Cosmetic dentistry is a specialty. Cosmetic dentistry requires vast knowledge, proficient clinical expertise along with the ability to anticipate the end results. Knowing limitations and proper treatment planning are critical factors in the success of cosmetic dentistry. We need to be able to imagine and picture how patient would look like after the treatment, even before we start the case. The purpose of doing cosmetic procedures is to make a person look better and if the end results look fake, we have a failure.
Cosmetic dentistry is not just about crowning teeth. It is not about doing 6 or more crowns at same time. Main objective in cosmetic dentistry is to enhance a smile in a way that it looks completely natural. Smile makeovers need to blend in with the face and rest of the teeth in a way that no one can tell any treatment has been performed on the teeth. The dentist should be able to discern and scrutinize even the minutest of details to yield a perfectly natural looking result. These cases need to be thoroughly planned and considered. You should know your limitations. If you cannot do it, refuse it. Do not waste patient’s resources and give him an irreversible, unsightly and ill-favored result. It is a crime to do that. On the other hand, a well-planned and well executed smile makeover can change the life of a person for good in the most miraculous of ways.
We need to be extra critical in starting a cosmetic case, as it is an elective procedure. I have seen cases which look horrible and make that person look worse than they were before treatment was done. PFM restoration is the last thing you want to use in cosmetic cases especially on front teeth. Even with zirconia we can’t have a natural look. It is a radio opaque material and never looks as natural as your own teeth; hence selection of material is critical to a cosmetic case.
Whenever we do any restoration, we make sure gum health has been established. No bleeding point should be present on probing, and if there is then proper gum treatment should be done. Before starting up a cosmetics case, multiple factors are thoroughly checked and measured in order for us to achieve the desired result. A customized diagnostic wax up is designed after proper analysis of face shape, lip position, gum line, type of tissue, teeth condition, bruxism, TMD, clenching, phonetics, line angles, black triangles, buccal corridor, smile line, space available, golden proportions, long term prognosis, occlusion and function. Diagnostic wax-up acts as a guideline and mock to do a cosmetic case. It is a proposed smile design which we actually try in patient’s mouth and it helps us in preparation of permanent restoration and establishes the gum line. Teeth preparation needs to be minimally invasive unless we are aligning the arch form. We start with establishing proper gum line and that determines the margin of the prep. The most common error in cosmetic dentistry is over preparation, therefore it is crucial to keep the preps in enamel and as thin as 0.5mm. If we end up over prepping the facial surface, the restoration will not bond properly with the tooth and would eventually result in failure. The life of restoration depends on proper preps. Under-prep causes over contouring and weak restorations, on the other hand, over-preps weaken the teeth and compromise long term prognosis. Any sharp line angles will cause fracture of porcelain. All of these factors and various other factors have a colossal impact on the case end results.
Face bow records are important for long term prognosis. We also need to thoroughly check if there are any dark areas which could reflect through porcelain. If there are, then these areas are properly managed and blocked in restoration. Post-prep pictures are taken and then we make temporaries. These are made from a suck down of diagnostic wax up.
Temporization is a try in of the new proposed smile. It lets us determine if this smile is best fit for patient as far as aesthetics, function, shape, size, position and phonetics are concerned. We finalize everything and make necessary changes in the temporary smile, if needed. Once we finalize everything and the patient is happy with new smile, we duplicate it exactly in permanent restorations. This gives us predictable and best results.
Your lab technician is a key factor in the outcome of your cosmetics case, you can visualize the end result of your cosmetic case but it is your lab technician who is going to design the final restorations. Perfect communication is required between the lab and the dentist in order to bring out the best result. It is important for the technician to be trained in proper anatomy, line angles, shade matching, and material handling, as the lab work is a direct reflection of a dentist’s competency to handle a cosmetics case.
Knowledge of proper bonding techniques and materials is very important. Once temporaries are removed permanent restorations are tried in for margin fit (verified by X-ray), color, shape, size and smile. Any bleeding points in working area are managed as we need blood and moisture control for proper bonding. Even moisture from breathing in and out can reduce bonding strength up to 30%.
Doing a cosmetics case is a life changing experience for the patient. Under no circumstance is it acceptable for the patient to have a restoration placed in their mouth that might lead to rotting of their original tooth. Here is the sequence of things that we need to do in order to ensure the perfect outcome for our case. Each and every step is critical for a successful smile makeover, skipping even one of these will not deliver the desired outcome.
1. Patient education
2. Patient Expectation vs. reality
3. Know your limitations (Are you able to deliver results? If not, don’t start)
4. Photos and other records
5. Visualized end results
6. Diagnostic wax up
7. Healthy gums (absolutely NO bleeding points.)
8. Preparation guides
9. Establish gum line
10. Establish arch form
11. 60% smile is determined by central incisors (shape, length and symmetry)
12. Axial inclinations
13. Impression and bite records
14. Temporization (Should look like the planned final result)
15. Follow-up appointment
16. Adjust temporaries
17. Final shape and length (Take photos and impressions)
18. Taking care of temporaries
19. Delivery appointment
20. Check margins for proper fit, no overhangs
21. Color, shade, shape, length of teeth
23. Proper bonding techniques
24. Proper occlusion is very important for longevity
25. Tekscan (if possible)
26. Follow up and hygiene protocols
27. 5-year follow-up
If we follow all these principles, take proper smile design training, and refine our skills to the proper standard, only then we can have a successful cosmetic case. . Patients leave with a perfect smile and the impact it has on their lives and personality is a motivation that keeps driving me forward. I am following the same standard of cosmetic dentistry here in Pakistan which I was in America, and I am getting the same results as well. I am certain that following these principles anyone in Pakistan can deliver aforementioned outcomes.