Cosmetic or esthetic dentistry?

Louis Z. G.Touyz, BDS, MSc(Dent), M Dent (POM)*/Eli Raviv, DMD"/Mili Harel-Raviv, DMD'"

This artide, tiirough presentation ot case studies, defines differences and suggests separate definitionstor the terms cosmetic dentistry and esthetic dentistry. Dentistry strives to emuiate iiarmonious form andfunction tor therapy, and modification of appearance is an intégrai part of dentai treatment. Cosmetic den-tistry suggests a certain accommodation and is a compromise cf current teci^nclogy Cosmetic dentistry iscommonly selected as an interim procedure tiiat does not necessariiy tunction ideaiiy and does not aiwaysemuiate the pristine state ot a natural dentition. Esthetic dentistry requires iess accommodation, incorpo-rates acceptabie biologic technology tor long-term survivai. functions suitahiy. and mimics the pristineState of the naturai dentition. Cosmetic and esthetic dentistry are different in definition, concept, and exe-cution. (Quintessence Int 1999;30:227-233)

Key words: cosmetic dentistry, esthetic dentistry, proslhodontics

In the pursuit of excellence, plastic surgery has consis-tently emulated the natural state of optimal human

development and health.'- Conversely cosmetic plasticsurgery can permanently alter the human body and notmiinic the pristine state.' For example, tattooing, elon-gating necks, and ear lohe or lip mutilation are attrac-tive in certain cultures, but can be classified by currentsurgical standards as primitive cosmetic plastic surgery,

Dental treatment that modifies crofacial appearancecan be considered part of plastic surgery,^ becausephysical appearance is critical to both specialties.'- -"-*Cosmetic surgery and esthetic surgery have been tradi-tionally regarded by many surgeons and health careproviders as synonymous with an identical philosophi-cal approach. In addition, the majority of dental pa-tients, dentists, and personnel of dental insurance com-panies have mistakenly believed that cosmeticdentistry and esthetic dentistry are identical entities."-"*

Most dental therapies treat both hard and soft tissuesto modify appearance." If modification of appearanceinvolves elimination of component parts, it can be tech-nicaDy termed mutiiation; when modification consistsof changing the shape of a part, it is called dejorma-

'Diiector and Associate Professor of Periodontics. Faculty of Dentistry,UcGiii Uniuersity, Montreai, Quebec, Canada.

"Director of Prosthodortics, Sir Mortimer B, Davis-Jewisti GêneraiHospitai, Mortreai; Assistanl Professor, Faculty ol Dentistry, McGili

University, Montreal, Qjebeo, Canada,

'•'Director, Preuenlive and Community Dentistry Division, and AssistantProtessor, Faculty of Dentistry, McGiil Universily, Montreal, Quebec,Canada.

Reprint requests: Dr Louis Touyz, Faculty of Dentislry, MoGill University,/•W Docteur PenfielO Streel, Montreal, OC H3A 1A4 CanaOa. E-maii'touyz ©medcor.mogili.ca

tioii.'- When deformation or mutilation is performedduring dental treatment, the clinical results commonlydetermine if the procedure is esthefie or cosmetic den-fistry.'"" Specific guidelines as to what is esthetic andwhat is cosmetic dentistry are rare: The Glossary ofProsthodontic Terms fails to define cosmetic dentistry,^'

Patients, dentists, other health care professionals,third-party health care providers, and insurance com-panies are confused about what constitutes esthetic orcosmetic dentistry.'=-'' Tbis article presents workingdefinitions for cosmetic dentistry and esthetic den-tistry, differences between them, and, through casestudies, attempts to define specific concepts for thetwo ways of management.

TISSUE ACCOMMODATION AND REACTION

Cosmetic dentistry demands some physical accommo-dation and manifests some physiologic tolerance orreaction. The artificial crown on the maxillary rightcentral incisor (Fig la) has created irritation of thegingival fissue with violation of the biologic width, byoccupying dentogingival space intended for gingivalfibers and ¡unctional epithelium. A low centralfrenum, deep pericoronal pocketing extending fromthe free gingival margin to the base of a pocket thatexceeds 4 mm, and interdentai papillary infiammatoryhyperplasia are present. This is cosmetic dentistry thatcompromised tissue tolerance, and vital tissue accom-modation evoked a soft tissue reaction. °•• -

After specific periodontal treatment, a new crownwas piaced on the maxillary right central incisor (Figlb); the soft tissues are within normal limits and

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Fig la Ccsrnetic crown on the maxiliary right central inoisorImmediate crown piacement satisfied instant appearancedemanda but induced a periccrcnai seit tissue reaction

Fig Ib Esthetic crown on the maxiiiary right centrai incisor. Afterperiodontal intervention, the permanent crown satisfies appear-ance demands witb minimai soft tissue reaction.

Fig 2a Provisionai crowns on tbe maxiliary anterior teeth. Theywere purposefuliy oonstructed to primarily meet immediate cos-metic needs. Functional demands are ol secondary importance.

Fig 2b Maxiliary fixed partiai dentures. Desirabie form, appear-ance, and function are provided with this esthetic resulL

healthy. This is an example of esthetic dentistry,requiring minimai tissue accommodation and tolerance.

PROVISIONAL VERSUS PERMANENT

A provisionai fixed partiai denture (FPD) of 6 singleunits placed on maxillary teeth (canines, central in-cisors, and lateral incisors) during restorative treatment(Fig 2a) can be pleasing in appearance, provide tempo-rary coverage of prepared teeth, and be functional.Selection of specific techniques and materials for provi-sional artificial crowns is acknowledged as a short-term, interim measure. This could be an example ofcosmetic dentistry consciously selected as a temporarytherapeutic measure. The definitive maxillary FPD,which has an improved appearance and suitable func-tion, is purposefully intended for long-term survival {Fig2b), but most biomaterials, including porcelain fused tometal (PFM), are not expected to endure permanently.

IDEAL FUNCTION

Attempts to provide cosmetic dentistry can result inmutilated tceth^' (Fig 3). Major reduction of the edgesof central incisors seriously compromises ideal func-

Fig 3 Mutilated incisors of a Mahimba female from Namibia,incisai contact becomes impossibie after this cosmetic procédure.

tion. This mutilation, or any similar cosmetic proce-dure producing occlusal disharmony, causes consider-able masticatory dysfunction.

On the other hand, esthetic PFM crowns on in-cisors can be used to ensure optimal anterior guidanceand group function, without interceptive occlusal con-tacts, have ideal omnifunctional gnathic excursions,and serve harmoniously within the dentition (Fig 4).

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Fig 4 Estiietic erawns m harmonious lunction. Form and (unctionare ideal.

Fig 53 Discoiored maxiilary left central incisor, compiioating asuccessful retrograde root treatment.

Fig 5b Maxillary ieft centrai incisor after permanent bleachingThe appearance has been enhanced withoul any further compro-mise in survival or function.

Fig 6a Gingival asymmetry and permanent intrinsic discolorationof incisors. The appearance was unacceptabie to the patient.

Fig 6b Cosmetic asymmetric porcelain iaminate veneers on theincisors The improvement in coior restored the patient's seif-esteem, and the gingival asymmetry became unimportant.

PRISTINE NATURAL STATE

Root canal therapy can restilt in tooth discoiorations.For example, a maxillary left central incisor, discol-ored by a treated root canaL may not reflect the nat-ural state of the dentition (Fig 5a). Recently, successfulesthetic bleaching has heen introduced to emulate thepristine natural state of teeth -* (Fig 5b).

Asymtnetry and discoloration frequently representat! aberration. Discrepancies of symmetry in vertical

height and staining of incisors may result in an un-acceptable appearance (Fig 6a). Placement of porce-lain laminate veneers, without an alteration in verticalheight of the incisors, can produce a pleasing appear-ance. Laminate veneers are piaced tnainly to improveappearance, but minor postcementation irritation ispossible un the facial gingival margin, despite well-fitting supragingival margins and acceptable emer-gence profiles of the veneers (Fig 6b). However, porce-lain laminate veneers function well compared to resin

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Fig 7 Cosmetic cowns on maxiliary incisors with chronic mar-ginal intiammation. Ctironic gingivai irritation produces ttiis tiyper-plastic reaction.

Fig 8 Cosmetic crowns on leetii with edematous marginal gin-giva. Bieeding occurs with tiie slightest stimuius.

Fig 9 Diamond inlaid into natural enamelot a maxiiiary canine Sociai values andpersonal desires dictate selections for cos-metic decoration

Fig 10 Two briiiiant-out diamonds deco-rating the facia i surface ot maxiliary premo-lar gold crowns. The diamonds serve oniyas cosmetic enhancers.

Fig 11 Round crystal in the incisor ot a removabie partialdenture. The entire cosmetic piosthesis is devised to en-hance self-esteem.

Fig 12 Gold dollar symbol on the maxiliary central incisor andgold distoincisai restoration on the ieft centrai inciser in a remov-able partiai denture. Tooth jewelry is intended to intiuence sociaiprestige.

composite veneers, acrylic resin veneers, and crowns.In tbis case, cosmetic porcelain laminate veneers donot equal tbe pristine natural state of teetb and, witb-out gingival modification, do not ensure the optimalsymmetry of supporting tissues.

TISSUE HEALTH

Tbe major mission of health care providers is to sustain,

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promote, or enhance bealth. Cosmetic PFM crownscan manifest subgingival impingement and compromiseorai healtb (Fig 7). Porceiain-fused-to-metal crowns fre-quently blanch gingival tissues, and the reacfion is fol-lowed by a chronic inflammatory adaptive response. °" 'Tbe red edematous marginal gingiva and violafion ofthe biologic width ' ^ resulfing from cosmetic crownscould cause the patient's oral health to deteriorate (Fig8). These inflatned tissues often bleed and progressfrom gingivitis to periodontitis.

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Fig 13 Complete-mouth cosrreiic resloratio.n Progressive solt(issue managemenl and ooniemporary restorative techniqueswere not used

11Fig 14integrat

Comprehensive complete-moutin esihetio rehabilitation,ng modern managemenl of both iiaid and soft tissues

DECORATION

Tooth decoration with unnatural artifacts is consid-ered appealing in certain cultures. Extraneous dentaltlecorations can imply not only enhanced beauty butalso social wealth, status, and power. However, ametal-mounted diamond permanently inlaid to naturalenamel of a canine is not curative but is considered bydifferent ethnic groups as a cosmetic mode of treat-ment (Fig 9). Cosmetic decorating of restorations isnot always conducive to oral health. Two briOiant-cutdiamonds, placed in the facial surface of gold crowns,provide a good example (Fig 10),

The insertion of cut crystai into removable partialdenttires (RPDs) or FPDs ser\'es visualiy as a cosmeticadjunct (Fig 11).

Monetary symbols ($, <t, £, ¥) are occasionally cos-metically adapted on teeth to elevate social status oramusement. A gold dollar symbol positioned on themaxillary right central incisor and a gold distoincisalpseud ore sto ration affixed to a maxillary ieft central in-cisor are both cosmetic decorations when fitted in anRPD (Fig 12).

COMPROMISED TECHNIQUES

Scientifically substantiated modem dentistry can providetreatment options that were previously only dreamed of.Selecting the confirmed optimal treatments dictates ex-pectations and esthetic success. Various factors, such asskills, attitudes, and finances may influence decisions fortreatment plans. If patients are subjected to questionableprocedures, the approach is usually cosmetic, until re-placed with superior doctimented treatment. For exam-ple, placement of an acrylic resin veneered crown that isnot in correct alignment and supported by inflamed softtissues is cosmetic therapy (Fig 13).

Comprehensive oral rehabilitation, embracing en-dodontic, periodontic, orthodontic, and prosthodontic

procedures, renders an esthetic dental treatment plan,without compromise of chosen techniques (Fig 14),

DISCUSSION

Cosmetic dentistry has existed for severai miilennia,and many relics from pritiiitive populations havedemonstrated dental rnutilation or decorative modifi-cation. ''' '' Esthetic dentistry certainly has its origin incosmetic dentistry, but, because of the refinements ofmodern treatments, these entities have evolved intotwo distinct directions and, therefore, should haveseparate definitions and approaches. Table 1 lists sug-gested criteria for differentiation between cosmeticdentistry and esthetic dentistry.

The dentist shouid understand the differences be-tween the concepts, execution, realization, and mis-sions of esthetic and cosmetic dentistry. These con-cepts can infiuence the dentist's judgment as towhetber the planned procedures are esthetic or cos-metic. At this stage, the dentist should present thetreatment plan to the patient, explain the differencesbetween cosmetic and esthetic dentistry, and state hisor her wiilingness to perform an esthetic denial treat-ment plan. Occasionally, there may be a compromiseor hybrid therapy, but most treatments can be definedas cosmetic or esthetic if the provider and patient aremutualiy involved in treatment planning.

Subjective vaiue systems of beauty impact on botbtypes of dentistry.'"'5 Consequently, making cosmeticdecisions may he perfectly desirable and estheticallyacceptable to some patients. Patients' opinions shouldbe included in decisions involving appearance-modify-ing procedures. Hasty, hedonistic procedures that areneither durable nor physiologic, aithough intended asesthetic, will be deemed cosmetic in tbe long run.Nevertheless, there are some overlapping areas com-mon to both esthetic and cosmetic dentistry, such asappearance modification.

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TABLE 1 Suggested factors for differentiating cosmetic and estheticdentistry

Factor

Physical accommodation/tolerance

Siiort-lerm ( interim/provision aLong-term (durabiiity)FunctionPristine stateHealth

Superfiuous decoralicnTectiniquesCtioice of materiaiOuaiity of materiaiMcdifies appearanceTtie rape utic

Cosmetic dentistry

Tole rated/acceptable

Consciousiy seiectedRareiy ctiosenNot idea iDoes not emuiateDoes not sustainDoes not eniianceDoes not promoteUsuaily providesCompromisedLeast irritating/ctieapestSecondary importanceYes/short termYes/short term

Esthetic denlislry

Net tolerated/unacceptable

Not selectedAlvjays chosenIdea iAlways emulatesSustainsEnhancesPromotesNever providesUncompromisedNonirritating/nol cheapPrimary importanceYes/long termYes/long term

A dentist who prescribes a gold crown for anteriorteeth has adopted the decorative aspect from cosmeficdentistry and may dilute the esthetic value of treat-ment. This selection affects appearance, but a natural-appearing, ideally shaped PFM crown can be classifiedas estbetic denfistry. A plastic restoration, an arfificialcrown, and a resin composite facing are all cosmeUc iflong-term success is not evident. Limitations of treat-ment and patient cooperation force compromise, be-cause cosmetic dentistry is less expensive, requiringless detailed manipulation than esthetic dentistry.

Exposure of unsightly metal, as may occur on metal-ceramic crowns, distinguishes these as artificial and cos-metic, in spite of good bealtb and long-term survival.Alternative techniques, rendering a perfectly natural ap-pearance in metal and ceramic of the replacementcrowns, would be regarded as esthefie. Esthefie dentistryinherently demands more detail and involves more ex-pense because it is definitive, pristine, biologically stable,and periodontal-conscious dentistry. The ulfimate prae-fice of esthetic dentistry is preventive dentistry withpreservation of intact, natural, and attractive dentitions.

Nevertbeless, cosmetic denfistry can be a valid thera-peufic approach for the dentist. Cosmetic dentistry doesnot commonly survive long-term function and is char-acterized by ease of manipulation, but requires frequentreplacement. Social appearances, involving self-esteemand fear of evoking undesirable value-judgments, in-duce many patients to choose a rapid cosmetic result tosustain a desirable image in public, Tbe pinnacle of cos-metic dentistry has been "theatrical denfistry," when theonly requirement is appearance, regardless of long-termcomfort, funcfion, health, or expense.

All dental procedures affecfing appearance can be

classified as esthetic or cosmetic dentistry, and thedefinitive determinants are longevity, predictablehealth, and harmonious funcfion. Ideally, esthefie den-tistry does not jeopardize appearance and should be in-disfinguisbable from a natural appearance. Complete-denture service that involves future modification can bedesignated, in certain instances, as cosmefic dentistry.Most prostheses that implement desirable modificatiotiscan be so classified. Maintenance of the natural denti-tion with optimal appearance, health, and functionshould be regarded as the best of esthetics. Guidance orexploitation of growth or opfimal heahng that includesorthodonfics and pcriodonfics to maintain oral healthwithout addifional degeneration is also considered tobe esthetic dentistry.^' Tooth-colored fissure sealantsare preventive and termed estbetic dentistry.

CONCLUSION

Cosmetic dentistry and esthetic dentistry should bedifferentiated and approached differently. The sug-gested working definitions could be the following:

Cosmetic dentistry requires accommodation of oralphysiologic function and is primarily concerned withimmediate self-esteem, changes in color and shape,instant comfort, form, and appearance. Attentionto long-term well-being, reactions, and function issecondary.

Esthetic dentistry is harmonious integrafion of oralphysiologic functions with equal emphasis on promot-ing pristine, ideal dentitions, through the restorafionof color, shape, form, and function, to ensure optimalhealth and durability.

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ACKNOWLEDGMENTS

Figure 5 courtesy of Professtir J. F. van Reenen. Paíít Dean.University of Witwaiersrand, South Africa.

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