Cosmetic Dentistry

Dental procedure
Overview
Chipped tooth

Tooth chipped in a sports injury.

Cosmetic restorations (which may include crowns, fillings, inlays, onlays, bridges and veneers) are done to improve the appearance of the teeth. There may or may not be other reasons for doing them, such as tooth decay, chips (Figures 1a and 1b) or cracks. Cosmetic restoration of a single tooth is sometimes achievable with modern dental materials (even in highly visible areas of the smile). It may be possible to re-create the shade, transparency and optical characteristics of uniform natural tooth enamel, although it can be challenging.

The dentist may recommend crowns, veneers, or other types of restorations on neighboring teeth to better match the restoration placed on a damaged or discolored tooth. It may be true that the overall appearance of a patient can be enhanced with multiple restorations (e.g. intrinsically stained teeth that can’t be whitened can often be beautified with veneers).

Repaired tooth

Tooth repaired with composite resin (bonding).

However, if only one tooth is a problem, and cost or invasiveness are of concern, matching the involved tooth to the others, to the satisfaction of the patient is often achievable. Doing so requires skill, artistry, and close collaboration between the dentist and others involved in the procedure (e.g. a laboratory technician). If lab procedures are needed, precise blending of the single restoration usually involves a custom shade match, in which the patient visits the laboratory technician who will be making the restoration. This may not always be feasible. When it is, the technician will evaluate the patient’s teeth for basic shade, intensity of shade (chroma), shape, light/dark balance (value), and any subtle characteristics that will need to be re-created in the restoration to make it blend imperceptibly.

The restoration will be evaluated in different lighting conditions, because teeth can look noticeably different under different light sources. Usually, these will include incandescent sources (which have a yellow cast); fluorescent light (which looks blue); and full spectrum light (e.g. the sun). Full spectrum lighting is available for dental office light fixtures, and is often used for shade matching as it is the most natural light source.

If a visit to the lab isn’t an option, the dentist may be able to communicate with the lab using both black/white photographs (to establish value); and color images to show the shade, optical properties, etc . It is important that the color profiles of the camera, the computer, and the printer (if used) be synchronized to produce consistent color characteristics from the patient’s mouth, to the dentist’s imaging equipment, to the lab. To learn more about synchronizing color monitors (so the lab and dentist are seeing the same colors), search on “synchronize color monitors” and “display calibration.” It is essential that the monitor records the true color and lighting properties observed in the patient’s mouth to achieve a perfect match in the restoration.

The process

Cosmetic dentistry is a general term for a variety of procedures. The process for each procedure is different.

Commonly prescribed dental procedures that may have a cosmetic focus include: crowns, fixed bridgework, dental implant restorations; fillings; onlays, orthodontic procedures; certain periodontal surgery procedures; removable dentures that involve visible teeth; tooth whitening; and veneers.

Your dentist can discuss with you the procedures that would be appropriate options in your case.

Advantages and benefits of cosmetic dentistry

If an acceptable cosmetic result can be achieved by restoring only one tooth, the patient is spared the expense, treatment time, potential discomfort, potential complications, and maintenance issues associated with restoring more than one tooth. While the dentist’s goal is generally to treat a condition in the least invasive way possible, it may not always be practical to restore a single tooth and achieve the cosmetic expectations of the patient.

Modern dental materials and techniques are true bioengineering marvels, and generally allow teeth to be imperceptibly restored to the esthetic expectations of the patient. They are durable, color stable, and match the optical and shade properties of natural teeth with incredible precision.

Ultra-conservative tooth preparation techniques have been developed which do not always require removal of sensitive tooth structure. In appropriately selected cases, these can completely eliminate the need for local anesthetic, and the risks and discomfort associated with it.

Complete “smile makeovers”—involving crowns, onlays, and/or veneers on all or most of the visible teeth—have become commonplace in dentistry, and the results can be stunning. Smile makeovers and dental rehabilitation are usually indicated when multiple teeth are damaged, decayed or cosmetically unacceptable to the patient in ways that cannot be corrected less invasively. If an acceptable cosmetic result can be achieved less invasively, the need to reshape multiple teeth and place multiple restorations (that may need to be replaced multiple times over the life of the patient) can be avoided.

Bleaching, bonding of tooth-colored composite resin filling material, and minor adjustments to the shape of a patient’s teeth can often be achieved very economically, with outstanding cosmetic results that require little (if any) maintenance.

Disadvantages and risks of cosmetic dentistry

Custom shade-matching may be required in order to achieve the best cosmetic result for single cosmetic restorations. This requires the patient to visit the laboratory technician who is making the crown, which may not always be feasible. Multiple visits to the lab may be required.

Teeth that have irregular features, such as discolorations, dark shading, mottling or speckling can be very challenging to match, but a good ceramist can often do it. It is important that the patient decide whether masking such irregularities in the teeth is a treatment goal. If so, more than one tooth may require treatment. Restoring multiple teeth adds to the cost, complexity, and potential complications of treatment.

A beautiful, natural appearance is generally among the treatment goals whenever a visible tooth is restored (metals are still commonly used in non-visible areas). However, restoring teeth purely to improve the cosmetic outcome should be done as conservatively as possible in consideration of the patient’s expectations. Cutting away any sensitive tooth structure can cause the affected tooth to be sensitive after it is restored, and can lead to inflammation of the tooth pulp, which is not always reversible.

In such cases, additional treatment such as root canal therapy may be needed to alleviate the symptoms. These unfortunate occurrences are reported in the literature to happen in about 10% of teeth being prepared for a crown. They may surprise a patient who is unaware of the possibility with significant additional cost.

Depending on the type of cosmetic treatment the patient and dentist decide upon, local anesthetic may be needed. Local anesthetic may be uncomfortable, and has risks of its own which are generally minor, but which should be understood.

Cutting the teeth for dental restorations means the patient will have to maintain the restorations for life. It is likely that the original restorations will require replacement at least once during the patient’s lifetime, involving additional time and expense.

Dental restorations (crowns, fillings, bonding and veneers) can chip, discolor or dislodge from the tooth, requiring repair or replacement. Teeth can also decay beneath dental restorations, often requiring additional procedures to correct—in addition to replacement of the original restoration.

Your dentist may know of specific risk factors based on your individual medical or dental history, which you should understand, and which should be managed before treatment is begun.

Other care that may be needed
Bite collapse due to aggressive bruxism habit.

Figure 1: Bruxism led to the loss of nearly 50% of this patient’s visible tooth structure.

Cosmetic dental procedures vary in complexity from single tooth restorations (which can be among the most challenging to accomplish!) to full mouth rehabilitation of patients whose existing teeth and dental restorations are broken, decayed, extensively worn or otherwise so damaged that fixing them all becomes necessary (Figure 1).

If you are a patient with extensive needs, learning as much as possible about your diagnosis or diagnoses and treatment options is critical to achieving a successful, long term treatment result. Realize that extensive procedures invite multiple opinions, and may involve treatment by a team of dentists who must all work well together to produce ideal outcomes.

Many dental procedures require local anesthestic, and depending on the number and type of restorations being done, you may want to consider the risks and benefits of general anesthesia or sedation. Recent X-ray images (radiographs) of all involved teeth will be needed during the treatment planning process. Diagnostic photographs will often be taken before and after treatment to facilitate communication between you and your dentist; and between your dentist and the laboratory technician (if any)—as well as to document the goals and outcome of treatment.

If gingival re-contouring is recommended prior to dental restorations, a knowledge of the additional cost, risks, benefits, and consequences of not being treated is important.

You should realize that any dental procedure involving the removal of sensitive tooth structure introduces the possibility of developing pulpitis or an abscess in each involved tooth. The anticipated risk of developing an abscess or irreversible pulpitis necessitating root canal treatment is approximately 10% of treated teeth (based on available literature for teeth being treated with crowns). There can be significant individual variation, based on a patient’s individual dental and medical history. Root canal procedures generally add cost and treatment time if they become necessary.

Some cosmetic treatment plans involve whitening the teeth prior to restorative treatment. Others may involve a combination of orthodontic tooth movement and restorative treatment. Prior to beginning treatment, your dentist will evaluate the bite relationship between the upper and lower teeth. Some adjustments may be recommended before the cosmetic work is started. If you have a history of clenching or grinding your teeth (bruxism), your dentist will likely recommend protecting any new restorations with an occlusal guard (bite splints or night guards), which may also add cost.

Other treatment options

Cosmetic dentistry can involve many different dental procedures, including tooth whitening; porcelain or composite resin veneers; fixed or removable dentures; dental implants; fillings; onlays; ceramic crowns; orthodontic tooth movement; and gum surgery (periodontal surgery).

The decision of which type of treatment should be involved is based on many factors, including presence or absence of dental diseases like tooth decay and gum disease; number of decayed, missing or filled teeth; presence or absence of destructive habits, like tooth grinding (bruxism); presence or absence of misaligned, crooked or rotated teeth (malocclusion); patient awareness of viable treatment options, and the risks/benefits of each; and finally, cost issues.

Orthodontic tooth movement may be an option if the primary concern of the patient is crowding, crooked appearance, rotation or misalignment of the teeth. This is especially true if the teeth are unrestored (no fillings, etc.); and generally have a uniform appearance with desirable size, shape and proportionality.

If the teeth appear dark or stained, tooth whitening may be a good option.

It is important to realize that teeth which appear slightly rotated, tipped or have minor chips in the biting edges can often be adjusted and re-contoured with smoothing disks and burs to give significant improvement in their appearance with minimal treatment. It is possible in some cases to accomplish these goals without placement of a single restoration.

What if I do nothing?

Cosmetic dentistry can truly be life changing in terms of its ability to enhance a person’s appearance and self-esteem. If cosmetic dentistry is being undertaken solely to improve the appearance of the smile, the only real consequence of not being treated is that these benefits of a more attractive smile will not be realized.

If a cosmetically beautiful result is merely a desired outcome of a restorative procedure, the consequences of not being treated depend on the nature of the dental problem being treated. If the tooth is chipped, cracked or decayed, not treating it can lead to infection, pain, swelling, tooth loss, and compromised appearance. Minor chips may or may not be of concern, depending on how visible they are.

Author: Thomas J. Greany, D.D.S. / Editor: Ken Lambrecht

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This page was last updated on July 8, 2015.

Evidence-based information for dentists and dental school students

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Links to dental and medical journals

Intended for dentists and dental students, ToothIQ.com links to additional information from over 100 U.S. and international dental and medical journals. Disclaimer: Full-text articles are linked to, when available. Some links lead to content requiring payment. Symbyos is not compensated by the organizations or authors whose articles are linked to. Symbyos is not responsible for the content linked to from ToothIQ.com.

Information you may wish to read before making a decision on treatment

Beauty and the Teeth: Perception of Tooth Color and Its Influence on the Overall Judgment of Facial Attractiveness
Hofel, Lea, Dipl Psych, et al.
The International Journal of Periodontics & Restorative Dentistry
2007 27 (4): 349-357
Editor’s notes: The study concluded that “tooth color is not necessarily perceived, and does not have a major impact on facial attractiveness.

Treatment of localized anterior tooth wear with a glass-fiber-reinforced composite resin: A clinical report
Akar, Gulcan Coskun, DDS, PhD and Dundar, Mine, DDS, PhD
The Journal of Prosthetic Dentistry
2007 97 (3): 133-136

Editorial: Tooth bleaching- increasing patients’ dental awareness
Kielbassa, Andrej M., Prof Dr med dent
Quintessence International
2006 37 (9)

Facing the challenges of ceramic veneers (PDF, 208K)
Christensen, Gordon J., DDS, MSD, PhD
The Journal of the American Dental Association
2006 137 (5): 661-664

Interdisciplinary management of anterior dental esthetics
Spear, Frank M., DDS, MSD, et al.
The Journal of the American Dental Association
2006 137 (2): 160-169

Minimally invasive operative techniques using high tech dentistry (PDF, 148K)
Brostek, Andrew M. Dr., et al.
Dental Practice
2006: 106-106
Editor’s notes: Online publication date September/October 2006.

Randomized clinical trial on the efficacy of 2 over-the-counter whitening systems
Zantner, Catharina, DDS, et al.
Quintessence International
2006 37 (9): 695-706

Point of Care (PDF, 511K)
Boksman, Leendert, Dr.
Journal of the Canadian Dental Association
2005 71 (11)
Editor’s notes: Discusses ways to minimize bleach sensitivity

Strategies for management of single-tooth extraction sites in aesthetic implant therapy
Sclar, Anthony G., DMD
Journal of Oral and Maxillofacial Surgery
2004 62 (9): 90-105

Surgical Extrusion Technique for Clinical Crown Lengthening: Report of Three Cases
Kim, Chang-Sung, DDS, PhD, et al.
The International Journal of Periodontics & Restorative Dentistry
2004 24 (5): 412-421

Repositioning of the gingival margin by extrusion
Chay, Siew Han, BDS, MOrth, MOrth RCS (Edin) and Rabie, A. Bakr M., Cert. Ortho, MS, PhD
American Journal of Orthodontics & Dentofacial Orthopedics
2002 122 (1): 95-102

Predictable peri-implant gingival aesthetics: surgical and prosthodontic rationales
Kois, J.C., and Kan, J.Y.
Practical Procedures in Esthetic Dentistry
2001 13 (9): 691-698

Predictable single-tooth peri-implant esthetics: five diagnostic keys
Kois, J.C.
Compendium of Continuing Education in Dentistry
2001 22 (3): 199-206

Porcelain Laminate Veneers. A Retrospective Evaluation After 1 to 10 Years of Service: Part II—Clinical Results
Dumfahrt, Herbert, Dr med and Schaffer, Herbert, Univ-Doz Dr med
International Journal of Prosthodontics
2000 13 (1)
Editor’s notes: Findings in this study were generally positive, and provide evidence in support of porcelain veneers.

A classification system for loss of papillary height
Nordland, W.P. and Tarnow, D.P.
Journal of Periodontology
1998 69 (10): 1124-1126

The Interproximal height of Bone: A Guidepost to Esthetic Strategies and Soft Tissue Contours in Anterior Tooth Replacement (PDF, 54K)
Salama, Henry, DMD, et al.
The Journal of Practical Periodontics and Aesthetic Dentistry
1998
Notes: PDF of the article originally submitted to The Journal of Practical Periodontics and Aesthetic Dentistry for the Anthology Edition in 1998.

The 5-year clinical performance of direct composite additions to correct tooth form and position: II. Marginal qualities
Peumans, M., et al.
Clinical Oral Investigations
1997 1 (1)

A New Technique for Restoration of Worn Anterior Teeth—1995 (PDF, 565K)
Christensen, Gordon J., DDS, MSD, PhD
The Journal of the American Dental Association
1995 126 (11): 1543-1546

A classification of marginal tissue recession
Miller, P.D., Jr.
The International Journal of Periodontics & Restorative Dentistry
1985 5 (2)

Endocarditis Prophylaxis Information
American Heart Association web site
Last viewed: 9/23/2010

Background information

Do Whitening Toothpastes Work?
Go Ask Alice! web site
Last viewed: 7/15/2016
2005
Notes: ©The Trustees of Columbia University

Implant Restoration of External Resorption Teeth in the Esthetic Zone
Block, Michael S., DMD and Casadaban, Michael C., DDS, MD
Journal of Oral and Maxillofacial Surgery
2005 63 (11): 1653-1661

The advantages of minimally invasive dentistry
Christensen, Gordon J., DDS, MSD, PhD
The Journal of the American Dental Association
2005 136: 1563-1565

Minimally invasive dentistry
Murdoch-Kinch, Carol Anne, DDS, PhD, and McLean, Mary Ellen, DDS
The Journal of the American Dental Association
2003 134: 87-95

Eating habits that can harm teeth
ADA Division of Communications
The Journal of the American Dental Association
2002 133 (12)

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