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A Reason to Smile 

Makeovers can improve your teeth and make your whole face look better.

1 Whitening New Orleans dentist Dr. Deborah Lesem says the No. 1 thing patients seek to improve first is the color of their teeth, which has made teeth whitening the most popular cosmetic procedure. The most common type of bleaching dental offices use is the take-home tray in which a dentist fits a patient with custom-made trays to use at home with bleach distributed by the dentist. This bleach is typically a higher concentration than what is available over the counter, and having a customized tray is critical for keeping the bleach in contact with the teeth.

To achieve the best, longest-lasting results, the bleaching trays should be used 40 minutes to an hour daily for two weeks. The benefit of this type of bleaching versus in-office whitening is lower cost.

Most dentists encourage the use of the at-home tray above other options, but for those looking for the fastest way to brighten their teeth, there are high-energy light source and laser treatments. These typically take less time than the take-home trays or other in-office deep-bleaching methods — usually only one hourlong, in-office treatment. Dentists, however, hesitate to say results are better, only faster.

"(A) high concentration of bleach is painted on the teeth and then activated with a high-energy light source or laser for an hour or three 20-minute increments," says Morgan. "Still, patients usually end up going home with the bleach to make sure they've maximized its potential. But people are very busy so they don't want to fiddle with [the bleaching trays]. The results aren't better, just a little faster if they want to get it done."

While people love the idea of the light or laser treatments, Willhite says, "it's not an advantage. You pay more for it because the gel is so strong — and it's more likely to create sensitive gums. Home bleaching with custom trays is really the best."

Furthermore, Lesem has found that her patients experience more discomfort with in-office bleaching because their jaws become sore from the length of the procedure and their teeth become more sensitive because the bleach is more concentrated. She says patients who experience a high level of sensitivity after these treatments often don't follow up with the at-home trays and therefore don't get maximum results.

However, for people who have extremely deep or stubborn stains, such as those caused by tetracycline, there may be other deep-bleaching methods available. Moreau offers an alternative that involves at least two rounds of deep bleaching with a very high concentration of bleach in the office, followed by at-home trays, which he says are able to penetrate the enamel of the tooth deeper than conventional methods. Best for: Teeth stained from foods, wine and other dark liquids, smoking and age. Some deep-bleaching methods can also correct tougher stains caused by such things as tetracycline. Patients should have low risk of cavities and receded gums.

Cost: $150-$500 for at-home bleaching, $500-$2,000 for in-office bleaching.

Length/Time of Treatment: 40 minutes to an hour per day for two weeks with at-home bleaching; one hour for in-office treatments such as zoom or deep bleaching. Depending upon lifestyle, the patient may need a 30-60 minute touch up every one to six months.

Advantages: The least invasive of cosmetic dental procedures, bleaching is a relatively inexpensive and easy way to improve your smile with no drilling or anesthesia and very little discomfort.

Disadvantages: Bleach will not work on porcelain material, so people with crowns, veneers or white fillings on their front teeth may need to get them changed to match teeth after whitening. It is possible to over bleach teeth if you bleach them more frequently than your dentist recommends. Patients can reach a plateau where their teeth actually appear darker as more enamel is worn away and the teeth become translucent. 2 Direct Veneers/Bonding Direct veneers, also referred to as bonding, involve the application of tooth-colored material onto the front of a tooth to mask a cavity, crack or chip or to minimize the appearance of gaps or wear between teeth. They are considered "direct" because the dentist applies them to the tooth in the dental office without using an outside manufacturer or lab technician.

Lesem says direct veneers may be the preferred choice for some individuals because if they chip or break, they can be repaired in the office at a much lower cost than a porcelain veneer. In addition, a dentist often can apply direct veneers without using anesthesia because they are placed on top of the tooth instead of requiring the tooth be cut to make them fit.

Moreau says direct veneers last 10-15 years because the resin used in direct bonding often is not as strong as a porcelain veneer baked in a lab and therefore breaks more easily. Sometimes, however, Willhite says weaker may be better, as in the case of a patient who grinds his teeth at night. "If they have bonding put on and don't wear a protective nighttime splint, then the bonding will wear out faster. But it will be less likely to damage natural teeth that are remaining and is therefore better as it fails, whereas porcelain veneers would be more likely to have a dramatic failure and can damage the natural teeth as they are more resistant to friction." Best for: Specific problem teeth that have small cracks, chips, cavities or particularly tough stains from trauma to the tooth, internal darkening or antibiotics like tetracycline.

Cost: $300-$1,500 per tooth

Length/Time of Treatment: One dental visit for permanent application followed by regular check-ups to clean and maintain.

Advantages: The veneer doesn't have to be manufactured in a lab, so patients can get the procedure done more quickly, plus adjustments and repairs can be made in the dentist's office. They cost less than porcelain veneers and are a more conservative approach to cosmetic dental repair.

Disadvantages: The bonded surface is not as strong as porcelain and doesn't last as long. It also is less resistant to stains than porcelain. 3 Indirect/Porcelain veneers An indirect veneer is usually a porcelain veneer manufactured in a lab by a ceramist or lab technician who custom-creates the veneer to the proper shade and shape according to directions provided by the dentist. They serve the same purpose as a direct veneer— to cover cracked, chipped, worn or deeply stained teeth, making them appear straighter, more uniform and whiter. Porcelain veneers are stronger than direct veneers, are highly resistant to stains and last a minimum of 15-20 years. Because an outside lab is involved, veneers often cost more than direct bonding performed by a dentist. In addition, the surface of the tooth often must be altered before a veneer is fitted, requiring a dentist to use anesthesia. Depending on how many teeth are treated, an initial visit can take about an hour and a half for impressions to be made and for the teeth to be prepared. The impressions are then sent to a lab, where a technician designs the veneer according to a color formula the dentist has chosen to match the patient's other teeth. This process generally takes about two weeks, during which time the patient wears temporary veneers.

As demand for cosmetic dentistry has increased, Morgan says, veneer manufacturing by ceramists has become an art, and veneers now are the result of a team effort between the dentist and ceramist. "I like to involve the ceramist — have them come and actually physically see and meet the patient to find out their expectations, and physically take a (tooth) shade on the patient so nothing is lost in translation from dentist to ceramist," he says. "Usually it's better if they participate." Because the veneer is shaped in a lab instead of on the spot, Morgan says it could be a better fit because the ceramist can examine the veneer under a microscope and perfect it by hand.

Despite the fact that direct bonding doesn't require altering the surface of the tooth as porcelain veneers do, the in-office procedure is not an easy thing to do, Willhite says. Therefore it is more desirable to delegate the work to a dental laboratory for porcelain veneers. "Bonding still has an important place in dentistry," he says, "but for bigger cases, most dentists will choose porcelain." best for: Teeth that have cracks, chips, cavities or particularly tough stains from trauma, internal darkening, or antibiotics like tetracycline. They also work well for minimizing gaps or wear between teeth.

Cost: $800-$2,000 per tooth

Length/Time of Treatment: May take up to two weeks and require two or three dental visits to measure and prepare teeth, have a lab make the veneers, then install them permanently.

Advantages: Veneers are highly resistant to stains, the porcelain is a much stronger material than that used in bonding, and the procedure is less invasive than crowning.

Disadvantages: Porcelain veneers made by a ceramist cost more than direct bonding in the dental office. Veneers often require reducing the size of the natural tooth so they must be worn permanently. 4 Crowns Dentists recommend crowns for cosmetic improvement only in cases where teeth are severely damaged and need extra support and strength. A crown is used when a tooth is weak or so misaligned that it is necessary to reduce a lot of it to make it look straight.

When a dentist applies a crown, the natural tooth is whittled down so the crown can cover the entire tooth instead of only the front and edges that are covered in bonding or veneers.

Some dentists use a technology called computer-assisted design and computer-assisted manufacturing (CAD/CAM) to make a crown in the dental office. Moreau says these machines take a digital picture of the tooth, which is used in combination with design software to create a pattern for the new crown. The data is sent to a milling machine in the office where the new ceramic crown can be made on the spot, the main benefit being that a return visit and temporary fixtures can be eliminated. Best For: Severely damaged teeth for which veneers or bonding are not options.

Cost: $850-$4,000

Length/Time of Treatment: Depending on whether your dentist makes crowns in the office or in conjunction with a lab, the entire procedure may take up to two weeks with up to three dental visits.

Advantages: With digital technologies, patients no longer need to have impressions sent to a lab so they can have a crown placed immediately without coming back for a second appointment. In cases where a tooth is severely damaged or weak, a crown is the best option for strengthening a tooth.

Disadvantages: Crowns are the most invasive and permanent of all cosmetic procedures and are often used only for teeth that need extra support and strength. 5 Implants With this procedure, dentists have the option of replacing a missing tooth with a single tooth implant. An implant consists of a pure titanium fixture placed underneath the bone as an anchor, or root substitute, to hold a new tooth in place.

Moreau says this is a quick and simple procedure that can be performed immediately to replace missing teeth. "Patients that lose teeth can often — after consultation with a restoring dentist — go to a surgeon and have the implant placed. Then they can have a permanent-looking crown put on top immediately." Patients then wear this removable, temporary tooth for four to six months before the permanent tooth is installed.

"It takes time for the implant to ... connect to the bone," explains Willhite. "There are limited situations where you could pretty much use the permanent tooth immediately, but we have to make sure there is a stable connection between implant and bone." He says the length of time required for this process varies from case to case.

Before implants, the only options for restoring missing teeth were removable dentures or permanent bridges, Lesem says. The old bridge method required that the teeth adjacent to the missing be cut down for crowns and used as anchors for the replacement tooth. "If you were in an accident and you lost one front tooth, you had to cut the two teeth on either side. So you'd have two crowns with a fake tooth in the middle, and if one leaked you'd lose the whole thing."

Even though an implant is most like a natural tooth in how it works, Willhite says, it is not possible to adjust it afterward in the way that a bridge can be modified and changed if a patient isn't satisfied with its appearance. The biggest advantage with the implant , however, is that it does not require cutting adjacent teeth as is normally the case with a bridge. And, with the implant, you can have a tooth immediately instead of waiting two weeks for the crowns and bridgework to be made. Best For: A patient who has an adequate amount and good-quality of bone to hold the implant in place, which is required before an oral surgeon and dentist will approve a patient for an implant.

Cost: $2,200-$8,000, including implant and surgeon's fees

Length/Time of Treatment: The implant and temporary tooth can be placed in one day. This is typically worn for four to six months before the permanent tooth is placed.

Advantages: An implant and temporary tooth can be installed immediately so patients don't have to wait for weeks after losing a tooth before it is replaced. It also is an alternative to the invasiveness of bridgework.

Disadvantages: May not work on those who have weak bone structure or other structural complications. It cannot be adjusted. 6 Gum Lift: Gum lifts, or gum contouring, are available for people whose gum tissue is very prominent or uneven. Gum lifts also are used to correct a "gummy smile," in which gum tissue covers too much of the tooth, making the tooth appear small. Oftentimes they are done as part of an overall smile makeover in conjunction with implants or veneers.

Many dentists perform gum lifts using a laser, which can "reshape gum tissue without scalpel and suture," Moreau says, allowing the doctor to perform the procedure without anesthesia. Lasers can also recontour gums that appear thick or puffy.

"Cosmetic gum procedures are generally pretty mild, and often the gums are only minimally sculpted with a laser as opposed to extensive gum surgery performed in the case of a pathology such as gum disease or gingivitis," says Morgan.

However, if more significant recontouring of the bone itself is needed, a dentist may refer a patient to a periodontist for a more complex procedure.

Compared to serious gum surgery for periodontal diseases, "Cosmetic surgery is entirely different," Willhite says. "There are rarely post-operative problems. It is not one of those situations for people who have health problems with no alternative."

Moreover, he says gum lifts heal very rapidly and predictably. Best For: People with puffy, uneven or extended gum tissue and low risk of receding gums or other periodontal diseases.

Cost: $200-$1,000 depending on what is done; it may cost more if changes to bone structure are required.

Length/Time of Treatment: Can be done in one visit to your dentist's office in as little as 10 minutes, depending on gum tissue and the number of teeth treated.

Advantages: This procedure involves very little discomfort, is permanent and requires no touch ups. Laser gum lifts can be performed without using stitches and require little or no anesthesia.

Disadvantages: In some cases, the patient may need to follow up with veneers or bonding if some of the root surface shows afterward. 7 Invisalign Probably one of the most popular alternatives to braces, Invisalign involves a series of removable aligners used like retainers or invisible braces to straighten teeth over time. Due to demand by patients, both general dentists and orthodontists frequently offer Invisalign.

"Very precise impressions are taken before you get started," Morgan explains. "A series of aligners like mouth guards are then made in a lab using computer technology to predict how teeth will move through time. Every two weeks you get a new aligner."

Most dentists agree that Invisalign is most effective on patients whose teeth are in excellent condition and need minor straightening. They all recommend that a patient see an orthodontist for anything that involves a more serious realigning of the teeth. Best For: Patients who already have had braces and have experienced minor shifting, or patients who need only a minimal degree of straightening.

Cost: $1,200-$5,000 depending on the orthodontic work required.

Length/Time of Treatment: Aligners are changed every two weeks; the entire process can take several months, depending on the severity of the case.

Advantages: Aligners are removable and clear so they are not as noticeable as other orthodontic appliances.

Disadvantages: They are most effective on those with only minor problems, and they have been known to crack.

click to enlarge q-uimp-15296.jpeg
click to enlarge Smile makeovers often include any combination of - procedures, such as take-home bleaching trays, a gum lift - and freehand bonding, or direct veneers.
  • Smile makeovers often include any combination of procedures, such as take-home bleaching trays, a gum lift and freehand bonding, or direct veneers.
click to enlarge q-uimp-15296.jpeg
click to enlarge Dentists can use porcelain veneers to close gaps and cover - cracked, chipped, worn or stained teeth, making any smile - straighter and brighter.
  • Dentists can use porcelain veneers to close gaps and cover cracked, chipped, worn or stained teeth, making any smile straighter and brighter.
click to enlarge q-uimp-15296.jpeg
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