The word “aesthetic”* appears very frequently in the field of dentistry, even occurring in the titles of several journals. It is, however, essentially meaningless in many if not all of these contexts, as it is never used in the sense of appreciation of beauty (a purely philosophical and personal matter), but rather nearly always refers to the appearance of a restoration (especially the plural form: “aesthetics of . . .”), and—worse— as an attribute of the material itself, as if this was a matter of physics. Dentistry is itself either a process, and as such it is hard to see how it could be the subject of such appreciative contemplation, or its outcome. However, an “aesthetic” restoration, it would seem, is merely one that has achieved a high standard of similarity to the tooth tissue in or on which it sits. Whether this has intrinsic, universal “beauty” is doubtful, no matter the vernacular use of “beautiful work.” This confusion and abuse is unfortunate, as it relates more to advertising than prowess, function, or material properties. I am of the opinion it is a high-flown, overblown word, misappropriated (because misunderstood) to lend a mystical aura (with fashionably “academic” Greek roots) and so vaingloriously elevate the prestige of its practitioners.
Appearance may be considered from two points of view. Mimicry of tooth tissue, essentially “invisible repair,” is the common—and quite reasonable—goal, as this seeks to match adjacent tooth tissue in shade, translucency, and so on, and often with heed to the localized non‑uniformities of natural teeth (as in high‑quality porcelain work). The undetectability of the restoration is the measure of goodness: invisible dentistry the aim. (“Restoration” is a weasel word: it refers to a prosthetic device. We are not yet at the point of biological restoration, as in wound healing—we cannot actually repair a tooth as we can a car.) On the other hand, cosmetic dentistry (an honest term in itself) is concerned with the reconstruction of the dentition in terms of arrangement (orthodontics), shape (extension for closure of diastemata, edge regularity), or blemish obliteration or whiteness (bleaching), albeit far too often toward some imagined (and unnatural) paradigm of perfection, and too often promoted for purely venal reasons. This may be confused with (the perhaps simultaneous) repair of congenital or developmental defects, or the repair of function otherwise impaired, or the reconstruction required following surgery or the rectification of pathologic conditions, but the purposes are quite distinct: vanity‑driven mutilation or exaggeration as opposed to reestablishment of anatomical and functional adequacy related to absence of undesirable side‑effects or to quality of life: this is rehabilitative dentistry. In contrast, there have been attempts to address appearance from the point of view of aesthetics (properly) in both classical¹ and pragmatic² terms.
It should be borne in mind that standards of beauty are not universal, but culturally determined, frequently ephemeral. There remain societies in which, for example, anterior teeth are filed to sharp points or even removed (particularly in Africa), black teeth are thought to be desirable (in parts of Malaysia, the Philippines, and formerly Japan), societies in which demonstration of wealth is achieved through gold‑capped or ‑inlaid anterior teeth (in China, even if the “gold” is often brass), inlaid diamonds are not unknown, and various other decorations are promoted. While people are usually vain (ie, show appearance-consciousness) to a greater or lesser extent, and some account can legitimately be taken of this in prescribing a treatment, it remains inappropriate, misleading, and a source of bias to describe any of this as “aesthetic” or involving “aesthetics.” The usages are meant to impress but are essentially hollow and pretentious, their use unthinking and uncritical. Thus, wherever the words appear in dentistry, “aesthetics” can normally be replaced by words such as “appearance,” and “aesthetic” by “toothlike” or “cosmetic,” with no loss—in fact, with much clearer meaning.
To return to “invisible dentistry”: the goal is, in fact, mimesis—not in the structural sense of replicating the chemistry of a tissue but in recreating the appearance. The optical properties must match those of the replaced tissue. Biomimesis seems to be a step too far, as there is no biological inspiration for what is made in any sense and no attempt to replicate or imitate a biological process. What I suggest is being attempted is visually mimetic dentistry. If we grasped this essential truth, I feel we would be thinking more clearly, acting more rationally, and be seen to be plain-speaking and honest. The point is that an undetectable result of a dental procedure may be remarkable, amazing, praiseworthy, and so on, but if work is undetectable how can it be beautiful (sensu strictu) and so subject to rapt contemplation? To transfer the epithet to the smile of the wearer and take full credit is pompous.
Even so, it should still be recognized that the service performance of a material remains a major consideration of ethical dentistry. Thus, for posterior restorations, for example, strength and wear‑resistance are extremely important and may override the demand for toothlike appearance altogether (silver amalgam, gold) or partially (machined ceramics). Thus, tolerance of non‑toothlike appearance, as for partial‑denture clasps, is possible if not common. Cost is also pertinent.
Terminological abuse is rather common in dentistry,³ and my argument is that it does us no favors. Rather than grab the first impressive polysyllabic term that comes to mind, a little thought can simplify communication and retain credibility—and even hauteur, if this is needed. So, let us be clear. There are several markets to serve, including rehabilitation (surely this is central?) and cosmetic purposes—which are sound enough, if they remain ethical. But what most of us desire, and what most practitioners aspire to delivering, is, quite simply, mimetic dentistry.
Change of journal name, Mr Editor, Sir?
1. Levin EI. Dental esthetics and the golden proportion. J Prosthet Dent 1978;40:244–52.
2. Burke FJ, Kelleher MG, Wilson N, Bishop K. Introducing the concept of pragmatic esthetics, with special reference to the treatment of tooth wear. J Esthetic Rest Dent 2011;23: 277–293.
3. Darvell BW. Dental materials science— Terminological inexactitudes. Dental Asia 2006;2:54–57.
*Webster prefers the ‘ae’ spelling, as does The American Society for Dental Aesthetics (“dedicated to improving the cosmetic [sic] dentistry field for patients and doctors alike . . .” [http://www.asdatoday.com/]). The conflation of aesthetics and cosmetic is revealing.