A perfect smile

Constructing an aesthetically pleasing smile is now easier due to the advances in aesthetic dentistry.

A great smile lights up anyone’s day, especially if the recipient of the smile gets to see perfect, pearly whites.

However, not many of us are born with straight, perfect pearly whites.

As a result of the combination of our genes and the way we treat our teeth, they can become stained, decayed, broken, crooked, twisted, loosened and even missing; while our gums can recede or conversely, look too prominent.

Driven by patient demand, the field of aesthetic dentistry has gained much prominence in recent years. Due to advances in dental technology and materials, coupled with a better understanding of the various clinical problems, dentists can now create more aesthetically pleasing smiles.

What constitutes an attractive smile?

When designing smiles, aesthetic dentists aim to have teeth shapes and dimensions to be proportionate with one another and in harmony with the surrounding gum.

This concept is called optimising the White (referring to teeth) and Pink (referring to gum) aesthetics. This is important as each complements the other.

Therefore, to design a smile to be more proportionate, symmetrical and harmonious, the aesthetic dentist may do one or more of the following:

1. Reposition crooked and twisted teeth

2. Reshape disproportionate teeth

3. Re-shade stained/yellow/dark teeth

4. Replace missing teeth

5. Reposition the gum line

6. Reshape the gum

There are various treatment options available to achieve the aforementioned objectives.

Orthodontics (braces)

This involves the use of metal wires and brackets attached to teeth to correct or align crowded teeth and uneven bite.

It can also be used to close gaps or for minor tooth alignment to enhance a person’s smile.

The single most important advantage of using braces is that it leaves the natural teeth intact. However, tthe treatment involves regular follow-up over a period of one to two years. Nonetheless, I must stress that this is still the best option for correcting over-crowded teeth and minor gap closure.

The good news is ceramic aesthetic brackets are now available to replace the “eye-catching” metallic brackets.

Porcelain veneers

Porcelain veneers are thin, custom-made ceramics designed to cover the front side of teeth. They’re made by a dental technician, usually in a dental lab, working from a model provided by your dentist.

You should know that this is usually an irreversible process. Typically, the teeth receiving porcelain veneers must first be lightly trimmed or prepared to make room for the veneers.

After the teeth are prepared, the dentist makes an impression for the dental laboratory which fabricates the veneers on a stone model made from the impression.

At the next appointment, the finished veneers are tried in the mouth to assess the colour, form, and fit. Then each veneer is bonded to the prepared tooth with composite resin cement.

Once bonded to the enamel surfaces of the tooth, the porcelain veneer is very strong, although patients are still advised to avoid biting hard foods or objects, to prevent chipping.

Porcelain veneers are used to close small gaps in your front teeth or correct teeth that are stained, badly shaped or crooked. Teeth with large fillings may not be suitable for porcelain veneers and may need to be treated with crowns.

Alternative treatments for teeth that might be treated with porcelain veneers include tooth whitening (for yellow or mildly discoloured teeth), direct bonding with composite resins (for slightly spaced teeth and minor aesthetic corrections), and full coverage with crowns (for extensively restored teeth and more complex aesthetic modifications).

Porcelain crowns

Crowns are dental restorations that cover the entire tooth on which they are cemented. They are indicated for rebuilding broken or decayed teeth and restore them to their original size and shape. They are also used to strengthen teeth with large fillings and very little sound tooth structure left.

Crowns can be either porcelain-fused-to-metal crowns (PFM crowns) or full porcelain crowns. The former consists of porcelain supported by a metal coping on the inner surface to combine the aesthetics of porcelain with the strength of the metal. While this has been very popular in the past, it is losing its appeal due to its poor aesthetics as a result of the metal coping which blocks light transmission through the underlying tooth. This optical setback gives the PFM crowns a very opaque and unnatural appearance.

While full porcelain crowns offer superior aesthetics due to their translucent nature and similar optical properties with natural tooth structure, they were shunned in the past for lack of fracture toughness or mechanical strength.

However, the advances in material science and dental technology has changed this.

The present generation of full porcelain crowns are very durable and have fracture toughness that can well withstand normal chewing forces. It is now possible to achieve very life-like and durable restorations with full porcelain crowns.

This option is made even more attractive by the escalating costs of gold, which has made the PFM crowns very expensive. Note that I am assuming gold alloy, as professionally recommended, is being used as the metal in PFM crowns.

Implants

This is perhaps the most significant development that has occured in dentistry. Implants have turned dental handicaps, who otherwise have to wear dentures for the rest of their lives, into persons who can now enjoy all the freedom, optimal chewing ability and self-confidence that natural teeth afford.

Implants are titanium screws that are surgically placed below the gum into the jawbone to act as substitute for missing roots as a result of tooth loss. When successfully placed, these implants will be slowly fused to the surrounding bone over a period of few months and they can then be used as base or support for individual replacement crowns, bridges or dentures.

Implants are better treatment options for replacing missing teeth when compared to fixed bridges or dentures.

Firstly, there is no need to trim or sacrifice tooth structure adjacent to the missing gap, as is required in bridges. Secondly, the implant-supported replacement tooth will be more stable than dentures, which tend to come loose during function.

In situations where all the teeth of the arch are missing, full dentures can also be supported on several implants to provide stability and retention during function.

Implant-supported crowns or bridges feel more natural as they are firmly anchored to the jaw bone and they also function as well as natural teeth. Over and above that, implants will also reduce the bone shrinkage that almost certainly takes place after tooth loss.

Candidates for implants must be medically fit as it involves surgery and they must have healthy gum and adequate bone to support the implants. In the hands of an experienced and competent implantologist, the success rates for dental implants should be well above 95% over a five to 10 year period.

It is also pertinent to note here that implant survival in the mouth does not equal implant success, which is taken to mean functional and aesthetic success.

A successful implant-supported restoration should replicate the natural tooth as closely as possible without undue or excessive metal sub-structure showing beyond the gum as well as having proper tooth shape and proper bite with the opposing teeth in the mouth.

This calls for very precise implant placement in the right positions in the jaw bones besides proper management of the bone and gum surrounding the implants.

Very often, additional bone or gum grafting may be required to optimise the treatment outcome from both the functional and aesthetic standpoints.

Periodontal (gum) plastic surgery

Just as a beautiful painting needs to be complemented by an equally good picture frame, our teeth also need to have healthy, harmoniously proportioned gums draping over them for an attractive smile.

The usual aesthetic problems associated with the gum are gummy smiles and a receding gum. These aesthetic issues can normally be addressed by periodontal plastic surgery by removing or adding gum tissue.

In a gummy smile, the gum covers too much of the teeth, making the teeth appear very short and show a lot of gum. This is certainly very unsightly as the gum appears to overshadow the teeth during a smile. Periodontal plastic surgery can remove the excess gum tissue and some underlying bone in a procedure called “crown lengthening” to show more of the teeth so that the smile is more balanced and attractive.

When the gum recedes, the tooth root becomes exposed and this makes the teeth appear very long.

This situation can sometimes give patients an aged look besides the usual problem of sensitivity associated with exposed roots.

Gum recession commonly occurs due to periodontal disease, excessive tooth brushing, trauma and hereditarily determined thin and weak gingival biotypes. You will need to see your dentist to have the causes determined and the underlying problems removed to prevent further recession.

If, after all the necessary basic treatments have been rendered and the condition stabilised, and the gum recession poses an unappealing toothy smile, then soft tissue grafting procedures should be considered. This helps to create more gum to prevent further recession and to re-establish root coverage.

It involves removing a piece of connective tissue from the palate which is grafted onto the gum recession site. To reduce surgical trauma, biologically engineered graft material like human skin (acellular dermal matrix) is gaining popularity and the results have been promising. The reconstructed gum tissue is usually very stable but patients must practise good brushing technique and maintain optimal oral hygiene to prevent recurrence.