Cosmetic dentistry for the 21st century

Dentistry is ever evolving. This is especially true of the cosmetic dentistry revolution, which has now reached the UK. Patients are now electing to have cosmetic dentistry treatment done rather than just needing it. Programmes such as “Extreme Makeover UK” and “10 Years Younger” have further accentuated this and have opened the general publics’ eyes as to what is now possible.

This article on cosmetic dentistry is written by Dr David Bloom of Senova Dental Studios, Watford.

Our patients’ aspirations are changing and we must be able to meet these if we are to keep them as patients in our practices. By not evolving ourselves, they will find another practice that does offer them what they want.

However, with this change, we cannot only consider our clinical skills in isolation. We need to consider what now constitutes a 21st century practice. This includes getting the team fully on board and suitably trained, understanding the power of marketing and, most importantly, making our patients the centre of attention whenever they are in the practice, so that their expectations are met and, ideally, exceeded at every visit.

Cosmetic dentistry is not purely about making teeth look pretty. Everything has to start from a basis of health. All such information can be gleaned from a comprehensive examination. The patient is involved in this examination, as they must take responsibility for what is happening in their mouth, this is called co-diagnosis. Following a full mouth series of radiographs (for all new patients or patients being re-enrolled) and digital photographs, a diagnosis can be made and a treatment plan formulated which meets the expectations of all concerned.

As a starting point, any decay or holes in teeth should be dealt with, the gum condition improved with the importance of effective home care, and on-going maintenance with the hygienist stressed. Referrals can also be made to appropriate specialists if applicable.

What is cosmetic dentistry?

A simple answer to this is whatever patients want it to be. We will now consider the various cosmetic options and techniques available.

Tooth whitening

Tooth whitening can be done in-house at the practice with a power light, or at home by the patient with trays, or using a combination of both. Studies show that home whitening alone is still the most effective way to lighten teeth although this does depend on patient compliance. With the advent of power whitening, this process can be kick started to give the patient an instant wow factor. Ideally they should still home-whiten for up to 2 weeks to stabilise the end result and top up as required.

Whitening of a dark, previously root-filled tooth is best accomplished by home whitening using an inside/outside technique whereby the access cavity is left open but sealed so that the active agent can be placed freshly each time by the patient.

Direct Posterior Composites

This is probably the most common cosmetic procedure undertaken, often in response to failing amalgam restorations. Their main advantage is that they can be bonded to the tooth unlike an amalgam silver filling, which fills a hole but adds no strength and will ultimately leak, corrode and allow secondary decay to develop. However, their use should be limited to smaller cavities as they are not as strong or hard wearing for large cavities. In these cases, other options should be considered.

Anterior Composite Bonding On Front Teeth

White fillings on front teeth can be used to close spaces and improve the shape and form of teeth. However, it requires a lot of skill to make these look life like and takes much time to complete. Thus, the best reason to do this is to avoid preparing teeth, i.e. removing tooth tissue.

It requires a lot of skill to make these look life like and takes much time to complete. Thus, the best reason to do this is to avoid preparing teeth, i.e. removing tooth tissue. They will require re-polishing every so often as their shine can dull.

Indirect Tooth Coloured Inlays

When direct posterior composites are inappropriate due to their size or operator preference, indirect tooth coloured inlays can be fabricated as they are custom made in the laboratory. There needs to be a period of temporisation whilst this occurs.

These forms of inlay can be made from porcelain or reinforced composite materials. Not only do they look beautiful, but being bonded to the tooth, they can reinforce and strengthen the remaining tooth structure thus minimising the removal of any remaining sound enamel as would be required for a conventional crown preparation.

Porcelain Laminate Veneers

These are ultra thin ‘false fingernails’ of porcelain that are permanently bonded to teeth. Indications for their use include making changes to the shape of the teeth and their arrangement within the arch rather than a purely colour reason (when tooth whitening may be a better option). They can even be used for “instant orthodontics” if the patient refuses conventional orthodontics but still wants to make changes to the arrangement of their teeth.

Dramatic life-altering changes can be achieved with minimal tooth preparation (often as little as 0.3mm compared to 1.5mm for a conventional crown) with the appropriate planning.

All Porcelain Crowns and bridges

Historically, crowns could be made as porcelain jacket crowns. These were all porcelain but their strength and fit could not always be guaranteed. Then came the advent of porcelain fused to metal crowns. Whilst very strong, these require a skilled ceramist to get a lifelike result as the metal sub structure needs masking out with opaque porcelain before the base porcelain and the various effects are built in. Another possible problem is if a black line or halo around the margin is visible. Recently, a shift back to all porcelain crowns has happened with the advent of stronger core materials. Initially, this was with Procera cores and more recently with zirconium cores both of which are milled by machines, the model of the tooth preparation having been laser scanned. Porcelain is then built upon these cores in a conventional fashion. Zirconium is incredibly strong and can even now be used for extensive bridge spans.


Titanium implants should now be considered the gold standard for tooth replacement as they enable missing teeth to be replaced without having to prepare the adjacent teeth for bridges. This is especially so if these teeth are un-restored.

The implant can be placed and left to integrate with the bone or immediately loaded by way of a provisional restoration. New surface treatments of the titanium enhance this integration process greatly.

They can be used to support single crowns, bridges, dentures and even full arch bridgework. Most recently, “All-on-4” implant concepts with zygoma implants allow full upper arch reconstruction in cases that would otherwise have required extensive bone grafting.

Soft tissue management is critical to achieve a natural looking, healthy gum margin whereby the implant tooth looks as though it is emerging from the gum like a real tooth.

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Cosmetic dentistry for the 21st century