Cosmetic Dentistry Turns Right
To a greater extent than ever before, a conservative approach to esthetic procedures fills the bill, especially during tough economic times.
Reality makeover show “reveals” notwithstanding, quick-fix cosmetic dentistry seems to have gone the way of the windblown face facelift and cookie-cutter nose job. That such dramatic dental overhauls have fallen out of favor is due to a combination of factors—including the impact of the global recession on patients’ budgets, which has prompted a trend toward subtler, more “staged” interventions. But a new emphasis on so-called conservative cosmetic dentistry also reflects a movement toward the use of new materials and approaches that emphasize long-term preservation of the dentition and more natural-looking improvements in tooth-color and smile design.
Conservative Cosmetic Dentistry Defined
What is conservative cosmetic dentistry? To a dentist, all interviewed made it clear, it’s all about preserving tooth structure—especially enamel—and that structure-sparing approaches should be attempted before more aggressive tactics whenever possible.
In his 2009 American Academy of Cosmetic Dentistry (AACD) Presidential Inaugural Speech, Michael Sesemann, DDS, used the term responsible esthetics to describe the concept of conservative cosmetic dentistry at its best. “Esthetic dentistry should complement the overall general health of the patient—and, above all, do no harm,” he says. Sesemann, who maintains a private general dentistry practice in Omaha, Nebraska, continues, “For me, the phrase conservative cosmetic dentistry refers to appearance-related dentistry that enhances a person’s anterior teeth and/or smile presentation using dentistry that does not exact a significant, irreversible biological deficit.”
John Sullivan, DDS, a private practitioner from Tulare, California, is the current president of the AACD. He describes it as: “tooth-colored restorations provided in a manner that minimizes the destruction of healthy tooth structure, removing either decay or disease or broken tooth structure in as conservative a manner as possible to allow us to just restore what needs to be restored.”
Dennis J. Wells, DDS; Gregg Helvey, DDS; and K. William (Buddy) Mopper, DDS, all maintain dental practices that are primarily cosmetic. All three make it clear that lasting cosmetic procedures depend on the quality and amount of the patient’s underlying tooth structure. Wells, a Nashville, Tennessee, private practitioner who invented DURAthin no-drill veneers, says, “It is all about preserving the God-given enamel. We want to be really certain that before we have to subtract any structure that we have a really good reason to be doing it.”
Mopper, a private practitioner in Glenview, Illinois, is the co-founder and chairman of Cosmedent, Inc., and one of the early pioneers in the use of composite materials. His criterion for conservative cosmetic dentistry is “minimally invasive dentistry, which, at its best, provides esthetics, biologic compatibility, and long-term maintenance of the hard structures in the mouth.” Helvey, whose expertise is in ceramics, is a laboratory technician as well as a private practitioner in Middleburg, Virginia. He is also an associate professor at Virginia Commonwealth University School of Dentistry, where he teaches mainly techniques focused on ceramic restorations. He says simply, “The most conservative cosmetic approaches are those that stay within the enamel, period.”
Among those who factored in the patient’s finances as well as dentition were Harald Heymann, DDS, MEd; and Elliot Abt, DDS, MS, MSc. Abt, an adjunct associate professor in oral medicine at the University of Illinois, as well as attending staff at Illinois Masonic Medical Center, defines conservative dentistry in general as the least invasive, least costly method of satisfying a patient’s needs, emphasizing that this definition holds true for patients who express a desire to change the appearance of their teeth. Heymann, a professor in the Department of Operative Dentistry in the School of Dentistry at the University of North Carolina, believes it is prudent to consider costs too, but not at the expense of oral health. As a proponent of orthodontics to preserve dentition, he feels that dentists should accommodate patients’ desires to improve their appearance with more conservative and less expensive options. This, he says, means attempting to maintain as much healthy tooth structure as possible while also attaining the desired result, “knowing we can pursue other options later if necessary.”
Finally, weighing in on the topic was Van B. Haywood, DMD, best known for his expertise in what is generally considered the most conservative esthetic procedure of all—tooth whitening. The Georgia Health Sciences University professor who, along with Heymann, introduced what became known as the vital nightguard bleaching method offered this definition: “Using the least [amount of] material and the greatest skill to preserve the maximum tooth structure for the best long-term esthetic and functional outcome, based on risk/benefit and cost/benefit considerations.”
Sometimes It’s a Matter of Treatment Philosophy
In an article published in the Journal of Esthetic and Restorative Dentistry, Didier Dietschi, DMD, PhD, ranked procedures in order of most to least conservative based on their impact on tooth structure.1 First among those that could be considered esthetic are chemical treatments—ie, bleaching, then orthodontics, followed by freehand bonding, veneers, then full crowns. He notes that treatment philosophies are frequently in opposition, such as orthodontics versus prosthetic restorations.
Heymann is among those who eschew “instant orthodontics”—where healthy teeth are sacrificed for the quick fix of veneers or crowns to correct malaligned or malpositioned teeth—favoring the real thing. “Unfortunately, the most conservative option may not be the most expeditious option,” he says, warning that many “dental cripples” are created as a result of the efforts of well-intentioned dentists to provide quick-fix dentistry with contours that may not prove to be optimal for gingival and periodontal health. The long-term implications of these treatments, he insists, do not compare with orthodontics, which he says maintains the structural integrity of the teeth.
Helvey agrees. “We have to keep in mind that nothing lasts forever. Restorations done today will have to be redone at some point, so it’s always nice to have a lot of tooth to begin with.”
Like Heymann, Helvey warns about cutting corners. He cites no-prep veneers—where the dentist just takes an impression and bonds the veneers to the teeth without removing any tooth structure at all—as an example of a conservative approach that can come back to haunt a clinician. Noting that such an approach may be indicated for teeth that are undersized, lingually versed, or when a minimal shade change is required—he points out numerous potential problems, including the need to remove aprismatic enamel to avoid a decrease in the enamel bond strength. A whole other set of problems, he says, is associated with attempts to feather the edges of a ceramic restoration to avoid resulting brittleness. “There must be a certain thickness of ceramic at the margin for strength, but this creates a ledge, a ‘speed bump,’ where bacteria can accumulate, especially interproximally.” The ledges, he says, can be reduced once the veneer is bonded in place, but thinning can cause chipping. He adds to this list of concerns over-contouring in the interproximal embrasures when treating normal-sized teeth. One alternative that he recommends and teaches involves using a minimal preparation to make the ceramic blend into the contour of the tooth.
The Beauty of the Conservative Approach
The good news/bad news take on recessionary times is that the mouthful of aggressively prepared veneers or crowns that were common when the stock market was booming may not have been the best investment. Sullivan observes that financial constraints have not lessened the demand for cosmetic dentistry, “it just delayed it until [patients’] finances improve.” This delay can be a boon for their dentition, because as Sullivan also points out, due to improvements in the strength and esthetics of new materials, many of the preparations and designs being done today are being done in an entirely different manner. He explains that with an understanding of patients’ final esthetic goals and treatment planning, they can often be treated incrementally, “so we can still reach their long-term goals, but find ways that they can do it a step at a time.” This could start with bleaching, followed by some minor composite work in the anterior, with the idea that sometime in the future, they could proceed to porcelain restorations. “The less tooth structure we take away, the more likely it is that we can repair things in the future still using the conservative approach without having to go to a full-coverage porcelain crown," he says.
Educating Patients About Cosmetic Treatment Options
Discussing the topic of cosmetic options can be tricky. How the topic is broached may depend on the dentist’s reputation and/or practice balance. For dentists considered to be strictly cosmetic, patients’ concern about the appearance of their teeth should be automatically presumed. But even those with primarily cosmetic practices often hesitate to take the lead, instead using a questionnaire or having a staff member pop the question during appointment set-up.
“Never assume the patient doesn’t like their teeth,” says Helvey. “I always ask if they have any concerns about the appearance of their teeth. If they say no, that ends the discussion. If they say yes, I have permission to continue the conversation.”
“We’ve had to learn to tread lightly when we ask patients questions about how they feel about their teeth,” says Sullivan, whose questionnaire poses probing questions to learn about patients’ concerns, which they can then discuss during the consultation. “Even when they start by talking only about color, the conversation often progresses to other issues,” he says, adding that he may sometimes ask, “where do you want your smile to be 20 years from now?”
Heymann considers patient education/discussion of procedures to be an important part of informed consent and takes care to handle this himself. “Ultimately, when it comes to the specific treatment warranted for a patient, the dentist should be the one to discuss those options,” he says, contending that the dentist is the one in the best position to give educated answers to specific questions and allay any patient concerns. He offers his patients a range of treatment options, which he says is important not only from a standpoint of conservation of tooth structure, but also in consideration of the potential economic limitations of each patient. He also makes sure patients are fully informed of the pros and cons of each procedure. “It’s an important part of informed consent to discuss potential problems that may arise when pursuing a specific treatment option,” he says. “Patients must know the possibilities up front.”
For example, he lets patients whose veneers warrant replacement know that they can be “a bit of a Pandora’s box,” because the condition of underlying tooth structure cannot be ascertained until the old veneers are removed. “If inadequate enamel remains, we may have no choice but to pursue another option, such as all-ceramic crowns,” he explains.
Mopper takes a visual approach, borrowing the phrase “show and tell” from his pediatric dentist days. “We use the intraoral camera and blow it up so that the patient can clearly see the destruction,” he says. Once they’ve seen what needs to be done, he uses a self-adhesive material on the tooth surface to quickly create a mock-up to demonstrate the corrections he thinks will benefit their smile. “When they see that, they get the idea—understanding, for example, that the one tooth won’t fix what they want, but multiple teeth can,” he says.
Where Evidence-Based Dentistry Fits In
Abt directs the journal club for dental residents at Illinois Masonic Medical Center and maintains a private practice in general dentistry. While his practice is a general “meat and potatoes” type of practice, his interest is in what he calls “the scientific basis of our profession,” which motivated him to return to graduate school for a master’s degree in evidence-based healthcare, and serves on the Critical Review Panel of the American Dental Association’s Center for Evidence-based Dentistry, which is steadily adding cosmetic-related literature to its online library, which can be accessed at http://ebd.ada.org.
He believes the difficulty of applying evidence-based principles to dental treatments lies in the difference between medical and surgical treatments. “There’s a lot more science when the interventions are medical rather than surgical, mainly because it’s easier to conduct randomized trials that compare drugs than to compare surgical procedures.” This, he says, is a problem in dentistry, where nearly all interventions are surgical in nature. “We treat disease by physically removing it, so we don’t have an awful lot of randomized trials, especially in the area of cosmetic dentistry.”
Given the scarcity of such trials—especially in an economic environment in which industry support for them has fallen off—those interviewed urged their colleagues to offer their patients proven procedures based on clinical excellence.
“All of us who practice dentistry aspire to be evidence-based,” says Wells, but points out that the proliferation of dental procedures and innovations in recent years has made it difficult to amass the evidence needed to verify their effectiveness and best practices for their use. “Thankfully,” he says, “the whole cosmetic adhesion revolution has sort of caught up—the evidence is there, the studies are there, and the long-term statistics are there,” which, he says, supports conservative approaches. He hails what he sees as a return to more proven, enamel-preserving procedures in keeping with the spirit of EBD. “Now, we’re back to what we’ve been doing for over 30 years—etching and bonding ceramic to enamel, which we have plenty of studies to show that is safe ground. EBD today is synonymous with good conservative esthetic dentistry that is adhesion-based.”
Heymann urges dentists to be discriminating dental consumers. “Don’t buy new products simply based on the recommendations of a speaker who has no better crystal ball than you do, with regards to what the final outcome of that device, material, or technique will be,” he says. While he says controlled clinical trials represent the gold standard in the validation of success for most materials, “the most critical element in how well something works ultimately is the tincture of time. Once proven, good materials plus clinical excellence with regard to technique translates into success—most of the time.”
Sesemann agrees that evidence-based dentistry should play an important role in shaping the direction of appearance-related dentistry. “When used in conjunction with other decision-making aspects of clinical practice such as objective and astute clinical judgment, responsible practitioners and researchers will lead the way in determining the best course of cosmetic dental options,” he says.
Sullivan insists that cosmetic dentistry and evidence-based dentistry go hand in hand mainly due to patient demand for tooth-colored restorations for fractured or diseased teeth. Representing the view of other dentists interviewed, he says that because all dentistry should be esthetic, all dentists should be trained in esthetic procedures. “Whether you want to admit it or not, if you do any kind of composite work in the anterior, you’re a cosmetic dentist. After all, what’s the alternative? Uncosmetic dentistry?”
1. Dietschi D. Masters of esthetic dentistry: Bright and white: Is it always right? J Esthetic Restorative Dentistry. 2005;17(3): 183-190.