Cosmetic & Esthetic Dentistry
A beautiful, youthful smile! We all want it, but what does it take to get it? Common sense dictates that there are different ways of doing things, some better than others, right? So what should the discerning dental patient know about cosmetic dentistry, especially if our only problem is solely for appearances sake, and we possess a totally pain free set of teeth but simply want some “sprucing up”? This section will address various procedures, tips, techniques, and downfalls of what cosmetic dentistry can and cannot do for the dental patient, including several virtually unknown aspects, which should always be respected when trying to improve the appearance of our “pearly whites”.
Click the topic of interest:
- Whitening Teeth
- Straightening Teeth/Closing Gaps
- Reshaping Teeth
- Reshaping Gums
- Replacing Missing Teeth
- Bonding Teeth
- Veneering Teeth (Veneers)
- Fillings (White)
First of all, some pertinent definitions are in order:
Cosmetic dentistry is generally used to refer to any dental work that improves the appearance (though not necessarily the function) of a person’s teeth, gums and/or bite. Many dentists refer to themselves as “cosmetic dentists” regardless of their specific education, specialty, training, and experience in this field. Though the American Dental Association does not recognize cosmetic dentistry as a formal specialty of dentistry, there are dentists that promote themselves as cosmetic dentists. Most notably, the American Academy of Cosmetic Dentistry (AACD), with its 20,000+ members, is the world’s largest international dental organization, with a charter designed to provide its dental professional constituents with the latest advances in the application of cosmetic dentistry technologies, techniques, and ethical practices via conferences, lectures, workshops and publications. A member who participates in this organization, tends to qualify as a doctor who is at least introduced to the concepts required to classify ones practice as not only cosmetic in nature, but esthetic as well. There will be more on this distinction shortly. The AACD offers a very challenging credentialing process, which very few of their constituent members have earned. An individual who has earned this status in the AACD is known as an Accredited member of the AACD. There exist approximately 400 dentists on the planet with accredited status in the AACD.
Esthetic dentistry encompasses cosmetic dentistry and much more. It is a much more complex and lofty undertaking. Esthetic dentistry actually includes the myriad intricacies involved in the harmonious function and appearance of the masticatory/chewing system, and not just the appearance of the teeth and gums. Muscles, joints, bone, cartilage, ligaments, neurology, anatomy, biochemistry, physiology; all of these aspects come into play when a dental professional truly strives to create an esthetic, pain free, and functional (and not just a cosmetic) solution for their patients.
In other words, the cosmetic dentist is concerned primarily with “covering up” something ugly, with little emphasis placed upon form and function. The esthetic dentist, is concerned not only with how it all looks cosmetically, but how it functions as well, trying to ensure that the end result will function harmoniously within the miraculous stomatognathic/chewing system which we all take for granted, until something goes wrong. Obviously, the concept of esthetic dentistry is much more complex than cosmetic dentistry. In summary, cosmetic and esthetic dentistry are different in definition, concept, and execution. Now that this distinction is out of the way, what types of services do patients concerned with improving their appearance desire and what do they need to know prior to implementing “cosmetic dentistry”?
Whitening teeth: professional bleaching/whitening agents very effectively lighten stained, yellowing, and unsightly teeth, with basically two limitations:
- Artificial fillings, crowns or veneers do not change shade with these chemicals so be wary of this fact
- Intrinsic (deep within the tooth) developmentally darkened teeth do not completely respond to bleaching agents and often need to be covered with opacious porcelains to whiten them completely
In-office prescription bleaching methods are certainly the most effective and quickest options for whitening. Brand names such as Zoom® will effectively bleach the patient in less than 90 minutes as several 20 minute sessions are performed in a single dental visit on the patient after the gums are protected and special lights are used to catalyze the bleaching chemicals. This is the fastest and quite possibly most effective method of bleaching. Take-home prescription bleaching agents are almost as effective, but take several days to accomplish the same change that the in-office bleaching does. Custom trays are made for the patient into which the take home bleaching chemistry is dispensed, effectively ensuring an even distribution and even whitening of all their teeth. The least effective bleaching methods are over the counter as they are non-prescription, weak, and potentially dangerous as some of these products actually use acidic chemistry that can etch tooth enamel in an uncontrolled manner. Before bleaching, it is always best to ensure that no cavities are present, a dental cleaning has been performed, and that there are no leaking fillings or other restorative materials in that patients dentition.
Straightening teeth/closing gaps: orthodontic movements with braces, bridges or implants can be used to correct misaligned teeth in the jawbones. Every case is different and should be properly evaluated by an experienced dental practitioner before the patient undergoes any of the above three options. Special consideration should always be given to the implications that closing spaces via the above 3 modalities will have on:
- The gum tissues
- The bone in both the maxilla and the mandible (upper and lower jaws respectively)
- The effect that tooth movements have on:
- the bite
- the TMJ’s
Beware the cosmetic dentist ignoring the effects that straightening teeth have upon the bite and the TMJ’s. Most ignore this critical interaction between the bite and TMJ health. They are each interrelated. Violating these 2 parameters can lead to chronic issues such as headaches, hypersensitive teeth, and chronic “TMJ” dysfunction.
Reshaping teeth: for a “prettier smile” seems relatively innocuous, but beware… The alteration of the shapes of top or bottom front teeth, in particular on the edges of either upper or lower teeth, and on the inside of the upper and outside of the lower front teeth, can trigger neurological consequences relative to timing of the “chewing machine” which can readily lead to “TMJ” problems such as headaches, hypersensitive teeth, and “TMJ” pains. A doctor who has a handle on the intricacies of “TMJ” issues should only perform these types of alterations. Quite simply put, altering the shapes of teeth indiscriminately for cosmetic reasons only will most likely lead to esthetic compromises with potentially painful consequences.
Reshaping gums: too much gum or not enough gum, recession, root exposure, blunting of the pointed gum tissue between teeth… These are all intricately related to the beauty and youthfulness of a smile. Sadly, as we age, these sorts of gum issues can take hold. Think of the gums like a frame encircling a piece of art, which is the tooth. If the frame is cheap and defective looking, it will take away from the beauty of the tooth, no matter how pretty it may appear. An attention to periodontics, that discipline in dentistry that is specifically concerned with the gum, bone and ligaments surrounding the teeth, is paramount for successful esthetic outcomes. An enlightened practitioner will always avoid having the edges of crowns, veneers or fillings buried too deeply beneath the gum line and too close to the bone that lies beneath, and if this is necessary, measures to implement to negate the harmful consequences. Such a physical spatial violation of the artificial prosthesis can readily lead to an invasion of what is known as “biological width”, with a subsequent inflammatory response that can cause ugly recession and attendant bone loss to occur.
Replacing missing teeth: implants, bridges, or dentures are used for this scenario. Implants are typically the best of the 3 choices, dentures are most certainly the worst, while bridges are a decent “fix” but they involve not only cutting down the adjacent teeth to the missing tooth/teeth space, but tend to have a limited life span of approximately 10 years. It depends on the situation. Bridges also require the usage of stiff floss threaders to floss underneath the connected bridge, while free-standing implants do not. With the implant, special attention needs to be given to the gum and bone tissue. Typically, the wavy interdental papilla, or pointy gum between front teeth, tends to melt away after a tooth is extracted. This papilla can almost never be recovered, even with the most intricate of gum surgeries, because the papilla’s presence is highly dependent upon the presence of a thin pointy peak of bone underneath. This peak is typically lost in an extraction of the tooth unless meticulous attention is given to an atraumatic extraction protocol coupled with appropriate bone grafting procedures. Bottom line: if you are faced with the unpleasant necessity of losing an esthetically important tooth and desire an implant, have your surgeon or dentist take great measures to ensure that the bone and gum tissues are not “roughed up”. Anyone can pull a tooth. Few in dental medicine can atraumatically extract a tooth and preserve the delicate surrounding bone and gum tissues. Remember this before having a key esthetic front tooth extracted. Lastly, also remember that one typically has only about a years time to place an implant to restore a missing tooth as over time, what bone and gum tissue does remain, tends to blunt/flatten out and recede, regardless of whether or not bone or gum tissue grafting was performed at the time of the atraumatic extraction or not.
Bonding teeth: composite/white filling materials are typically used for esthetic bonding of front teeth. In the right hands, these various tooth colored materials can imperceptively mimic mother nature, even to a trained dental professional, IF a laundry list of steps are followed and high quality materials are utilized, in a bone-dry isolation field. If your dentist does not routinely use a rubber dam or a vacuum apparatus known as an Isodry® to thoroughly dry the area to receive composite bonding, do not use this dentist. Truth be told, many of these white fillings are not created equal. Some are designed for lifelike appearance, while some are designed for strength. Some are cheaper and stain or break off readily, while others are far more expensive and tend to last longer while looking better, longer, as well. The white composite fillings are typically composed of synthetic resins, a photoinitiator (light sensitive component catalyst which cures when exposed to certain wavelengths of light), and a silica filler. All of these materials shrink slightly when hardened. The key is to ensure that one drops these materials in place and then harden them with light in a certain direction, applying the inevitable ~1% shrinkage back towards the particular wall of the tooth that it is covering (rather than across the entire void of missing tooth structure), taking advantage of the shrinkage consequence. Ignoring this technique can readily lead to “debonds”, or the bonded filling falling off. Many dentists are either unaware of this fact or chose not to spend the time to initiate this practice. Additionally, most dentists use only one type of material for all of their bonding. This is ludicrous. An esthetic dentist should have at his/her disposal a variety of different materials for different applications to truly provide the best service for his/her patients. Additionally, there is most certainly more than science behind effective bonding. The doctor either has an innate artistic ability or doesn’t. Another little pearl in regards to composites. The outer most layer of the bonding composite material has what is known as an oxygen-inhibited layer on it which does not fully cure/harden. The dentist MUST apply a layer of glycerin over the material at the end stages of the bonding to effectively eliminate the oxygen by creating a vacuum with the glycerin, effectively curing the outermost layer of composite material. Ignorance to this practice will always result in the tacky outermost layer (which is readily seen by the patient) staining and pitting in short order. There is little cosmetic or esthetic about a recently bonded front tooth that picks up stain within a few months of placement…!
Veneering teeth: the “Hollywood smile” is typically associated with thin ceramic works of art that are made of beautiful porcelains which very effectively emulate natural enamel, and are bonded in place on front teeth. In most dental practices, the veneering process requires that the dentist reduces small amounts of natural enamel, applies temporaries to the treated teeth, takes a mold of his/her work, and then sends the mold off to a dental laboratory while the patient walks with the temporaries in place for several weeks. Several weeks later, the patient returns to have the dentist try in the porcelain veneers which the laboratory has fabricated, hoping that the laboratory has effectively created an esthetic situation in regards to the cosmetics and that particular patients bite. Sometimes, dental practices purport to providing their patients with “no prep” veneers, whereby the patients teeth are very minimally or even not at all prepared/ground down. Beware the no prep veneers. A requirement of esthetic outcomes is that they imperceptively emulate nature and do not cause problems with the gums. Natural white enamel on human teeth has a certain thickness and translucency that absorbs, bends, and refracts light to various degrees. This requires a thickness of enamel, which is typically between 1-2 millimeters thick. Porcelains need a similar thickness to esthetically emulate nature as well. The “no prep” veneer concept sounds appealing in that less tooth structure is removed, but understand that the refractive properties cannot be accurately emulated without a corresponding porcelain thickness. Additionally, these no prep veneers can lead to chronic gum inflammation resultant of an overcontoured “emergence profile”/excessive thickness, not to mention the fact that they also require time for a laboratory to fabricate these veneers.
In the past decade, digital dental techniques and procedures have evolved which allow an adept and talented dental practitioner to fabricate and create porcelain veneers on site, the same day, via digital CAD/CAM technology. With the CEREC® CAD/CAM chairside technology, amazingly natural and esthetic veneers can be created while the patient waits! No temporaries to fall off, no distorted molds, no laboratory mix ups or delays, no sensitivity issues, less bacterial contamination with subsequent complications, less time away from school, family or work; these are but a few of the advantages of this technology. Though there are very few contraindications for this process, most in dentistry will not even consider this option due to the enormous expense, training, and skill required to provide this service, not to mention the time crunch placed upon the practitioner as the patient waits anesthetized for the end result, THAT day. And quite notably, the array of robotically millable ceramics and manual porcelains that are available for truly customized porcelain veneer chariside fabrication are mind-boggling and as good or superior to what laboratory fabricated porcelains can provide. A final critical and often overlooked point that should be made in regards to porcelain veneer treatment involves the final bonding of the beautiful ceramic works of art. An absolutely dry field needs to be created, involving not only controlling the minuscule crevicular fluids that leach from within the periodontal/gum pocket surrounding the front teeth to be treated, but also the very humid breath of the patient and the potential weakening this contamination may have upon the final bonded result. A rubber dam, fluid control for the periodontal sulcus, and/or an Isodry® dry field vacuum isolation system, plus a high quality composite resin bonding agent must be used to ensure a strong, esthetic, and lasting result. In summary, consideration of minimally invasive porcelain veneers should include:
- How much tooth reduction is necessary for an esthetic end result
- Whether or not temporaries are to be dealt with
- The experience and knowledge of the dental practitioner who is to provide the service
- Whether or not a dental laboratory will be utilized for veneer fabrication
- The final bonding procedure including fluid control and quality bonding agents
- Whether or not the patient wants full input as to the final outcome-with chairside CAD/CAM, the patient watches the virtual design of the final veneer, obliterating the need to communicate with an outside lab source
Step into the future of dentistry…! See Video
Fillings: Replacing metal fillings/crowns with naturally appearing alternatives: Esthetic dentists no longer need to rely on unsightly metals to replace tooth structure lost to decay, but use high density, state-of-the-art plastic (composite resins) and porcelain materials instead. These materials more naturally mimic the look, feel, and function of natural teeth and actually bond directly to the remaining enamel and dentin. This means that new fillings preserve more of the natural tooth so less repair work is necessary immediately and in the future. These modern filling materials are also more natural in appearance; it’s almost impossible to tell that your tooth has a filling. Dentists are using more tooth-like materials (composite resins and porcelains) that are both safe and predictable. The most important feature, for many people, is that they look and react more like natural teeth than do the older metallic materials of old. An amazingly accurate, esthetic, and long-lasting option for larger fillings are known as onlays. These ceramic restorations can be created while the patient waits in about an hour using CAD/CAM technology and robotic milling of solid ceramic blocks. The blocks fit the missing prepared tooth structure to within microns tolerance, and are bonded/fused to the remaining tooth structure, disallowing leakage, and additionally, they are virtually imperceptible to the patient. These ceramic alternatives are the best option for larger filling situations when the patient desires a natural looking, esthetic restoration, which actually helps fuse the tooth together to an almost virgin state. Smaller filling situations are less susceptible to shrinkage issues, and the smaller surface area in need of filling is typically amenable to composite/white filling materials. Gone are the days of mercury-amalgam fillings in the esthetic dental practice!
Crowns are inevitable, sooner or later we all hear the words, “…you need a crown”. Crowns are placed on front or back teeth for many reasons. The purpose of the crown is to hold or “cap” what little is left of the tooth together, allowing the patient to retain a tooth that would not be predictably restorable otherwise.
Traditionally, crowns are made in an off-site dental laboratory after the dentist grinds down much of the top, and all four sides of the tooth to the gum line, effectively leaving a “stump”. A mold is then taken, a temporary restoration is placed on the tooth for several weeks, and the mold is sent to the lab. Some weeks later, the crown is returned to the dental practice at which time the patient is called back in to evaluate the fit, function and cosmetics of the new restoration. Occasionally, the crown needs to be returned to the lab YET AGAIN, and the temporary replaced. Eventually, the crown is finally cemented in place… Talk about frustrating and inefficient for all of those involved!
In contrast, CAD/CAM crowns constructed in the dental office provide patients with a much more efficient, desirable, and timely alternative, THE SAME DAY. Since no temporaries are involved, the CAD crown usually requires less tooth removal. The ALL-CERAMIC restoration is capable of being bonded very strongly in place regardless of the geometry. This is in contrast to the traditional crown, where the retention of the crown is dependent upon radical removal of tooth structure to allow the crown stay on top of the “stump”. A special camera is utilized to obtain a digital impression rather than a physical mold. The experience is much more efficient and comfortable for the patient. Also, the instantaneous feedback that this digital image produces on the computer monitor for the dentist affords your doctor the opportunity to modify the tooth preparation in the event that things are imperfect. If imperfect, your dentist may simply re-image moments later. Since these all-ceramic crowns are bonded directly to the tooth structure within hours, this usually eliminates the need for radical removal of all the walls to the gum line. This allows the retention of more NATURAL tooth structure. Sensitivity issues relating to bacterial leakage and seal are also reduced, as there is no temporary that will leak over time. This also decreases the likelihood of a subsequent root canal following the crown procedure. CAD crowns are made from beautiful porcelains that are not only totally customizable by a knowledgeable operator, but also allow the penetration of x-rays so that your dental professionals can visualize what is underneath the crown over the years. This again, is in contrast to laboratory crowns, which are usually constructed of core materials that do not allow x-ray pass-through, effectively masking subsequent problems that might arise over time… And let us not forget that this single visit convenience also allows this procedure to be accomplished with just one anesthetic injection!
And why don’t more dentists take advantage of this amazing technology for their patients? Due to the enormous economic and educational sacrifices necessary for integration of CAD/CAM technology into a dental practice. In addition, many of the concepts involved in this technology are contrary to concepts of traditional dentistry…
BOTTOM LINE: WHEN THE PREPARATION AND FABRICATION PRINCIPLES OF SINGLE VISIT, ALL-CERAMIC CAD/CAM CROWNS ARE APPLIED PROPERLY, THE ESTHETIC CAD/CAM CROWN WILL TYPICALLY FIT MORE ACCURATELY OVER A LESS INVASIVELY PREPARED TOOTH THAN A TRADITIONALLY PREPARED CROWN. ALSO, THESE CAD/CAM CROWNS TYPICALLY PROVIDE A LESS SENSITIVE AND MORE BEAUTIFUL ALTERNATIVE TO LABORATORY FABRICATED CROWNS.
Nick Yiannios DDS-experienced NWA Cosmetic and CEREC Dentist
- Fellow & Accredited Member, The Academy of CAD/CAM Dentistry
- Member, International Academy of Oral Medicine and Toxicology
- Member, International Association of Mercury Free Dentists
- Accreditation Candidate, the Academy of Cosmetic Dentistry
- 1993 Graduate The University of Texas Health Science Center at San Antonio Dental School