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Dr.Thamrong Limpanapa
Dr.Nattaya Chinpongsanont
Dental Design Clinic & Lab
Prior to starting any procedure of esthetic dentistry, it is essential
for dentists to make a thorough diagnosis and careful step-by-step
plans. The dentist has to make sure that the patient’s overall
oral health is sound and determine any pre-treatments necessary
for the schemed procedures. Before going forward with any procedures
of esthetic dentistry, some patients may need oral bone surgery,
gum surgery, bone grafting or even orthodontic treatments so that
the patient’s natural teeth are affected at the least during
the restoration process.
The patient’s attitudes and expectations are just as important.
The dentist should know what matters most to the patient: function,
beauty, or expense. The patient has the right to know about all
alternative treatments for his/her conditions, the costs of different
treatments, the time used, and the possible impacts or side effects
of each treatment. The dentist should also be able to recommend
the most appropriate treatment plan, but the decision should remain
the patient’s. This article is intended to briefly discuss
all practices in esthetic dentistry, which will help the dentist
make the right decision for the patient.
Restoration techniques in esthetic dentistry
Bleaching (Tooth Whitening Case Presentation)
Bleaching is one of the most popular techniques chosen by the dentist
to improve the patient’s smile today due to its effectiveness,
safety, and minimal impact on tooth structure. The decision to go
for bleaching should depend on the patient’s need, the degree
of tooth discoloration, and the number of teeth needed to be treated.
If the patient is going to need crowns or veneers, bleaching is
not necessary. However, bleaching can be used before all ceramic
work to obtain a lighter shade of tooth color.
There are two main types of tooth bleaching: vital bleaching—procedure
done on teeth that have live nerves—and non-vital bleaching—procedure
done on teeth that no longer have live nerves.
Vital bleaching can be done in the dentist’s office
or at home. Tooth whitening solution usually contains hydrogen peroxides
or carbamide peroxide as whitening agents and the concentration
of solution depends on bleaching technique used. Teeth with dark
gray stain and teeth discolored by tetracycline antibiotics may
not respond well to this treatment. Bleaching should not be recommended
for non-cooperative patients and patients with highly sensitive
teeth, damaged tooth filling, fractured teeth, and large tooth pulps.
The popular technique of non-vital bleaching today is
known as walking bleach. The whitening substance used is sodium
perborate, which is easy to use and safe. Some patients may need
both vital and non-vital bleaching to achieve the desired effect.
Nevertheless, the key to the dentist’s success lies in the
careful practice that aims at minimal side effect on the patient’s
teeth, the appropriate procedures for different needs, and good
communication between the dentist and the patient.
Microabrasion (Filling Case Presentation)
Microabrasion is another option for correcting tooth discoloration.
It is done by removing small amounts of the stained enamel. The
process may also employ rubber cup and the use of pumice and acids
such as hydrochloric acid for the polishing of teeth in rubber dam.
Water spay is also sometimes used. Microabrasion may be combined
with bleaching and tooth filling, depending on the depth of discoloration
inside the tooth. The treatment is suitable for white or brown spots
in tooth enamel that are caused by fluorosis.
Cosmetic Recontouring
Cosmetic recontouring or tooth reshaping can be used to improve
the patient’s smile in many ways: reshaping tooth enamel, rounding
off the tooth edge, removing crevices, correcting uneven teeth and
changing the line angle of tooth. Small flame-shaped medium diamond
bur can be used, followed by the use of carbide bur. Polishing can
be done through polishing disk, abrasive stripe, or rubber polishing
wheel.
Direct Tooth Colored Restoration (Filling Case Presentation)
Direct tooth colored restoration is filling the tooth with tooth-colored
materials. The procedure has become very popular because of its
convenience, relatively low cost, and a wide range of filling materials—e.g.
GI cement, resin modified glass ionomer cement, compomer, and giomer.
The most popular filling, however, is made with composite resin,
which yields colors that are very close to the natural colors of
human teeth and is strong enough to be used for both front and back
teeth.
The treatment is good for cases with Class III, IV, V Restoration,
diastema closing, overlapping teeth, teeth with fluorosis or hypoplastic
enamel, and filling of the back teeth (upon the patient’s preference).
As for back teeth filling, the dentist should make sure that the
cavity is small to medium in size. Indirect tooth color filling
should be opted for in cases with large tooth cavities. Due to its
low cost and repairing convenience, composite resin is also used
to make direct composite veneers. However, it is often accompanied
with the problems of quick wearing, shaping difficulty, leaking
around the margin and low resistance to stain.
Other factors for the success of this treatment are the correct
process and appropriate degree of moisture to prevent postoperative
sensitivity, loosing material, defective filling, or any other side
effects.
Indirect Tooth Colored Restoration (Inlay, Onlay) (Ceramic Inlays/Onlays Case Presentation)
This method of esthetic restoration, which requires collaborative
work between the dentist and a laboratory, is a suitable option
when the tooth structure has been so damaged that the direct tooth
colored restoration is not possible and the patient prefers a natural
colored tooth.
Materials widely used in the procedure today are composite and
ceramic. Composite resin is popular since it is relatively inexpensive,
can be easily shaped, polished and repaired, causes no damage on
opposing teeth, and looks natural. On the other hand, composite
is not resistant to wear, leakage around margin, and staining. Unlike
composite resin, ceramic is highly durable, staining and wear resistant,
and even more natural-looking. However, it is costly and difficult
to make and repair.
Indirect veneer (Porcelain Veneers Case Presentation)
Veneer is a restorative procedure in which the front side of teeth
is covered with a thin, tooth-colored shell. The treatment works
well for stained tooth that cannot be corrected through bleaching
and microabrasion, for teeth that are badly-shaped or slightly badly-aligned
, but it is not recommended if teeth are badly discolored, are broken
or cracked, have large cavities, or if patients have teeth-clenching
or teeth-grinding habits, or if it cannot help the patient achieve
the desired effect.
There are two main types of veneer: composite veneer and porcelain
veneer. Porcelain veneer has become very popular because it looks
more natural and beautiful than composite resin and PFM crown, less
tooth structure are affected than in crowning, porcelain is stronger
and more resistant to wear and staining than composite resin. Although
porcelain veneer is more lasting than composite one, it has higher
cost, and more difficult to repair when cracked or broken.
All Ceramic Crown (Crowns & Bridges Case Presentation)
If crowning is necessary, all ceramic crown is preferable if the
tooth is in a position that can be clearly seen or the patient is
allergic to metals. Compared to PFM crown, all ceramic crown yields
a more beautiful natural look and goes better with the gum tissue.
However, the crown could be difficult to fit neatly, and it tends
to break or crack easily if the tooth is not properly prepared,
the material is too thin, and the traditional dental cement is used
for bonding. The treatment should be avoided in patients with parafunctional
habit or when the remaining tooth structure is not thick enough
after preparation, and teeth to be restored as abutment for removable
partial denture.
Porcelain Fused to Metal Crown (Crowns & Bridges Case Presentation)
Porcelain fused to metal crown has been in wide use due to its durability
and beauty, even though the metal crown can sometimes be visible
at gum margin and the tooth color can be somewhat unnatural. The
drawbacks however can be solved by using porcelain margin for the
crown side that faces the inside of the lip, using high-grade metals,
and making sure that the prepared tooth is thick enough to avoid
unnatural color. The treatment is suitable for patients with severely
damaged tooth, broken or cracked tooth, worn out tooth due to bruxing
or clenching, and biting level problems.
Implant (Dental Implant Case Presentation)
Restoration of missing tooth can be done via replacement, which
can be in the form of removable denture or fixed denture such as
all-ceramic bridge or PFM bridge. Although removable denture has
relatively low cost, it is not as beautiful and natural-feeling
as fixed denture, which, in turn, can cause loss of healthy teeth
during the procedure. The drawbacks of both removable and fixed
dentures can be solved by using implant for restoration of tooth
loss.
With such advantages, implant is becoming more and more popular.
In addition, a single-tooth implant has an over 90% success rate.
Some of its drawbacks are the high cost, the time consumed, and
esthetic problems such as inaccurate position of implant, high gum
line, loss of interdental papilla and improper shape and fitting
of the crown .
Thus, to achieve success with implant, a thorough diagnosis, carefully
thought-out plan, and decision on proper techniques are prerequisites
to the start of this procedure.
Conclusion
What leads to a great success in esthetic dentistry is the dentist’s
recognition and understanding of the patient’s need and expectation,
which need to be adjusted to practicality, the dentist’s skills
and capability, and the patient’s sensitivity to financial
matters. Careful oral examination, diagnosis, and treatment plan
are the first steps toward success and there needs to be good and
clear communication between the dentist and the patient, who should
be accurately informed of all possible alternatives in treatment.
While the dentist should be able to recommend what is the best way
to meet the patient’s desire, the patient should be the one
that makes decision for himself/herself based on good advice from
the dentist.
When deciding on treatment techniques, the dentist should first
consider the ones that minimally affect tooth structure—e.g.
bleaching and microabrasion. In case of severe discoloration, bad
alignment, and great concerns over durability and beauty, a technique
with higher impact is going to be necessary.
Esthetic dentistry has become something of great importance and
necessity in today’s world and is considered a challenge for
dentists, who should and need to regularly keep up with all the
advances in materials and techniques.
Reference : Thamrong L., Nattaya Ch., Esthetic Dentistry, The Dental
Journal of Bangkok Dental Supply, Vol.9, No.16, November 2005.
Note : For more information please see more case study indicated
in “ Case Presentation ” section
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