This document discusses issues with cosmetic or aesthetic dentistry when it is not practiced as part of comprehensive restorative dentistry. The author expresses concern that some cosmetic dentists focus only on appearance and disregard patient oral health and function. Examples are given of cases where improper cosmetic procedures led to problems like loss of tooth structure, premature restoration failure, and patient harm. The author argues that successful cosmetic dentistry requires understanding all aspects of restorative dentistry like occlusion, periodontal health, and risk assessment. Clinical cases are presented that illustrate the need to address underlying dental issues before focusing on appearance. The future of cosmetic dentistry, according to the author, relies on training that incorporates all elements of restor

1. 68 The Dentist April 2014
AestheticDentistry
T
he American Academy definition
of cosmetic dentistry is
comprehensive oral health care
which combines art and science to
optimally improve a person’s dental
health, aesthetics and function. I
attended my first American Academy
of Cosmetic Dentistry Annual
Scientific Session over a decade ago
and at the time was alarmed at the
nature of some of the presentations.
This definition seemed to have little
relevance to many of the cases
presented where cosmetic appearance
was the only concern with little or
no regard (or understanding) for the
patient’s long term oral health and
with little or no understanding of the
implications of functional occlusion.
Certain speakers were misguided
enough to proclaim that veneers
could solve the patients occlusal
problems and appeared unaware or
unconcerned that excessive removal of
tooth structure would have disastrous
long term implications for the patients
oral health. Unfortunately I have
witnessed the same mistakes repeated
and promoted in the UK by some
individuals and organisations the UK.
A change in philosophy is long
overdue with the realisation by
some of the profession that cutting
away large amounts of tooth tissue
Cosmetic, aesthetic or
restorative?
to satisfy cosmetic demands is
indefensible and the appreciation
that correcting occlusal disorders is
essential to ensure longevity of any
restorations. This has always been the
case, although it appears to be a new
concept for some.
Unfortunately for a great number of
us in the profession the use of the term
‘cosmetic’ will always be tarnished
by the trail of destruction left by some
cosmetic dentists that has resulted in:
 loss of pulpal vitality,
 extensive sacrifice of tooth structure,
premature loss of restorations,
 early extraction of compromised
teeth, and
 emotional and financial trauma to
patients.
Cosmetic or aesthetic dentistry is just
a part of restorative dentistry which
places the patient’s dental well-being
at its core. Without a fundamental
grasp of restorative dentistry one
cannot practice successful cosmetic or
aesthetic dentistry.
When I initiated the UK’s first
MSc programme in Restorative
Cosmetic Dentistry at UCLAN,
restorative principles were at the
core of the programme (I have
subsequently moved the programme
to the University of Warwick).
Restorative dentistry has at its centre
comprehensive assessment of all
aspects of the patient’s dentition:
 Periodontal
 Tooth structure
Dominic Hassall
is associate clinical professor
restorative dentistry, University of
Warwick.
Dominic Hassall reviews the current state of aesthetic dentistry in the UK.
Fig 1: Anterior veneers which failed within a year.
Fig 2: Deep overbite in conjunction with a
restricted envelope of function.
Fig 3: Completed aesthetic anterior restorations
following comprehensive lingual orthodontics.
Fig 4: Generalised TSL with OVD collapse.
Fig: 5 Aligner used in an attempt to protrude the
upper incisor teeth so they could be crowned.
Fig 6: Collapsing OVD and loss of ICP.

2. 70 The Dentist April 2014
AestheticDentistry
 Occlusion
 Aesthetic
Aesthetics is just one component
of restorative dentistry and unless
there is an understanding of the other
components there will be premature
failure of the aesthetic dentistry.
Restorative dentistry also has
at its centre risk assessment and
multidisplinary long term treatment
planning, not short term poorly
planned quick fix cosmetic solutions
or quick fix solutions for the benefit of
the dentist’s bank balance.
The future is restorative
Without a thorough understanding
of all aspects of restorative dentistry
including functional occlusion and
the perio:restorative interface all
restorative, aesthetic or cosmetic
dentistry will fail prematurely. Smile
design and aesthetic appearance is just
one important but relatively simple
part of the restorative jigsaw puzzle.
It is only with comprehensive
postgraduate training in all aspects
of restorative dentistry, delivered by
appropriately trained and experienced
individuals that comprehensive long
lasting aesthetic dentistry can be
delivered to the benefit of our patients.
The following cases illustrate why
a fundamental grasp of all aspects of
restorative dentistry is the essential
key in successful predictable aesthetic
dentistry
Clinical cases
The following are some examples of
common mistakes I have witnessed
being regularly repeated. Figures
1-3 present an inappropriate veneer
case undertaken in a patient with
a deep overbite and restricted
envelope of function. All the veneers
debonded with a year. Comprehensive
orthodontics was required to correct
the occlusal disorder prior to the
veneers being replaced.
Figures 4-6 presents a poorly
planned case where an aligner system
was used in an attempt to protrude the
anterior teeth so they could be ‘simply’
crowned. However there has been
a failure to appreciate the actively
collapsing occlusal vertical dimension
(OVD) and loss of intercuspal position
(ICP) due to extensive tooth surface
loss (TSL) and loss of cuspal anatomy.
The case requires an increase in
Fig 7: Upper arch ‘smile makeover’.
Fig 8: Biologic width violation.
Fig 9: Absence of TSL on posteriors with incisal
and palatal TSL to the ICP on the upper incisors.
Fig 10: Patient smiling indicating high smile line.
Fig 11: Incisal and palatal TSL to the ICP.
Fig 12: Incisal and buccal TSL.
OVD and protective covering of the
exposed dentine and reintroduction
of an ICP that the patient can locate.
Only this will ensure long term
occlusal stability and long term
success of any anterior ‘cosmetic
restorations’. The case also requires
aesthetic and structural surgical
crown lengthening.
Figures 7 and 8 highlight a
poorly executed ‘cosmetic smile
makeover’. The entire upper arch
had been restored with anterior
veneers and posterior bridges. There
were numerous faults including
no control in tooth preparation
technique resulting in poor margins
on some restorations which resulted
in violation of the biologic width and
sore bleeding gums for the patient
despite excellent oral hygiene. The
UR1 had been over prepared and
had become non vital requiring
endodontic treatment and had also
discoloured. There was a large slide
from RCP (retruded contact position)
to ICP which contributed to the UL2
veneer debonding within months,
although excessive preparation
and bonding wholly to dentine has
contributed.
In the final case (figures 9-12) a
‘cosmetic centre’ had recommended
veneers on the upper incisor teeth to
improve the cosmetic appearance.
Unfortunately as in the first case
this young patient has a restricted
envelope of function with tooth
surface loss (TSL) on the upper
incisor teeth affecting the incisal
and palatal surfaces finishing at
the ICP position and incisal and
buccal TSL on the lower incisor
teeth, with absence of TSL on the
posterior teeth. This patient requires
orthodontics to correct the occlusal
disorder and realign the upper
incisor teeth. The patient would also
benefit from improvement to the
excessive gingival display. Simply
placing veneers would risk giving
the anterior teeth a square masculine
appearance. The veneers would be
subject to premature failure due to
excessive frictional forces.
Acknowledgements
I am indebted to Peter Huntley of
Orthodontic Excellence for the
orthodontic treatment in case one.