Of all the advances in dentistry in the past 30 years, the most striking have been made in the field of cosmetic dentistry. Unfortunately some of the more disappointing mistakes have also come in this area. Now, however, we know what works and what doesn't. The purpose of cosmetic dentistry is to improve your appearance. Often it changes lives. When a person learns that he or she can smile again, the self-image improves and that warm glow inside a person manages to get outside so the whole world can see. We have witnessed many happy people, with their sparkling new smiles, leave our office with a new attitude ... and more self confidence. For an evaluation of your own smile, go to Your Smile Certificate.

And, in our office, we are very careful to introduce only those procedures that have been tested and validated in scientific research. It's too bad that many dental manufacturers introduce products and techniques that have not been proven or tested over time. Some dental 'experts' lecture on these new methods and they have their following of dentists who quickly use them in their offices. What many don't realize is that the 'experts' are being compensated by manufacturers to promote their materials or devices. University-based research, published in scientific journals, is the most reliable data to use in evaluating what's new. What follows are techniques that will work in your mouth with dependability. Before and after cases that Dr. Bob has done are also presented. Dr. Bob has been sculpting esthetic smiles since the mid-1970s.

What does your smile look like? Is it crooked, stained, overlapped. Do the teeth look small or too long? Are the gums receding, exposing unsightly roots? Look at your smile closely in a mirror and you can see below which options would be available to correct your problems.

CROWDED, OVERLAPPING

A great treatment for crowded teeth is orthodontics. Even many older adults have braces today. Other faster options are: bonding, porcelain veneers, and cosmetic contouring. In cases where teeth have large fillings or are broken down, crowns can be done and can often 'straighten' the tooth but, if the tooth is in perfect condition, removing healthy tooth structure to do a crown must be done only in exceptional instances.

STAINED TEETH

If teeth have been stained over the years by coffee, smoking, and the like, then bleaching will often be the only treatment needed to whiten them back to their original color. If teeth have internal stains (like tetracycline-induced or fluorosis), then bleaching is less effective. For internally-stained teeth, more aggressive treatments would be necessary such as bonding, porcelain veneers, or crowns.

GAPS IN BETWEEN THE TEETH

It is fairly common to see gaps, especially between the upper front two incisors. If the gap is small enough, bonding will usually be sufficient to close it. If the gap is large, then other factors must be considered such as arch alignment, the bite, and the length of the tooth. Treatment options include periodontal crown lengthening, porcelain veneers, crowns, and orthodontics.

GUM RECESSION OR SHORT TEETH

If your teeth are too long (receded gums, exposed roots), then you can have periodontal surgery done to cover the roots with a graft of gum tissue. Pink composite bonding is another option. If your teeth have been chipped or eroded by clenching/grinding habits, then they should be made longer for a more esthetic appearance. This can be achieved by moving the gum further down the root, a perfectly safe and reliable surgical technique, usually done by a periodontist.

MISSING TEETH IN YOUR SMILE

Missing a front tooth? Don't worry, you have many options. Some are: a single tooth implant (much more predictable today), fixed bridge, removable partial, and a bonded bridge. The treatment depends on the degree of esthetics you want to achieve, cost, and durability of the final restoration.

This is commonly referred to as bleaching. There are two main types: one for teeth that are alive (vital bleaching) and one for teeth that have had root canal work and don't have a nerve (non-vital bleaching). Also, laser bleaching is another method that accomplishes the same result. It requires only one visit but it is nearly double the cost.

NONVITAL BLEACHING: If a tooth has had a root canal treatment, it will eventually discolor. It can be bleached as a single tooth by placing a bleaching solution inside and allowing the bleach to work internally. This usually requires two or three visits. A filling is then placed on the inner aspect of the tooth. The following example shows an extremely dark tooth.

The first photo shows the tooth darkened over many years. It has had trauma and has had a root canal. The iron from the release of blood in the accident caused the dark color.

The second picture shows the results after nonvital bleaching. The tooth has lightened but is still gray. Several options were available to this patient.

The third picture shows the results of bonding. The tooth still has a gray color but this was acceptable to the patient. The patient could have chosen a porcelain veneer or a porcelain crown for better esthetics. He chose the more economical bonding.

VITAL BLEACHING: Vital bleaching, or home bleaching, is a conservative, relatively inexpensive, safe, and effective method to lighten the color of teeth. After years of research, bleaching has been shown to be perfectly safe. Some patients complain about sensitivity, but it disappears after a few days. Results are usually dramatic within a week or two.

The process is simple. Impressions are taken in the office and a pre-bleaching tooth color shade it determined. The patient can select a desirable color on the shade guide. We will advise if this is a reasonable goal. A custom mouthguard is made in the laboratory. At the next visit, we instruct the patient how to place the bleaching gel inside the tray. The patient then loads the tray and keeps it in the mouth for two hours at a time. After two hours, the gel loses most of its effectiveness. Bleaching can be once or twice a day. After about ten applications, the patient usually will get the desired shade. The patient then returns to the office for a final evaluation.

While bleaching usually meets patients' expectations, there are some teeth that do not bleach well. These are very dark gray or dark brown teeth, often stained by tetracycline. Research has shown that, if bleaching is done over a long period of time (six months or more), these teeth may improve in color. Yellow or orange colored teeth and teeth browned by years of smoking normally respond very well to bleaching. Here are a few other considerations:

The first photo shows the case of a mouth where the upper teeth have been bleached and the lowers have not. You can see the obvious color difference. This clearly shows what bleaching can do to brighten a smile.

The second photo shows that the lower teeth have now been bleached as well. Note that certain teeth have been re-shaped for a more pleasing appearance. This is called cosmetic contouring.

Teeth that have minor chips or that are slightly crooked are often candidates for cosmetic contouring. In this technique, the dentist will use a drill to correct these minor irregularities by shaping the edges. This can make the tooth look completely natural. This method also works for teeth that have internal stains that are shallow. Often white and orange stains lie just beneath the surface and can be polished off without any need for bonding. If the stain is deeper, then that calls for bonding or a porcelain veneer.

Pioneer dentists in the 1950s gave us bonding but it was not until the late 1970s that it really became accepted as a wonderful esthetic modality. The method is fairly simple, yet it demands skill, knowledge, and working under magnification to achieve excellent results. A resin material is connected to the surface of the tooth by a mechanical lock. Just as nail polish hardens, so does this composite resin. Unlike nail polish, the resin adheres tenaciously to tooth structure and will last for many years in most cases. Usually there's no drilling, although sometimes the dentist will roughen or contour the enamel if esthetics demand it. Since there is no drilling, numbness is usually not needed unless the teeth are extremely sensitive in general. As a sculptor molds clay, the dentist molds and finishes the resin to the desired shape, creating an esthetically pleasing tooth. Because bonding is conservative, if you don't like the results, the resin can be removed. Bonding can last 3-5 years before it discolors. These are some examples of cosmetic bonding.

Before - Two discolored and worn fillings.

After - Composite bonding has been done to make the tooth seem intact. No dark line can been seen. The technique allows the dentist to blend the resin into the tooth with perfect harmony.

Before - Front teeth are chipped.

After - Because the teeth have plenty of enamel, they could be bonded back to their original shape and color. Bonding may discolor over a period of 3-5 years. Porcelain veneers could also be used here, although they are a more aggressive treatment. However they hold their color longer than bonding.

Before - This is a good example of teeth that have tetracycline-stain. There is also a lateral incisor missing.

After - Bonding was done to sculpt a very attractive smile. The missing tooth is not obvious because the canine was shaped and bonded to look like a lateral incisor. This picture was taken immediately after the treatment was completed.

Most laboratory-made veneers are made of porcelain but some are made of resin. Often this procedure does not require anesthetic, but sometimes it does. The teeth usually need to be shaped, beyond the original surface, so that, unlike bonding, the procedure cannot be reversed. The dentist takes an impression of the prepared teeth and sends it to a laboratory. When the veneers are finished, they are first put in the mouth for a trial inspection and then bonded into position. The porcelain surface of the veneer is lustrous and radiates light much like natural tooth enamel. The effect is a life-like restoration that is much more conservative than a crown. These beautiful veneers can cover stains and eliminate gaps, chips, fractured edges, and even mis-aligned teeth. They can also lengthen the tooth. If cared for properly, they can last 7-10 years. Dr. Bob placed his first veneers in 1985. As of this date (1999), they are still in place. Here are a few examples.

Before - This patient had bonding done but was unhappy with the results. The bonding has yellowed and the shape of the teeth does not look natural.

After - Porcelain veneers on the front six teeth make a dramatic difference. These veneers were done in 1987 and have held up well over time.

Before - This lady did not like her smile. Her teeth had yellowed; gaps were present; and teeth were overlapped. Also gum recession is evident.

After - Porcelain veneers have been placed on the front four teeth. The teeth appear straighter and the gaps are gone. The roots still need pink composite.

After - Pink composite resin has been bonded to the root surface. This is optional since the root surface is so high that it falls out of the 'esthetic zone' - that part of the smile that shows.

Developments in dental materials in the late 1990s have provided more esthetic choices for the restoration of back teeth. Silver amalgam used to be a primary choice for the average patient. However, in observing many silver fillings in teeth, it has become obvious that they cause teeth to crack. Often decay creeps in along this tiny crack. If the crack reaches the inside of the tooth, root canal therapy is needed. So, it is best to avoid silver fillings. They are economical, but they often cause problems. These fillings also contain mercury and some feel that this is a hazard as well but there is no scientific evidence to prove it. If a silver filling is functioning well and there is no evidence of a crack or recurrent decay, there is no reason to remove it. Silver fillings turn gray and black over a period of time. They also often cause the tooth to turn dark.

On the other hand, composite resins have been modified to where they have enough hardness to be used in the chewing teeth. They have an advantage over silver fillings in that they flex more with the tooth and are less likely to cause the tooth to crack. They bond better to the tooth and also match the tooth in color. To place these fillings requires more time and skill than to place a silver one, resulting in a higher cost.

If the area to be filled is quite large, then either an onlay or crown must be used. If a filling is placed in this situation, it will probably break before long. An onlay is a lab-processed restoration, in either gold or white material, that replaces most but not all tooth structure. Gold is the most durable, but it is not the most esthetic. Modern materials allow us to place white onlays, made either of a resin material or porcelain. If not enough tooth remains for an onlay, then a crown must be done. Crowns cost more than onlays, and onlays cost more than white fillings.

Before - This is a silver filling. Note the corroded edges and the cracks.

After - This is a posterior resin composite filling. The resin is more flexible and bonds better to the tooth than the silver filling can.

This porcelain onlay has been in the mouth since 1984.

This is an example of a Targis onlay.

When teeth are fractured or damaged severely, with little supporting tooth structure left, then a crown is the best restoration. At the first visit, the tooth is prepared by drilling; an impression is made; and the patient wears a temporary crown. At the second visit, the dentist checks the fit and color of the crown and, if it is acceptable, cements the crown. This procedure takes time and requires additional lab work as well, making it the most costly single tooth restoration. However, if done well, a porcelain-to-metal crown can last up to 20 or 30 years. However, after about ten years, the porcelain surface may show some wear.

All-porcelain crowns are also available, but are not as strong because they don't have the metal sub-structure. There is a risk of fracturing and they can wear down the opposing natural tooth. Newer materials are available that will not cause this wearing down, but again they have the risk of fracturing. Every year or two, dental manufacturers introduce a new material for crown construction. Dr. Bob is very careful to use only the finest materials and to wait until products have been used for several years before using them in his office.

These lower crowns are esthetically pleasing to the patient.

This porcelain restoration is a series of crowns, joined together to make a fixed bridge to replace this patient's front tooth.

You're thrilled with your new smile and you've spent a bloody fortune on it. Now, let's take care of it so that it lasts as long as possible.

BLEACHING: You've just rinsed out all the tiny pores in the enamel, so why would you want to fill them back up with ugly brown stains again? You'll get these stains by drinking coffee or tea, by smoking (a good time to quit!), by lots of brown cola drinks, and by excessive amounts of food or drink that has color (blueberries, grape juice, etc.). You'll want to freshen up the bleaching every year or so. The cost for this is minimal.

BONDING: Take it easy for a day or so and try to stick to a soft diet. Avoid chewing hard foods (carrots, peanuts, hard candy, ice). Be careful biting into an apple. Be sure to tell your hygienist that your front teeth are bonded - sharp instruments could damage the surface. Bonding also can pick up stain, so avoid food and drink that might cause discoloration.

PORCELAIN VENEERS AND CROWNS: Although these are more durable than bonding, care should be taken to avoid chewing hard foods. Ice can damage natural teeth as well as veneers. They can also pick up stain, although not as much as bonding does. Don't use these to chew your nails with and, as one of Dr. Bob's patients found out, avoid broom handles!