For as long as I have been a dentist, I have been taking classes and teaching other dentists the value of cosmetic dentistry. In 1988, my job was to solve our patients’ cosmetic problems in our hospital general practice. Some of these patients had teeth broken after intubation for general surgery. My job was not only to give them new teeth but to make them look good. During those years, I learned the importance of working with various dental specialists and knowing what was needed to get the final results. The doctors doing the treatment were recent dental graduates in their first years of practice.
Since the doctors were graduates of dental schools from all around the United States, they sometimes presented various ways of solving the same problem. I learned just as much as I taught in that program.
Tooth-colored fillings are what we call composites. These are taking over from acrylics as the long-term filling materials because they can match your teeth’ color and last longer. Composites used in dentistry are basically hydrocarbons with quartz and glass particle fillers.
Composites are widely used in aerospace and other industries to provide lighter, strong materials formed into various shapes. Porcelain is the other long-term material that we use for crowns and bridges, mostly tooth-colored. In the past, porcelain fused to metal or all-metal crowns was the technology for crowning teeth. This technology has served us well and is still the treatment of choice when you have decay or fillings with margins below the gums. Porcelain fused to metal is also the technology used to build porcelain bathtubs.
Other Cosmetic Dentistry Technologies
With the advent of Cad Cam technology and zirconium use as a substructure to porcelain, we now have many options to make teeth look beautiful. 3M Company uses technology to color the zirconium substructure the same color as the root structure, and then lab technicians apply porcelain to it, creating beautiful teeth. The resulting crown maintains the tooth color over a long time and is very aesthetic. It costs a little more, but it is well worth the investment.
Cad Cam technology uses a camera to picture the prepared tooth and fabricate the tooth’s missing part, using computer correlation technology to mill it. In-office Cad Cam machines are used to restore posterior (back) teeth.
Most cosmetic anterior aesthetic crowns or veneers are still finished by the artistic skills of trained lab technicians. Some technicians use the Cad Cam technology to fabricate the substructure and then apply porcelain for the final result.
A patient came to my office with an interesting request.
“Hey, Doc, I want a smile just like yours,” she said.
“Do you mean the shade of the teeth or the shape?” I asked.
“I just like the look of your smile.”
I completed my examination and found she had no upper teeth and only the lower front teeth. The remaining bone in the upper was enough to support an upper denture. However, on the lower, I would have to place some crowns and a lower appliance.
“Do you have any pictures of you in your late teens or early twenties? One where you have a full smile,” I asked.
“Yes! And yes, I would like to smile like that again.”
I collected all the information and proceeded to make an upper smile that showed teeth when she smiled. I shaped the contour on the appliance like real gums and made contours of her teeth like her own teeth from the pictures. No metal clips showed on her lower appliance, and we later took pictures together that showed that indeed she could smile as well as I did.
How Cosmetic Dentistry Works
Cosmetic dentistry involves smile creation, and the materials are not always porcelain veneers. All restorations can be used as cosmetic enhancements. I encourage bone grafts after extractions because it creates the contours that we need to enhance the cosmetic result. All dentistry that is considered functional can also be cosmetic.
Is Cosmetic Dentistry Art or Science
Dentists have long known that different styles of teeth fit people with other facial structures. We have used the Golden Proportion concepts to help us with rebuilding an aesthetic and functioning smile. Dentists who are very serious about cosmetic dentistry benefit from joining and participating in the various programs set up by the American Academy of Cosmetic Dentistry. The more an office combines the science of materials and techniques with the artistic talents of sculpting a pleasant smile, the closer they get to great results and a satisfied patient.
As a dental resident at Long Island Jewish Medical Center, I clearly remember a young lab technician who worked on developing thin porcelain wafers to cover unattractive teeth, telling us how they could solve cosmetic problems. They were called porcelain veneers. I became one of the early adopters of this conservative treatment mode, with my longest case that I know of still in place since 1989. Later on, I studied with Larry Rosenthal, who gave hands-on courses for other dentists. His techniques on straightening rotated teeth were beneficial then and are still helpful today. Good fundamentals are always useful. In North Carolina, Ross Nash and Rob Lowe have passed on valuable information to dentists, from photography to lasers used to enhance your results.
Cosmetic dentistry may involve working with various dental specialists to get a cosmetic and functioning occlusion. New types of braces, invisible and internal, can provide answers to adults who may be self-conscious during treatment. The most important part of your cosmetic treatment is that one dentist is in charge of coordinating all the treatment that leads to the patient’s result.
Sometimes part or parts of your treatment have to be done by another dental specialist, and your cosmetic dentist will do the final restorations. A periodontist may be needed to treat your gum disease or sculpt your gums so that the amount of gum shown is not unattractive when you smile. An oral surgeon may be required if you have lost a considerable amount of bone, need your jawbone repositioned, or impacted teeth extracted. A prosthodontist may be necessary if you have had extensive tissue loss from cancer treatment or an accident requiring a unique prosthesis. An oral and maxillofacial radiologist may be needed if a 3-D model shows an unidentified artifact. An endodontist may be necessary if you require a root canal treatment or retreatment of a previous root canal to make your cosmetic restoration feasible.
Most of the cases treated in our office require combination treatments, with or without sedation. Sometimes we have to do an extraction, place an implant, do a bone graft, root canal a tooth, place a fiber post, and then choose the right type of porcelain for each tooth to get the smile to look uniform. Many patients ask for veneers or lumineers; however, they may not be a candidate for those options because several teeth require several other types of treatment.
The more patients know about what they want, the more we can advise them if it is achievable or unrealistic.
Sometimes the achievable requires a little more perseverance on the part of the patient and doctor. Cosmetic Dentistry is a combination of science and art.