A beautiful smile -
the sign of a positive attitude towards life
The mouth is not only for eating and breathing; it is also our most important means of communication, automatically drawing other people's attention. It is therefore by no means surprising that beautiful teeth have been regarded as the epitome of an attractive and well-groomed body since ancient times. Archaeological finds show us just how much technical skill the inhabitants of those times used in attempting to improve oral aesthetics.
Etruscan bridge (7th Century BC,
found in central Italy)
Interview with Dr. Schulte
on Dental Aesthetics
(PDF, 450 kB, German)
Today, patients expect not only functional, sound treatment results; they expect the dentist to improve their appearance. Brilliant white, even teeth are attractive and considered a sign of vitality and health. An attractive smile therefore boosts your self-confidence. A person with beautiful teeth will laugh more freely and often than someone with unsightly teeth they would rather hide. Modern aesthetic dentistry complies with the need for cosmetic improvement and does so in a gentle but permanent way: by altering shade, form, and position of the teeth, as well as through corrective gingival surgery.
The fundamental techniques of aesthetic dentistry are:
- Tooth Whitening (Bleaching)
- Veneering (treating front teeth with porcelain facings)
- Tooth Shaded Fillings
- Ceramic Inlays
- All-Ceramic Crowns
- Adult Orthodontics (Braces)
- Improved "Red-Aesthetics" by Corrective Gingival Surgery
Veneers (Porcelain Laminate Veneers)
What are porcelain veneers?
Veneers are wafer-thin (approx. 0,5 mm) translucent porcelain (=ceramic) facings made in the laboratory after an impression. They are fixed permanently to the tooth's front surface using a special adhesive method. The porcelain facing covers the visible surface of the tooth completely.
The chemical bond between porcelain and enamel creates a translucent, tooth-shaded unit with perfect natural aesthetics. Even a dentist can have difficulty telling veneered teeth from untreated ones.
What advantages do ceramic veneers offer?
Fitting with the
In comparison with traditional crowns, veneering is much more conservative, and only minimal substance is removed from the tooth. In addition, veneers are robust and long-lasting.
The main advantage, however, lies in the veneers' outstanding aesthetics, which are by far superior to that of metal core crowns. In comparison to a crown, the transitional area of the wafer-thin porcelain facing is almost invisible and needs not be placed under the gums. Gingivitis, receding gums, and exposed crown margins are problems often associated with crowns, but not with veneers. Before veneering treatment, we recommend whitening discoloured teeth using a gentle bleaching process. This avoids the risk of unsightly shade effects.
Veneers are the first choice when correcting the form of anterior teeth. They allow successful correction of tooth misalignment, gaps, form and shade, with superb aesthetics.
|Unsightly, partly chipped and discoloured front teeth (left)
and the status after treatment with veneers (right)
|Harmonious results produced by veneering damaged front teeth
with simultaneous correction of misalignment
|Porcelain veneer restoration of attrited, discoloured front teeth
and simultaneous closure of diastemas (tooth gaps)
A word about care:
Once fitted, porcelain facings are robust, do not discolour, and need no extra care other than normal, regular and efficient oral hygiene.
Advantages and disadvantages of ceramic veneers:
- Ideal aesthetics
- Form and alignment correction possible
- Gentle to teeth and gums
- Fairly expensive
- Require two treatment sessions
The indication for a crown is when a tooth is damaged extensively and reconstruction with a filling, an inlay, or a veneer is no longer possible. This is the case when
- the defect is subgingival
- the tooth has been root-canal-treated (devitalized)
- the tooth is broken off (fractured) in a deep lying area
- caries or old fillings are widespread throughout the tooth
All-porcelain (=ceramic) crowns without metal core
Before and after providing the
front teeth with all-porcelain
are distinguished by their excellent aesthetics. Light is not only reflected, there is also real transparency as seen in natural teeth. This effect makes the all-porcelain crown perfect for use in anterior areas, whereby minor form and alignment corrections are also possible.
A further advantage of the metal-free ceramic crown is the tooth-shaded margin, which need not be placed under the gum line. Thus, the crown margin does not irritate the gingival tissue and prevents gum recession.
Porcelain (ceramic) is an extremely biocompatible material with no allergenic potential. This can be a real advantage to predisposed (allergic) patients.
With smaller defects, limited to the outer surface, we prefer treatment using porcelain facings (veneers), allowing more of the natural tooth to be preserved during preparation.
Progressive development in ceramics brings forth ever stronger materials, such as zirconium ceramic. Therefore, it is now possible to fit metal-free porcelain crowns in the posterior area.
These amalgam fillings have been replaced with aesthetic and
biocompatible metal-free zirconium ceramic crowns.
Although long-term results with these new ceramics have yet to be completed, present findings are very promising.
Advantages and disadvantages of metal-free all-ceramic crowns:
- True-to-nature, transparent aesthetics
- Highly biocompatible, no allergic risk
- Form and alignment correction possible
- Larger degree of preparation needed
- Fairly expensive
- No long-term experience of posterior applications
Fillings in Tooth Shades (Composite Fillings)
Discoloured, caries infected
anterior filling before...
...and after treatment
with composite fillings.
Our dental office has been an "amalgam-free zone" for a while, and so the search for possible alternatives to amalgam began years ago. Modern tooth-shaded filling resins (also known as "composites", made from an acrylic base with inorganic fillers) are of a high-quality standard. Above all, these composite fillings are the best choice for front teeth (incisors, canines), as well as smaller posterior fillings.
The adhesive bond between acrylic and enamel is achieved through etching and application of primer to the tooth's surface. In this way, even fragile teeth are strengthened. For almost every tooth shade there is a similarly shaded composite available, almost always allowing perfect aesthetic adaptation of the filling.
What are the disadvantages of composite fillings?
Electron microscope view of the marginal
gap between composite and tooth
While acrylic resin is a marvellous material for anterior use and for repairing smaller defects surrounded by enamel substance, its use in large posterior fillings, where the cavity reaches deep into the interdental space, can be problematic. Occasionally this may result in persistent bite sensitivity. Even now, there is no reasonable explanation for this. Another problem is the formation of micro-gaps between tooth and filling, due to the shrinking of composite materials during the polymerization. After several years, this could lead to bacterial infiltration and caries. In addition, the filling can become discoloured and, after a time, be worn down by chewing (abrasion).
The life span of such extensive fillings is therefore limited to around three to six years. This is, of course, dependent on the patient's oral hygiene. Ttreatment with ceramic inlays should therefore always be considered as an alternative to composite.
Advantages and disadvantages of composite resin fillings
- Fairly inexpensive
- Strengthening of the tooth
- Good aesthetics
- Treatment in only one session
- No long-term stability of larger fillings
- Occasional bite sensitivity
- Possibility of discolouration and abrasion
- Problems with defects reaching deep under the gums
Ceramic Inlays (Porcelain Inlays)
Ever more patients express the wish to replace their old amalgam fillings with a biocompatible and durable material. From an aesthetic view, ceramic inlays are regarded as the top of all available alternatives.
What is an inlay?
Inlays are indirect fillings applied in back teeth (premolars, molars). After removal of the old, defect filling or caries, an impression is made of the cavity (that is the drilled out defect). A filling is then made in the laboratory from gold or ceramic, which fits the cavity with the utmost precision and restores the original form of the tooth. In the second session, the inlay is cemented into place. Large inlays which cover the cusps are referred to as onlays.
For many years, gold inlays have been the tried and tested solution and have a long lifespan. Today, aesthetic awareness has led to a decline in their use.
What are the advantages of ceramic inlays?
Ceramic inlays have no metal core and are therefore translucent. They are bonded to the tooth using a special adhesive method, leaving no marginal gaps. A chemical bond is created between tooth and ceramic, restoring weakened teeth to their original strength. The high translucency yields an exceptional aesthetic quality.
Ceramic is exceedingly biocompatible. For example, allergies such as to certain alloys are unknown.
Ceramic inlays are long-lasting. The following diagram shows the longevity comparison between composite fillings and ceramic inlays
Can all teeth be fitted with ceramic inlays?
In principle, all back teeth (molars and premolars) can be fitted with porcelain inlays. Front teeth (incisors and canines), on the other hand, are treated with composites. Only in cases where the defect (caries or filling) reaches deep under the gum, or where the remaining tooth substance is weak and brittle (for example root-canal-treated teeth), is a crown the better and lasting alternative.
What is the view on computer-milled porcelain inlays (for example CEREC®)?
Instead of taking an impression, the cavity is scanned by laser. The data is then transferred to a computer-controlled 3D milling machine, which mills the inlay from a block of ceramic. The inlay is fitted in the same session.
At our dental office, we prefer inlays made in the laboratory after an impression. These are far superior to the computer inlays in form (marginal fit), occlusal function (intercuspidation), and shade.
The only argument for Cerec® inlays is the saving made on laboratory costs, as well as the ability to fit a restoration in only one session (although a very long session).
The actual case:
Fig. 1: Three defective amalgam fillings (premolar and two molars).
Fig. 2: The teeth are isolated from the rest of the oral cavity by a rubber dam. Following the painless anesthesia using the Peripress-method, the amalgam is removed using a water-cooled drill and suctioned away. This method eliminates any chance of contamination with heavy metals or quicksilver.
Fig. 3: As the premolar's defect is not too deep, the restoration is made with tooth-shaded composite. Both molars are prepared for ceramic inlays.
Fig. 4: The impression is made with a small, single-sided tray, which does not cover the entire palate. Upper and lower teeth are precisely registered at the same time, cutting out the need for additional bite registration. There is no nausea or choking as with normal impression trays.
Fig. 5: The finished ceramic inlays before fitting.
Fig. 6: After adhesive cementation of the inlays. Aesthetic, functionality and stability of the treated teeth are fully restored.
Advantages and disadvantages of ceramic inlays
- Exceptional aesthetics
- Long-term durability
- Strengthening of the teeth
- Ideal biocompatibility
- Fairly expensive
- Time-consuming, two sessions required
- Defects reaching under the gums can be problematic
Adult Orthodontics (Dental Braces)
Straight, regular teeth and an attractive smile from an early age are attributes for life, but nature has not been so kind to many people. Many adults suffer from malocclusion accompanied by aesthetic and functional problems because a dental brace was not used in childhood to correct tooth alignment.
Due to advances in modern orthodontics, malocclusion in adults can now be corrected without problems. Modern appliances (dental braces) for adults are much more comfortable to wear than earlier appliances, allow treatment to be completed in less time and are often not at all visible or almost invisible.
Malocclusion in a 40-year-old patient before
and after treatment with dental braces
More information about adult aesthetic tooth correction using fixed or removable dental braces.
Pink Aesthetics: Attractive Gums for Beautiful Teeth
An attractive smile is created when teeth and gum are in harmony. If the gum tissue recedes, e.g. due to periodontal disease, this can severely impair the overall cosmetic appearance. Modern microsurgical techniques can help in many cases. This is an example:
Gingival recession at a lower canine.
Coverage of the defect with a mucosal graft
|Recession at the canine before and after coverage with connective tissue graft|
Sometimes the opposite effect can impair the appearance: the gum tissue covers too much of the tooth crown and makes it appear too short. This is known as a
"Gummy Smile" before and
after microsurgical crown
Cosmetic periodontal surgery can also help in these cases. The excess tissue is gently and painlessly removed using a laser and a harmonious tooth shape restored.
Periodontitis and bone resorption are sometimes so far advanced that surgical reconstruction of the gingival tissue is no longer possible. The defect often not only spoils the aesthetics but also impairs the phonetics (affects pronunciation). Often the only solution for this type of large defect is a gingival prosthesis (artificial gum or gingival mask). After taking an impression, a very thin gum-coloured mask that fits very accurately onto the teeth is fabricated in the dental laboratory. This removable prosthesis is very comfortable for the patient. The aesthetics and phonetics are also greatly improved.