April 1, 2000
by Nicholas C. Davis, DDS
There is no doubt that the face of dentistry is changing, offering boundless opportunities for cosmetic dentists in this new millennium. The evolution of our profession in this field is undergoing a metamorphosis at an increasingly rapid rate. As we review the scope and technology of dentistry throughout the 1900’s, we find that the predominant type of treatment involved disease and pain control. Reconstructing the debilitated dentition during that era involved the extensive use of silver, gold and prosthetic appliances.
As we enter this new millennium in dentistry, we have already seen a preview of the future of our profession. The primary function will still be disease control. However, the means, goals and appearance of the final result will be changing. Early intervention will result in more conservative restorations. Teeth with failing restorations will be reinforced and replaced with minimal tooth removal. Overall, there will be the trend to preserve as much natural tooth structure as possible. In addition, the increasing use of dental implants and metal free restorations (Fig. 1) will result in a naturally beautiful, seemingly untouched dentition (Figs. 2 & 3). Clearly, there will be a greater artistic component to our scientific approach to treatment.
Today, the concept of changing one’s appearance purely for the sake of beauty is becoming more widely accepted by both genders. Men, for example more than ever before, are opting for cosmetic dentistry, liposuction, facelifts and more. Discussing one’s own cosmetic procedures, which was once considered taboo, has now become a common topic of discussion. In fact, many boast of their latest treatment. It is no longer considered vain to undergo such elective procedures. Rather, it has become more socially accepted to do all that is possible to look good.
Patient demands for a youthful appearance and smile have propelled cosmetic dental analysis and treatment to a new plateau in our profession. With the overall picture in mind, it is now possible to improve the facial appearance with dental related procedures. Orthodontics and orthognathic surgeries make it possible to physically change the skeletal makeup. By altering alveolar bone, gingival tissues and teeth, it is also possible to reshape the anatomy and change facial structure to achieve the greatest potential for both the smile and face. This, in turn, can rejuvenate the facial tissues by decreasing perioral wrinkles, facial folds and creases and by filling out the lips to create a fresh, youthful look.
New millennium cosmetic dentistry will require a paradigm shift from tooth-centered diagnosis to smile and facial enhancement treatment. Single-minded treatment planning will be a thing of the past. A multidiscipline approach with well-defined goals will be commonplace to achieve the best results. This approach to patient care will customize individual treatment plans and achieve the patients’ ultimate desires. It will not be unusual, to incorporate liposuction, laser skin resurfacing, cheekbone enhancement or chin repositioning as part of our esthetic treatment planning. The team of specialists will include orthodontists, oral and maxillofacial surgeons, periodontists, cosmetic dentists, cosmetic dental laboratories, plastic surgeons, dermatologists, estheticians, hairdressers and make-up artists.
A typical example is the case of a young lady who had always hated her smile and “little girl” appearance. Her chief complaints included her gummy smile, small teeth and thin lips. Her restrictions included a limited treatment time and non-acceptance for orthodontics or orthognathic surgery.
The examination and smile analysis revealed a condition of altered passive eruption. There was a steep palatal cant to the teeth that made them appear even smaller than they actually were (a foreshortening effect). The bicuspids were rotated and tipped toward the palate, which narrowed the arch and created a dark, bilateral buccal corridor.
The patient was encouraged to seek consultation for ideal treatment with an orthodontist and oral surgeon for proper tooth position and occlusion but she declined. An alternative treatment plan was prepared and explained to the patient. That treatment included crown lengthening, cosmetic bleaching and the placement of ten maxillary Finesse porcelain veneers. The patient was further explained the limitations and ramifications of our limited cosmetic treatment plan.
A detailed description of our treatment goals was communicated to the periodontist who would be performing the crown lengthening procedure. Additional periodontal techniques refined the end result. They consisted of reducing and sculpting the labial alveolar bone to establish an ideal osseous architecture for gingival symmetry and optimal lip drape. This procedure exposes more tooth structure thereby establishing proper tooth sizes and proportions. A dissected labial frenectomy was also performed which helped to relieve tension in the lip structure.
Changing the soft tissue profile was the first step in this process. The before and after surgical views (Figs. 4 & 5) demonstrate the improved esthetics even without the cosmetic restorative procedures. By increasing the visible portion of the teeth, more normal height to width tooth proportions become evident. The periodontal procedure also sharpened the gingival architecture and marginal line angles and reduced the amount of gingival tissue that showed when she smiled. This not only reduced the stretching of the lips but also produced a natural fullness of the lip structure itself.
Creative veneer preparations and veneer construction were also employed. The veneers were prepared by reducing the gingival one-third of the tooth while the remaining two-thirds were merely roughened. The incisal edges were reduced and well-defined finish lines were established. This technique slightly uprighted the appearance of the teeth. The dental laboratory also became an active participant in our treatment plan. With our ultimate goals communicated the laboratory was instructed to further upright the appearance of each tooth. This was accomplished by making each veneer thin at the gingival margin and progressively thicker as it approached the incisal edge.
The finished dentistry (Fig. 6) shows the completed smile makeover with straight, normal sized teeth. The smile line follows the curvature of the lower lip and the dark buccal corridor has been eliminated. In the pre-operative lateral view (Fig. 7) the stretching and thinning of the lips are more evident. This view also illustrates the severity of the palatal inclination of the teeth. The restored lateral view (Fig. 8) shows the development of long, straight line angles and uprighted teeth. The position of the veneers helps to further support the soft tissues of the face and adds to the fullness of the lips.
Although limited in scope, the overall cosmetic objective was met. A well-orchestrated treatment plan, with all members participating and focused with one goal in mind, was necessary to create this new look. In combination, the results of these efforts can be seen in the transformation of the patients appearance from that of a “little girl” (Fig. 9) to that of a sophisticated young lady (Fig. 10).
Our profession maintains more frequent and consistent patient contact than other medically related specialties. The confidence and trust that we develop over the years creates stronger bonds and offers more opportunities to discuss appearance-related issues. As time progresses, the public will increasingly recognize the significance of the role of dentistry in improving not only their smile but their facial appearance as well. The demand is here and growing, as is the technology. By being innovative, learning about facial beauty, working as a team and using state of the art materials, you will position yourself to meet your patients’ cosmetic needs in 2000 and beyond.
Acknowledgements are expressed to the members of the dental team; Dr. Michael Gahagan, the periodontist; and Stan Okon at Okon Dental Laboratory for the
ir expertise, skills and help in restoring the cases shown in this article.
Dr. Nicholas C. Davis is a 1973 graduate of Loma Linda University, School of Dentistry in Loma Linda, California. He is a member of the American Dental Association, California Dental Association and Orange County Dental Association. He has earned a Masters with the Academy of General Dentistry and is an active accredited member of the American Academy of Cosmetic Dentistry. He is also a Fellow of the International Academy of Dental – Facial Esthetics.