Smile and the world smiles with you

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Dr. Keith Cohen specialises in making people smile and talks a lot about "smile lines". No, he is not a comedian. He is a restorative dentist - and no, this is not a bad joke.

His work is anything but funny. Many patients see him because they cannot smile for fear of exposing unsightly, stained or chipped teeth or do not dare to wear lipstick because it makes the mouth the focal point of attention.

He aims not only to treat their dental problems but also to give them a new "designer smile" which can help to give them back their lives – and a sense of well being and purpose.

The idea of acquiring a new smile and (a new image) in the dentist's chair may sound extraordinary, but Dr. Cohen says: "Treatment can totally change someone's appearance. This is why so many women change their hairstyle and glasses after restorative dentistry. They really do look and feel like a completely different person. It's as much a matter of restoring their self-esteem and confidence as their smile."

Big mouthy gaps left one patient unable to smile at a job interview, reducing her to utter despair. She was rejected and turned to anti-depressants – but she now has a new smile and feels like "a new woman". (See attached Eleanor case history)

Several converging trends are driving the new "designer smile" era. Patients are becoming more demanding and more image-conscious, recognizing that of all the things we wear, none is as important as our expression – a winning smile can be measured in millimetres but "move mountains". Its value is recognized by people of all ages in today's competitive job market. Increasing life expectancy and improved health are encouraging middle-aged people to pursue health and vitality for as long as possible, often to stay in work. Seeking a new job at the age of 57, Roz (see case history two) feels her appearance has never been more important. Other people yearn for a so-called "dream smile" – with straight white teeth - simply to look good.

Most important are major scientific advances - bone re-growth technology, state of the art implants and veneers – which are transforming the traditional "drill and fill" image of dentistry.

Dr. Cohen says: "It is actually possible to design someone's smile to look better than their original smile, using 'smile specifications' laid down in the dental literature. This does not mean creating a uniform perfect smile. There's much talk about the perfect smile. There may be a perfect smile for a particular individual, but you couldn't give everyone else another person's smile, and you wouldn't want to. Smiles are very individual."

This is the critical point where art and science converge: the shape, colour and general appearance of the teeth must be in harmony with the lips and rest of the face.

The lip movements accompanying a smile are especially important. There are three basic smiles:

• The high smile shows all the front teeth and a wide expanse of upper gum –resulting in a so-called gummy smile.
• The low smile doesn't show enough teeth, to the extent that it may seem there are no teeth behind the smile.
• The 'ideal' smile in which 8 to 10 of the upper teeth are fully visible with a tiny amount of gum visible just above the neck of the teeth.

Dr. Cohen explained: "There are certain parameters we find attractive in a smile such as where you see the neck of the teeth in line with the upper lip. Creating a beautiful smile can involve moving teeth – that's orthodontics, altering the level of the gums - either up or down, bleaching and changing the shape and position of the teeth with resin fillings or ceramic veneers or crowns – in other words, restorative dentistry. Whole mouth treatment may also include bone transplantation." (see below for more details).

Another important aspect to consider, maintains Cohen, is dentures: "It is surprising that over eighty per cent of complete dentures do not have the teeth placed and set where they used to be originally – in that relation to the patient's natural smile. I have even come across teeth in a denture which are as much as a whole centimetre away from their original position. Of course, once teeth have been removed, the gum shrinks and so this crucial position can be lost.

"Additionally, ill-fitting dentures may directly contribute to poor appearance and facial profile – as well as being one reason for people beginning to develop sores at the corners of the mouth. Some women also find that it is difficult to apply lipstick because their lips are 'disappearing'. My feeling is that it is always as well to check that dentures provide a snug fit – faithful to the person's original smile and tooth alignment – before having to resort to botox, lip implants or even a face lift."

The Dentexcel team includes a restorative dentist (Dr. Cohen, BDS, LDS RCS, MSc, MGDS RCS, MRD RCS); a periodontist (for gum disease); an endodontist for (root canal treatment); and a craniofacial orthodontist (for tooth straightening and jaw repositioning etc.) and also a maxillofacial surgeon. It is highly unusual to have such a diverse range of specialists in a single UK practice.

Dr. Cohen concedes that while it is now commonplace for patients to have a 'designer smile' in the US – where they talk unflatteringly about "British teeth" – it has yet to be similarly recognized in the UK. He attributes this partly to fashion but also to the fact that patients are not used to paying significant sums for dentistry in this country unlike a number of other countries where teeth are considered as very important. The cost of an implant (see below for more details about implants) starts at about £1500.

Many people, he says, don't see their teeth as a priority even when it is a question of health or function and would rather spend their money on a car or a holiday or building work. Film editor Tina (case history three) opted for dental treatment in preference to a new car, paying £9000 for a smile similar to movie star Catherine Zeta Jones. Her visible teeth are now two millimetres longer, and in the centre, one millimetre wider. Custom-built porcelain veneers bonded against her natural teeth have closed the gaps between her teeth to create a broader, more open smile.

How does Dr. Cohen defend the cost of such treatment? "It's very labour intensive. We have the time and materials to give patients a good result. People ring to ask the price of a dental crown in much the same way they would for a 14-inch Sony TV set. What they don't realise is that it's not actually the same crown under discussion.

"In reality, it's more like choosing a restaurant or ringing a garage to ask about a car price. It'll depend upon age, condition, model, extras etc. One dentist may spend half an hour working on a crown and another three hours. It is the same with the technician – he may get £30 or £300 or £500 depending on the quality of the material and how much time and skill he has. With the more expensive materials, you can make, for example, a ceramic crown which is bonded to the tooth and which contains no metal. Obviously you pay for this.

"Matching equipment and materials to your patient's mouth and face can be very time consuming. Teeth have many different colours. One of the hardest things is to match one front tooth with another. The technician is like an artist painting a picture, blending in the different matching colours. There are blues, reds and oranges. Often near the neck of the tooth, you get more of an orange colour, while around the tip it tends to be blue. A technician may even put a brown line into the new tooth of an ageing patient to make it look natural like the adjacent tooth."

As noted above, the price of an implant starts at about £1500. An implant is a titanium fixture, which is surgically screwed into the jawbone to provide an anchor for a natural looking crown. It is critical to have enough bone in the area of the missing teeth for the implants to be attached to.

A deficit can be remedied with a bone graft either from the back of the mouth or hip or by using alternative synthetic or animal derived products - a small bone transplant may be the size of a watch battery and a big one the size of a double AA battery. It takes between three and six months for transplanted bone to regenerate in its new location. The strength of the implant is reinforced as natural bone literally grows onto it.

In extreme cases, to improve appearance, it may also be necessary to transplant gum and connective tissue from the side of the palate. Transplanted gum takes about four to six weeks to regenerate. Planning an implant can involve hours of careful preparation with analysis of clinical records, impressions, x-rays and photographs. During the regeneration period, the patient carries on as normal, with a temporary "restoration" - either a fixed temporary bridge or a denture. A straightforward implant case may only take three visits over 2 or 3 months whereas a complex case could take up to ten or more visits.

"It is very satisfying to see the transformation in a patient's appearance" says Dr. Cohen. But what does he say to critics who claim that cosmetic dentists may be responsible for generating unrealistic expectations and that we should accept the way we are rather than pandering to vanity?

Dr. Cohen replied: "Having a 'designer smile' is for those people who are fashion conscious and would consider other forms of cosmetic surgery. It is similar to wearing expensive clothes or jewellery.

"However, the health of the teeth is really the most important factor. If somebody already has a number of existing restorations or missing teeth with a poor result it is satisfying to improve that given situation. In other cases it may be better to work primarily with tooth straightening, which we often do (even for adults nowadays with almost invisible systems) than to treat unfilled teeth. In cases where cosmetic reasons are the driving force it is important that treatment should be carefully planned and carried out so that any intervention has minimal impact on future treatment. That said, there is usually plenty of scope for treatment of poor existing restorations, missing teeth or replacement of ill-fitting dentures for example."