veneers were employed to address concerns that did not
veneers became a “quick fix” solution for many perceived problems, necessitate intervention or only minimal intervention could have been
and their widespread appeal has, regrettably, fueled instances of over- done. Furthermore, the article discusses the influence of social media
treatment and questionably ethical applications.9 A previous paper on patient and clinician preferences and trends in this context.
published by the same authors discussed extensively overtreatments
due to fashion trends.1
Composite veneers are often used as a conservative and cost- 1.1 | Clinical example 1
effective alternative to ceramic veneers. Notably, they offer unique
advantages, including reversibility and the ability to be repaired A 25-year-old female patient presented with a set of composite resin
intra-orally without the need for tooth structure removal. A study by veneers from molar to molar in the upper arch, which had been placed
Meijering et al., in 1997, found no difference in patients' satisfaction 8 months prior. It's noteworthy that the patient was well informed
comparing composite and ceramic veneers.10 Improvements in dental about oral health practices and had a good grasp of proper brushing
adhesives and composite resins technology lead to a better under- techniques. However, she expressed difficulties in maintaining cleanli-
standing of procedures related to esthetic and cosmetic dentistry, and ness through brushing and flossing and had experienced persistent
consequently, a growing number of clinicians are using composites to bad breath issues since the veneers were applied. She also expressed
fulfill the esthetic needs and desires of their patients, surpassing concern that these gingival problems might progress to affect the den-
the use of ceramics in many cases. Clinical evaluations have shown tal support structures and potentially lead to the development of
the reliability of the use of composite resins for esthetic dentistry.11,12 cavities.
Moreover, the affordability and ease of access to direct compos- Upon clinical examination, we observed signs of gingival inflam-
ite veneers have prompted many clinicians to recommend these resto- mation, with evident bleeding on probing and the presence of gener-
rations, particularly when patients and clinicians do not have access to alized calculus. In the initial phase of treatment, we took extreme
high-level laboratory technicians. Yet, despite their user-friendly care while removing the restorative material, ensuring minimal
nature, composite veneers are subjected to the same challenges enamel loss to preserve the esthetic integrity of her dental anatomy.
observed with the “ceramic fever.” These challenges encompass cor- Given the patient's desire for whiter teeth, our treatment plan
rectly identifying suitable indications, addressing execution-related included in-office bleaching sessions as part of the smile restoration
issues, and observing the pervasive pressure from various media proposal. Following the final tooth whitening session, we allowed a
sources related to esthetic and beauty norms.1 15-day interval before proceeding with a conscious decision to
The aim of this article is to present a series of case reports address the restoration of the hypoplasia present on the central inci-
highlighting instances of over-treatment with dental resin composites, sors. We gently reconstructed the incisal edges, focusing exclusively
often misconceived as minimally invasive procedures. It also seeks to on restoring both central incisors, achieving the desired esthetic out-
prompt reflection on the excessive and potentially inappropriate come (Figures 1 and 2).

F I G U R E 1 Case 1. The patient presented with compromised health and esthetics resulting from inadequately executed restorative
procedures that neglected fundamental principles essential for preserving gingival health (A and B). Observe that a hair was present in the mass of
the resin restoration (C).

F I G U R E 2 Case 1. (A) Patient's

initial smile. (B) Patient's smile after
molar-to-molar resin removal.
(C) Patient's smile after resin
restoration of upper arch central
incisors only.
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HIRATA ET AL. 3

F I G U R E 3 Case 2. (A) Patient's initial smile. (B) Patient's close-up F I G U R E 4 Case 3. (A, B) Overcountoured resin composites that
picture revealing lack of consistency comparing his restorations and were triggering gum inflammation in the patient. (C) Previous set of
the rest of his teeth; the patient mentioned going back to his dentist resin composite restorations involving pre molar to pre molar.
in several follow-up appointments as he was not satisfied with the (D) Removal of the patient's resin restorations, revealing the natural,
final color of the teeth, hoping for an even-brighter solution even exquisite shades of her teeth.
though it was not the color of his adjacent teeth. (C) Observe the lack
of anatomy and stains present in his previous restorations. (D) Careful
removal of the patient's previous restorations.
2 | DI SCU SSION

1.2 | Clinical example 2 Ceramic veneers and composite resin veneers represent two restor-
ative options with very similar indications. While ceramic veneers,
A 29-year-old male patient sought dental attention with an exist- when properly indicated and executed, can potentially yield longer
ing set of composite resin veneers spanning from lateral to lateral clinical service, owing to the material's enhanced physical and
in the upper arch, which had been placed several years ago. Upon mechanical properties when compared to composites, composite
clinical examination, the resin veneers were found to exhibit inad- resins are potentially more conservative, cost-effective, and offer
equate surface anatomy, contour, interproximal contact, and greater accessibility to both patients and clinicians. However, it is cru-
color. In addition, there were evident signs of gingival cial to recognize that both treatment modalities can be susceptible to
inflammation. overprescription, especially in situations where patients and clinicians
Furthermore, the patient revealed that he had visited his den- do not thoroughly discuss treatment objectives, expectations, and the
tist on numerous occasions in pursuit of adjustments to the color potential consequences of irreversible tooth preparation procedures
of his restorations. He expressed a persistent desire for increasingly to facilitate the execution of veneers. Striking a balance between ade-
whiter shades, which, when compared to his natural teeth, were quate and iatrogenic treatment should be discussed by practitioners
noticeably incongruent with the coloration of the rest of his smile working in the field. Burke and Kelleher proposed an unscientific but
(Figure 3). relevant test called “The daughter's test,” which all clinicians should
consider when recommending treatment for their patients. The princi-
ples urge clinicians to approach treatment decisions as if they were
1.3 | Clinical example 3 treating their own children, fully aware of the benefits and risks of the
proposed intervention.13 Discussions on the topic of excessive treat-
A 25-year-old female patient presented at the dental clinic with exist- ments with ceramics and ethical misconduct have been previously dis-
ing composite resin veneers spanning from premolar to premolar in cussed by Hirata et al.1
the upper arch, which had been placed 2 years ago. During the consul- Despite being generally more conservative than ceramic restora-
tation, she expressed discomfort due to an unpleasant smell, attrib- tions, composite veneers can still be invasive procedures. In addition,
uted to excess resin composite material over-contoured at the as with any restorative procedure, placing direct composite veneers
gingival margin, along with a noticeable color discrepancy compared requires a deep understanding of dental and periodontal anatomy
to her lower arch. and physiology. Associated with the explosion in demand for
The proposed treatment plan encompassed the removal of the esthetic procedures using ceramics and composites, esthetic restora-
resin composite, cleaning, subsequent teeth whitening, orthodontic tions have become almost an “epidemic” of iatrogenic and discon-
alignment, and the strategic application of resin composites to her nected indication with the concept of minimal intervention in
central and lateral incisors (Figure 4). restorative dentistry.
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4 HIRATA ET AL.

Composite materials used for wear reconstructions in the anterior patients looking for cosmetic dental treatments who could suffer from
region have exhibited a success rate of 88.8% and a survival rate of body dysmorphic disorder, or BDD, estimated at 15%. These patients
13,14
95.6% in 2 years. In a sequence of clinical evaluations of compos- are nine times more likely to consider tooth whitening, six times more
ites in mandibular anterior reconstructions, the survival rate was 96% prone to orthodontic treatment, and present five times increased ten-
for 2.5 years and 85% for 7 years.14–16 A more dramatic result was dency to be dissatisfied with a recent treatment.30
shown by a systematic review that showed survival rates of anterior In their quest to alleviate the distress caused by BDD, patients
16,17
composites of 90% in 2.5 years and 50% in 5 years. However, it often begin the time-consuming cycle of esthetic treatments or retreat-
also has been shown that patient satisfaction with composite veneers ments.31 The dental literature has come to a term named
decreases one to 2 years after placement, mostly attributed to color “bleachorexia,” which describes the addiction to dental bleaching treat-
changes.10 ments, a condition where patients are constantly repeating bleaching
18,19
Social media has had an enormous impact in dentistry, giving procedures but remain always dissatisfied, as reported by Lee et al.32
rise to an escalating demand for “non-prep composite veneers” that This psychological aspect frequently leads to patients seeking multiple
promise ultra-bright appearance, and a “fast track” solution for a vari- dental esthetic restorations simply because they are not still happy with
ety of actual and perceived esthetic problems. Despite the advantages the results, primarily due to psychological anxiety. On the other side,
offered by online access in the search for knowledge and the engage- professionals with a simplistic view of: “They do it because patients ask
ment created in young dental students and graduates of dental them…” keep making unnecessary interventions repeatedly, one after
schools, a significant problem is faced by the profession.20 The height- another, contributing to the cycle of dissatisfaction we present here.33
ened exposure on social media platforms, along with the incessant Simonsen had raised concerns about ethical misconduct in which
emphasis on composite veneers, significantly shapes the perceived professionals have failed to adhere to the fundamental principle of
needs of patients and profoundly influences the treatment recom- potential harm versus potential benefit.34,35 Dentistry urgently requires
mendations and decisions made by both patients and clinicians. Burke new models and credible teachers to guide new dental students. Fur-
and Kelleher pointed out that exposure to “dental gurus” and “show- thermore, the incorporation of Ethical Esthetic Dentistry into the dental
men” via social media and/or lectures greatly influences dentists' school curriculum, ideally before graduation, is a vital step toward
decision-making nowadays.9 This influence holds particularly true for ensuring that ethical considerations are an integral part of a dentist's
the young generations of dentists. Social media also moderately influ- education36,37 In 2011, Kelleher criticized publications showing aggres-
ences the super white “Hollywood smile,” as demonstrated by a sive approaches using ceramic restorations for esthetic treatments with
21
recent study conducted on undergraduate students in Riyadh City. substantial commercial interest from ceramic companies.38
In social media, patients and professionals are being excessively The biggest threat in esthetic dentistry nowadays, voted by a sur-
exposed to an overwhelming array of esthetic dental treatments, leav- vey by the American Academy of Cosmetic Dentistry, was overtreat-
ing a profound imprint on patients' requests and professionals' ment.9 In this article, one comment of one survey member was: “We
choices. Kelleher warned about the impact of the destructive extreme are developing a reputation of money-hungry dentists.”
makeovers causing “smile design damaging.”22
Clearer boundaries of personal media profiles and professional
ones have been advocated.19,23,24 These authors emphasize the need 3 | CONC LU SION
for enhanced training of dental professionals in the responsible use of
social media and ethical conduct,25 given that prospective patients The influence of social media and evolving esthetic norms on the
frequently rely on social media profiles and posts when selecting their overuse of direct composite resin veneers raises ethical concerns
healthcare providers.26 within the field of dentistry. Dental professionals must carefully con-
Another concern is the propagation of fake news within numer- sider the balance between patient desires and genuine treatment
ous health professions. Fake news is becoming a global issue, and needs, with a focus on ethical and evidence-based practice. Clear
dentistry has not been immune to the spread of misleading stories boundaries on social media platforms, improved training, and critical
and false information, disseminated to patients and dentists.27 The evaluation of information sources are essential to mitigate the impact
term “Netizen” has been applied to frequent internet users. 26
of these external influences on treatment decisions and ensure the
Psychological factors are undeniably significant when considering long-term well-being of patients in esthetic dentistry.
the distinction between treatment needs versus wants in Dentistry. In In the context of dental treatment planning in contemporary den-
psychology, the “Quasimodo disorder,” named after Vitor Hugo's tistry, the significance of modern tools and a well-defined treatment
character in The Hunchback of Notre Dame, manifests as dysmorphic plan for achieving minimally invasive dentistry cannot be overstated.
obsessive-compulsive disorder where an individual develops an obses- A meticulous and transparent treatment planning process that thor-
sion with perceived defects, often centered around their facial fea- oughly assesses the advantages and disadvantages of each interven-
tures, and was first delineated by Morselli in 1891.28 Some studies tion is crucial. This involves a comprehensive examination of how
show that 91% of the patients with this disorder who undergo plastic each procedure can be optimized for minimal invasiveness. Taking
surgery procedures ultimately express dissatisfaction with the out- advantage of the capabilities of contemporary dentistry, such as digi-
comes.29 De Jongh et al. (2008) raised a need for attention for tal planning and advanced diagnostic tools, can be instrumental in this
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HIRATA ET AL. 5

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The authors do not have any financial interest in the companies
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