Cosmetic Dentistry

Cosmetic Dentistry

Cosmetic dentistry is a difficult term to provide a definition for. Any treatment that can be argued to improve the appearance of a tooth can be defined as cosmetic.

Aesthetics and beauty are subjective and not absolute and measurable. Personal opinion and fashion affect the assessment, therefore it is essential that you and your dentist understand what you want to achieve and what can be achieved within the time and resources available.

For example, a tooth coloured filling might be considered as cosmetic dentistry. At the upper end of cosmetic dentistry there are techniques of layering filling materials in twenty different shades in one restoration that can make a filling invisible to detect in the tooth. It can take several hours to provide a single filling. However the majority of “cosmetic” tooth coloured fillings are a few carefully chosen layers that blend the filling into the tooth while controlling the cost and time required.

The key to good cosmetic dentistry is communication and understanding because appearance and beauty are often personal opinions. Basic rules can be applied but the adapting of rules to the individual provides the best results.

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simon-cowell-boyOne of the photos to the left does not confirm to the “rules” of an attractive smile. There is a missing tooth, a gap, short teeth, uneven biting edges and a protruding fang. However it suits the 6 year old owner and many would see it as an attractive image. The other photo shows uniform bright white teeth that often divides opinion because it tends to look ‘unnatural’. Aesthetic dentistry in the UK tends to request a final result that appears uniform and healthy but retains some natural elements and small colour variations, not too obviously ‘made over’.

The point being made is that beautiful results need a unique balance of features that often do not conform to all the “rules”. The best results deliver what you want and not what someone else imposes. The results should be personal and unique to the individual . The time taken to discover the balance required for an individual is reflected in the higher fees associated with cosmetic dentistry.

Smile Makeovers

All smile makeovers begin with a discussion of expectations.what you are expecting to achieve. The following extensive planning is to confirm what is actually possible and the best way to achieve it. Surounding teeth are usually X Rayed to check for adequate support or hidden problems that require resolution before treatment begins. Photographs are useful as a baseline starting point and can allow simulation to help discussions about the final goals. Plaster casts with wax mock ups can also confirm mutual understanding of the final goal, confirm what is realistic in long term function against the biting force and direction of the individual.

Almost all smile makeover treatments start with tooth whitening. Please see the separate section the different tooth whitening systems.

Missing teeth

Missing teeth can be replaced by dental implants, bridges or dentures. The best option in an individual case will be determined by several options:-

  • The position and quality of the biting teeth in the opposing jaw so that the functional chewing forces do not damage the final restoration.
  • The quality of the teeth adjacent to the space. If the adjacent teeth are perfect there would be a good reason to keep treatment on them to a minimum which would tend towards implants or dentures. However teeth that have a guarded prognosis or require significant treatment anyway may suggest a bridge option.
  • The volume and quality of the supporting bone and gum. When bone volume has shrunk significantly, dental implants may require additional stages to replace the volume. The additional time and associated cost needs to be considered.
  • General health if treatment times are prolonged.
  • Available budget, although in some cases a lower cost option such as an implant supported denture compared to an implant supported fixed bridge might provide better function than the bridge.

In the four images below, there is a missing central incisor space with a shifted center line and reduced residual space to fit the replacement tooth. Three main restorative options were possible but required a very different budget and timescale. The computer simulated images helped the patient to decide on what would be the best outcome for them.

  1. Original image
  2. Existing space filled with an adhesive bridge
  3. Full arch orthodontics, requiring premolar extraction to correct center line shift and open residual space. Dental implant supporting and an all ceramic crown in the space created.
  4. Short / medium course orthodontics to close residual space and Veneers on the 3 front teeth to harmonise the shape of the three incisor teeth (accept additional center line shift

In this case the costs could range from less than £1000 to around £5000 and the treatment time taken could range from a few weeks to supply a bridge only (option 2) to circa two years for full arch orthodontics and implant treatment (option 3) .

Tooth position

Almost all people have some slight irregularity in their tooth position. The solution will depend on how much irregularity and how visible it is.
In general terms orthodontics moves the tooth roots and requires additional treatment time. After orthodontic movement the teeth will tend to want to return to their original position. Adults will often need to maintain the new tooth position for life using a night time retainer or a fixed wire anchored to the back of the front teeth. The advantage of orthodontics it that it reduces the need for healthy teeth to have veneers or crowns.
Recent advances in orthodontics can mean shorter treatment times and invisible appliances. St Johns Dental Practice are approved by Invisalign, Six Month Smile, Simply5 and Inman Aligners as well as conventional fixed braces.

See section on Orthodontics

The shape of teeth can be changed by removing excess enamel in procedures such as “ameloplasty” which removes protruding areas of tooth or “IPR” which reduces the width of teeth to assist orthodontic alignment. The amount of change is limited to the thickness of the existing enamel.

Tooth reduction is often combined with “cosmetic bonding”. For example a rotated tooth will have a protruding area and a deficient area, the protrusion is reduced and deficit is built up in tooth coloured filling or overlaid with a veneer, the end result is the new tooth face aligned in harmony with its neighbours. It is worth noting that the biting edge of the front tooth can feel “thicker” after such a procedure.

Crowns and veneers can appear to change a tooth position within a couple of weeks. The procedures are discussed in detail below.

Crowns & Veneers

A traditional crown preparation removes the outer surface of the tooth. The crown slides over the residual tooth rather like a thimble. In the image shown the metallic tip is a cast post and core that was fitted into the tooth root. Generally there is extensive tooth removal that we would avoid if possible, however in this case a road traffic accident had broken the front tooth and killed the tooth nerve. The tooth was treated endontically (nerve removed and sealed) before the post was inserted to retain an all ceramic crown.

A classic veneer preparation contrasts to the full wrap around of the traditional crown because it is a thin later that is bonded to the front surface of a tooth. Some veneers systems can be so thin that they do not require any drilling at all and the increase in final thickness is hardly noticeable. At the other end of the spectrum some veneers wrap around all of the circumference of the tooth and are considered as crowns. Veneers are often likened to contact lenses or false fingernails. Veneers systems like Lumineers , Thineers, and Da Vinci are brands that often come with additional warranties. Veneers can be made from resin, traditional porcelain, pressed ceramics and cast ceramics. StJohns Dental practice is an accredited Lumineer provider that has experience of many veneer materials.

White, bright and even style veneers across the front eight teeth
Natural veneers across the front four teeth

How to Compare Cosmetic Dentistry

Costs in dentistry can be complicated, but most people would like to be able know that when they are paying for a premium service that they are getting a premium product.

The harder thing to quantify is the quality of the skill and experience of the dentist. An ideal dentist is technically skilled, has good artistic judgment and is a good communicator.

10 ways to find a good cosmetic dentist:-

  1. They have photographs of their own work
  2. A recommendation from someone you know, or testimonials available from existing patients
  3. They take time to discover what your opinion is
  4. After talking to them you understand your options, the benefits and drawbacks of the different treatments, and how long the results would last.
  5. Does the support team provide good service
  6. Finance is openly discussed and options provided that can maximize a budget
  7. Warranty periods on treatments are available
  8. Are detailed treatment plans written down or just a computer print out
  9. Are they members of organisations that promote cosmetic dentistry
  10. They specify the materials used and the technicians subcontracted for Laboratory work such as veneers, crowns, bridges and onlays / inlays.

Materials & Specifications

After many drafts of this section we realised that it is not possible to provide a set of easy to apply rules. Some materials work well for some people in particular circumstances. Some lower cost materials give better results when used in the right way at the right time.

Therefore the following four statements are often true but are also INCORRECT or IRRELEVANT for significant number of cases.

1. Porcelain / ceramic is better than composite

2. Cast ceramics , pressed ceramic and milled (CADCAM) ceramic is better than feldspathic porcelain

3. All ceramic restorations are better than metal ceramic restorations

4. Laboratory work is better than “freehand” restorations built up directly by the dentist.

The specifications of the materials used is another way to compare cosmetic dentists. The internet can be a bewildering source of information on materials because product manufacturers use confusing and misleading terms “next generation, nano technology, superior handling” do not necessarily result in a “better” or “longer lasting” result. For example tooth coloured filling materials of 30 years ago evolved as 1st Generation until 5th Generation when no one could agree on what an improvement was. Material development means that some tooth coloured filling materials have improved mainly in strength and reduced wear where others have mainly improved the visual appearance. The result is that some filling are more suitable for chewing forces in back teeth, others are better in front teeth, middle ground is occupied by products that are satisfactory in both situations. It may be that a dentist who has a depth of experience with a controlled range of products achieves a better result than when trying to use a large range of constantly changing products.

Composite veneers are lower cost than porcelain veneers. When the veneer is built up on the tooth directly, the cost can vary hugely, the time taken might provide some guide as to the value. Compared to Porcelain, Composite veneers are considered slightly higher risk for staining with coffee, tobacco and red wines, however they are slightly less likely to chip or fracture and offer some scope for repair if they do chip.

Porcelain veneers, and all ceramic crowns can be made from feldspathic (traditional fired porcelain) cast ceramic, pressed ceramic or CADCAM milled ceramics. Comparison of statistical material test data may not provide much help for your individual situation. For example feldspathic porcelain is weaker than the other ceramics but because they are built in layers they can provide very lifelike aesthetics. In a case where there is no opposing biting tooth,they might be a good option.

Metal Ceramic crowns finish on a metal only edge which is very thin. However in some situations the metal margin might not be visible and by reducing the tooth removal required the residual tooth will be more likely to survive. Therefore the long term aesthetics are better.