OUR PHILOSOPHY OF CONSERVATIVE ESTHETIC DENTISTRY
Nothing has fired the imagination of patients like cosmetic dentistry as portrayed on the makeover type television programs. It seems as if everyone can have a perfect smile in a jiffy! You can see it on TV- people’s lives are radically changed with a new smile.
We share in the enthusiasm for esthetic improvements. We like to think we have changed many lives for the better over our practice’s history. Some patients have bettered their careers, others have found spouses after we have helped them.
However, our philosophy on such treatment is a little different than other general dentists. It is more conservative. We are as much concerned with longevity of the cosmetic improvement as the magnitude of the cosmetic improvement.
There are always tradeoffs between methods of improving patients’ smiles. The tradeoffs are between naturalness, durability, treatment speed, cost, and health of the teeth. Whereas most cosmetic makeovers focus on the magnitude of cosmetic improvement and getting it done quickly, we tend to favor durability, health of the teeth, and lifetime maintenance costs in our treatment planning.
Few patients realize the inherent problems in all-porcelain crowns so popular in cosmetic makeovers today. First, they require a LOT of cutting of the tooth- approximately twice the tooth reduction of conventional crowns. Because of this, the nerve of the tooth frequently dies, necessitating a root canal. The trouble is that when you cut a hole in an all-porcelain crown to do a root canal, it almost always destroys the crown!
The margins of all-porcelain crowns are more susceptible to leakage and thus decay. In our opinion, all-porcelain crowns are overrated. The esthetics of the best traditional porcelain baked to metal crowns is as good as most of the all-porcelain crowns we see. And the traditional crowns are more durable, less destructive to the tooth, and less expensive.
Porcelain veneers are the cousins of all-porcelain crowns, where only the front of the tooth is cut down. Veneers still cost around 85% of the price of all-porcelain crowns, and are NEVER covered by dental insurance. Veneered teeth seldom need root canals, but veneers can chip and stain around the edges. With age, the gums may recede, making the veneer unattractive. Like crowns, when the tooth is cut down for veneers, there is no going back. The tooth must always have either a veneer or a crown.
A major problem with porcelain cosmetic solutions is lifelong color match. Even if a porcelain crown or veneer matches natural teeth perfectly in the beginning, there will be a mismatch years later when the shade of the natural teeth are darker. Bleaching cannot restore the exact original shade of natural teeth.
What, then, are our favored treatment modalities in cosmetic makeovers?
We do occasionally use veneers and all-porcelain crowns, but here are our mainstays.
At-home bleaching- Bleaching is still the most popular cosmetic improvement we do. Often we start complicated esthetic makeovers with bleaching.
Despite constant radio advertising for one-appointment bleaching, we still feel that at-home tray bleaching is better and more cost effective. Scientific studies have found that the final results are the same with the two methods. Few people realize that a substantial part of the initial whiteness in so-called in-office “power bleaching” is dehydration of the teeth, which will disappear in a day’s time.
If sensitivity becomes a problem with tray bleaching, a patient may alternate nights with a fluoride solution. All bleached teeth regress in whiteness to some degree over time. With tray bleaching, the patient may “touch up” the treatment whenever desired.
And if that is not all, home tray bleaching is much less expensive than in-office treatments.
Adult orthodontics is essential in treating many esthetic cases. We solve many esthetic problems conservatively that other dentists solve by cutting down teeth and placing crowns and veneers. For a small sacrifice in time wearing braces, patients can have a lifetime of esthetic improvement.
Many esthetic problems are merely misaligned teeth. We believe it is overkill to cut down teeth to make them straight.
This case is clearly one of crowded and misaligned teeth. It would be radical, expensive, and inappropriate to treat this by crowns and veneers, as the patient originally desired.
Often when teeth are misaligned, the gums are misaligned as well. Many cosmetic treatments require what is called “plastic surgery of the gums.” Often, once the teeth are orthodontically straightened, the gums need no such surgery.
When your teeth are aligned by braces, the color will remain equal between the teeth as you age.
As far as lifetime cost, orthodontics wins hands down. An adult orthodontic case costs well under $5000. It does not take many crowns, veneers, and gum plastic surgery to equal that cost, not to mention the root canals and remakes that will be required during your lifetime.
Many patients ask us about “Invisalign” removable braces. We feel that technique is workable in only a small number of cases. It is not conservative, in that it usually involves cutting the teeth to reduce their dimensions, which can cause sensitivity. Invisalign also costs more than traditional braces.
This patient has had his smile improved by orthodontics lasting about 14 months. Afterwards, he bleached his teeth for three weeks. Note the color of the bleached upper teeth compared to his unbleached lower teeth. Happy with the results, he will now proceed to bleach his lower teeth.
Resin bonding- For correcting minor esthetic discrepancies, we feel that in many cases direct resin bonding can equal or exceed the esthetics of expensive porcelain veneers. Without a doubt, it is easier to match the color of adjacent teeth with plastic resin than with porcelain processed in the laboratory. Usually no cutting of the tooth is required in most cases, so no injections are necessary.
The cost is less than half the cost of a porcelain veneer. Depending on the bite and oral hygiene, direct resin bonding can be an excellent esthetic option.
Laboratory processed inlays and onlays- Where patients demand (usually against our advice) the esthetic replacement of silver fillings on back teeth, we favor porcelain or resin inlays fabricated in the lab. These are a little more durable than direct resin fillings. More importantly, they snugly contact adjacent teeth. That prevents food impaction and helps prevent gum disease.
What is needed to decide on your cosmetic treatment plan?
If not currently a patient, we need recent x-rays and an exam to make sure there is no decay in your mouth. Examining you bite and diagnosing grinding habits is important prior to starting treatment. Next, we make plaster casts of your mouth and take digital photos. Often it is possible to do virtual cosmetic improvements on the computer to let you visualize what can be done.
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