A collection of all of our favourite blog entries from our publications: Smile, BDNJ and The Probe.

Cosmetic dentistry should no longer be regarded as unnecessary and unethical

Cosmetic dentistry should no longer be regarded as unnecessary and unethical

Dr Tif Qureshi, BACD President-elect, explains why cosmetic dentistry should no longer be regarded as unnecessary and unethical...

Cosmetic dentistry has long been seen by some dentists as unnecessary, aggressive, immoral, expensive, risky, complicated and stressful. Cosmetic dentists themselves, can often tell you about that 5 per cent of patients who, it doesn’t matter how perfect, or how many sets of veneers you make, they are never, ever happy. You often only really find out who these patients are after you have prepared their teeth or done something irreversible. We’ve all had them and they’re a nightmare to treat – it’s not an attractive scenario. So much so that up until recently, many practitioners would not even bother with cosmetic or aesthetic treatments, because of the perceived hassle and risks involved.

In certain institutions, it still is seen as unnecessary and unethical, but I would urge anyone who still thinks this to take a look at how things are changing – starting in the UK. Every dentist in the UK can carry out cosmetic treatment and I’m going to explain how. 

Over the last couple of years an absolutely radical change has taken place that actually undermines some of the traditional principles and processes of cosmetic dentistry. Patients who used to have eight to 10 teeth prepared for porcelain veneers for an instant smile makeover, can now achieve an arguably more natural result with, in many cases, no tooth reduction whatsoever in less than 12 weeks.

What is especially controversial is that many of us are also re-examining the rules about what is actually considered aesthetic, and how patients who want cosmetic dentistry are being offered that treatment at the first consultation.

The traditional process was as follows: A patient would visit a practice where digital photographs were taken and software imaging was carried out to simulate a much, “improved” smile where teeth are lengthened, gums heights and evened out, golden proportion built in, buccal corridors widened, embrasures and connectors symmetrically reducing as the teeth go further back. This well known formula was known to produce the technically “perfect smile”. The problem was that this often implanted an image of a perfect smile in the patient’s mind, an image that was often immediately accepted by the patient as ideal. The patient never really had a chance to see their own teeth gradually improving and make a choice to accept a compromise on the ideal smile. Commonly, a wax-up was then made and the teeth were prepared to allow space for the veneers to be seated. If teeth were misaligned, you simply had to cut teeth back to allow space for the ceramic work. This could vary from minimal or no prep in additive cases, but more often than not, large amounts of healthy tooth structure were removed when teeth were proclined or rotated. 

In the UK, the advent of ‘Progressive Smile Design’ through Combined Alignment, Bleaching and Bonding (ABB) is changing this. Patients now get a chance to see their teeth improve gradually and often their initial perceptions on what they thought was needed are totally different once they see their own teeth become straighter and whiter. 

Simple tooth alignment is the most important first step. Different systems now exist that can enable dentists to align the anterior teeth quickly and with less expense. Using simple orthodontic techniques, GDPs can treat suitable cases easily and safely. As always, case selection is vital and good quality education can help dentists identify what cases can be treated and what cases should be referred to a specialist orthodontist. 

Ultimately, anterior orthodontics is a compromise on full mouth class treatment and patients must always be offered the total ideal solution through specialist referral. However, many adults will still want just an anterior solution. 

Combination with tooth whitening done during the alignment phase often then allows the patients to see big aesthetic improvements in short times. Far more effective whitening materials mean whitening can be done with simple home trays for 35 minutes a day. With the right trays, the right materials and correct instructions, anyone can whiten teeth effectively and quickly. If this is done during alignment by using removable appliances, I find patients are far more motivated and actually carry out their whitening more effectively rather than having to wait for brackets to be removed. At this stage, the patient’s perception of their smile will often change. 

Now, the perceived problem is more about the incisal edge outline; patients often ask if there is anything we can do about the edges. New nano-hybrid composites offered by many manufacturers mean strong and thin no prep edge bonding is now a reality. You don’t need to be a composite master and once teeth are straight and white, it becomes even easier.

All of a sudden, the components of the perfect smile, such as wide buccal corridors, perfect golden proportion, ideal gingival zeniths, become less relevant, because the patients are far more likely to accept an improved version of their own teeth, even though they may not be technically perfect.

Porcelain veneers can still be used here if the teeth are worn, pitted or heavily restored, or if the patient still wants a certain “look”, but critically at least the teeth are straight and they will actually be veneers and not three quarter crowns. New, thinner veneers are being pioneered by world-class UK technicians and some beautiful results are being produced using this approach.

There is now a drastic contrast in pathways between the traditional and this new approach, which is far simpler, less invasive and arguably the results are also far better as teeth will look more natural. I believe this type of treatment benefits everybody.

Patients get less or no preparation at all and arguably a far more natural result. The costs are lower too, meaning it’s available to many more patients. Even if veneers need to be used, they can be less invasive and bond to enamel rather than dentine.

Dentists take less risk, generally spend less time per case and the treatment is easier and more predictable. It means that many more dentists can offer treatment like this in any practice.

Orthodontists will also become busier because this type of treatment opens more adult patients’ minds to the concept of orthodontics. There will be cases that are just not suitable and these patients, I find, are more receptive to an orthodontic referral than they might have been beforehand. 

Technicians who might see an initial downturn in the number of veneers made on younger patients, will simply see the amount of treatment on older patients rise dramatically as people keep their teeth longer, because their straight teeth are healthier, but are still going to wear!

Many people think it may have been a long time coming and the detractors and critics of cosmetic dentistry may feel they have been vindicated. However, this change has come from within cosmetic dentistry itself. The vast number of cases, the photography, the techniques, the procedures and the pioneering education have come from the BACD particularly. 

The final question has to be, what would you have? If your front teeth were crooked and chipped, would you have your teeth cut back and have virtual three quarter crowns placed? Or would you prefer to align, bleach and bond them and perhaps use minimal or no-prep veneers if they were very worn or pitted? It’s not a difficult question to answer. So is it right to put a patient through a treatment that you would not undergo yourself? We have to be honest with ourselves and to do so will only promote patient trust in us and enhance our professional image.

I believe the British-borne process of ABB really is the next big thing in cosmetic dentistry and will have a big impact on general dentistry because so many more patients would be prepared to have it done. This new approach will make simple cosmetic dentistry far more accessible to every GDP.