Ethics of esthetic dentistryMichael Liebler, Dr med dent, DDSVAIessandro Devigus, Dr med dent=/Ros C, Randall, PhD, M Phil,F,J,Trevor Burke, DDS, MSc, MDS, FDS, MGDS RCS, FDS RCPS, FFGDPVUIIa Pallesen, DDSVAntonio Cerutti, MD, DDSs/Angelo Putignano, MD, DDSVDidier Cauchie, LSDVReinhard Kanzler, Dr med denWKari P. Koskinen, DDS, MS, PhD^Wenrik Skjerven, DDS'VGunhild V. Strand, PhD, DDS'̂ /Rob W,A, Vermaas,

Patient demand for esthetics has increased globally, and often for reasons of patient self-esteem.However, important etfiical issues encompass treatment for purely esthetic reasons. Also, perceptions ofwhat is esthetic differ among patients and clinicians. Therefore, the aim of this article is to make sugges-tions regarding some of the issues surrounding the ethical, esthetic treatment of patients, as well as pre-sent three cases illustrating the different meanings of esthetic heaith to different people, (Quintessence Int2004:35:456-465)

Key words: appearance, clinician-pafient communication, esthetic dentistry, ethics, patient choice

Ethics and esthetics-de rived from the Greek word"perception"-are both branches of philosophy.

Their interaction is central to contemporary restorativedentistry, in which the appearance of teeth is hecoming

'Private Practice. Nürnberg, Germany.

^Private Practice, Bulach, Switzerland

•'3M ESPE, St Paul, Minnesota.

'Professor, University ot Birmingham SchocI of Dentistry, Birmingham,United Kingdom.

^School ot Dentistry, University of Copenliagen, Copenhagen, Denmark,

sprolessor. University of Brescia. Faculty of Medicine and Surgery, Brescia,Italy,

'Associate Protessar, Department of Restorative Dentistry, University of

Ancona School of Dentistry, Ancona, Italy,

'Private Practice, Brussels, Belgium.

'Private Practice, Schwabacn, Germany,

"Private Practice, Helsinki, Finland

"Private Practice, Oslo, Norway.

'^Professor, Facjity of Odontology, University of Bergen, Bergen, Norway

"Private Praclice, Zevenaar, The Netherlands.Reprint requests: Dr FJT. Burke, University ot Birmingtiam School ofDentistry, St Chad's Queensway, Birmingham B4 6NN, United Kingdom,E-mail;t.j,t,bjrl<e@bham,ao,ijk

almost as important as the achievement of a comfort-able, healthy, functional dentition. In that respect, theadjective "esthetic" was introduced into English to sup-ply "sense of beauty,"' The Collins Dictionary^ defini-tion of esthetics, "concerned with beauty and taste"does not appiy well to dentistry, where function musthe an integral aspect of successful treatment. However,patient demand for restorations of good appearancehave highlighted the importance of this area,̂ The useof tooth-colored restorations for posterior teeth hasheen increasing in the United States (US),'' and thismay soon also occur in parts of Europe, led by environ-mental issues, patient concerns in respect of mercurytoxicity, and patient demands for esthetic restorations,A number of techniques, designed principally with theaim of improving the appearance of teeth, have heenintroduced within the past two decades. Among these,porcelain laminate veneers have shown good successrates,' with only minimal tooth preparation being re-quired. However, no restoration lasts forever, and pa-tients who decide to receive veneer restorations arenecessarily entering a cycle of restorative dental treat-ment from which they cannot exit. There are, therefore,important ethical issues surrounding the provision of

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restorations purely for esthetic reasons- There are alsoissues surrounding the provision of tooth-coloredrestorations that may not have the longevity! of less-es-thetic metal restorations. There are also issues relatingto the differences in patients' perceptions of estheticsand what is perceived as esthetic by clinicians,^ giventhat Brisman found patients preferred symmetricaltooth arrangements,^ while a majority of clinicianschose asymmetric arrangements as their preference.

Touyz et aP have discussed cosmetic or estheticdentistry. They presented information that indicatespatients, dentists, and dental insurance personnel haveconsidered cosmetic and esthetic dentistry to be thesame. However, they consider any modification of ap-pearance that involves elimination of component partscould be termed mutilation, and when modificationconsists of changing the shape of a part, it could betermed deformation.^

What is the definition of dentai esthetics?

There are few definitions of esthetic dentistry in dentaltexts or dental dictionaries. Moreover, the dictionarydefinition is not helpful in that it suggests estheticspertains to "beauty, taste, following the rules and prin-ciples of art,"^ In dentistry, restorations cannot be es-thetic in isolation of all else; they also must functionunder the forces of occlusion in a moist environment,often in contact with the dilute organic acids inplaque. Indeed, as clinicians' concepts of estheticswere found 20 years ago to differ from that of the pa-tients,̂ it may also be that clinicians' views on what isesthetic may differ from clinician to clinician. Perhapsthis will be related to the clinicians' training andknowledge-one who has recently attended a post-graduate education course on ceramic veneers is likelyto see more opportunities to prescribe this treatmentthan a clinician who is not aware of this treatment op-tion. Given these difficulties, it may be considered ap-propriate to suggest different levels of dentai esthetics(Table 1):

• A basic or classical level. This embraces the rules ofsymmetry, where the patient's smile conforms tothe Golden Proportion^ and where there is har-mony between white and pink, with a positive smileline.

• A cultural or regional level of esthetics. For exam-ple, very white, straight teeth are expected in theUS, while the provision of a full gold veneer crownin some cultures on an anterior tooth, is accepted.

• A cosmetic or fashion level. Image-related, no den-tal need, reversible, with no harm accompanyingthe provision of this treatment (eg, tooth jewelry,Dracula teeth for Halloween),

TABLE 1 Levels of estheticsCosmetic

ContourFormShadeTextureSymmetrySmile lineMidlineIncisai edgesGum lineSizeBlend with faceAlignment

A virtual level of esthetics is also possible, thisbeing a level of esthetics achievable on the computerscreen but not in a given patient's mouth.

Perhaps, the definition given to esthetics byPilkington"'-"thc science of copying or harmonizingour work with nature and rendering our art inconspic-uous"-two thirds of a century ago, is still most appro-priate. However, form must also follow function. Acrown of accurate color match will not be esthetic ifthe form is not harmonious with the surrounding tis-sues. In this respect, a malformed tooth is as unes-thetic as a discolored one. Indeed, it may be argued,with the advent of the 21st century, that the clinician'sobjective should be to carry out all treatments in anesthetic manner. That could include a gold crown on asecond molar tooth, which completely restores con-tour and function to a broken-down tooth. Each pa-tient will have a concept of their own ideal dental es-thetics. They may then be able to assess where theyare in terms of their own esthetic health. In conclu-sion, esthetic is in the eyes of the beholder; what ap-pears esthetic to the clinician may not appear estheticto the patient. It is therefore essential that the patientis aware of what treatment options are available andwhat the clinician is trying to achieve.

ESTHETIC TREATMENT:CLINICIANS' OR PATIENTS' CHOICE?

Esthetic treatment is a meeting of clinician and patientminds. It may be considered that many patients knowtheir life circumstances better than their clinician, andpaternalistic dentistry (or medicine) is a thing of thepast. Patients are also better educated than in the past;therefore, the approach to treatment must be patientcentered. With regard to esthetics, the clinician mustnecessarily know the rules of dental esthetics, such as

Quintessence i niernational 457

symmetry and the Golden Proportion" and must havelearned the clinical techniques that allow these con-cepts to be applied. Thus, communication between theclinician and patient is paramount. The patient's needsmust be defined by both sides. The clinician may in-form the patient on available treatment options by of-fering verbal and written information, video simula-tions, or wax-ups. And though the patient must be theone who makes the final decision, the clinician, withhis/her knowledge, should not carry out treatmentthat offends his/her consciousness. The patient's deci-sion cannot be honored if the treatment may be harm-ful to their well-being. The patient may demand es-thetic treatments, but the clinician's role is to informand warn. Furthermore, as patients tend to be mediadriven, basic treatment must not be neglected on thealtar of esthetics.

Performance of esthetic materials

Should patients be informed? Is there a trend tosacrifice function and longevity for esthetics?There are a numher of recent reports detailingrestoration age at replacement of tooth-coloredrestorations in posterior teeth in comparison to amal-gam restorations. Amalgam restorations outperformresin-based composite (RBC) in each of thesestudies.'-"'' However, while comparison of the twotechniques provides useful information, direct com-parison is difficuh, given that amalgam restorationsnormally require tooth preparation to provide reten-tion, while initial RBC restorations may be made withan adhesive cavity design, which saves tooth sub-stance. Therefore, the likelihood of pulpal insult witha properly bonded RBC restoration may be reduced,in comparison with amalgam restorations, of whichhalf may be found to exhibit deterioration of occlusalmarginal adaptation at 5 years.'^ Recent reports pro-vide evidence that poor wear resistance is no longerconsidered a problem and that resin composite mate-rials may be successful, with El Mowafy's meta-analy-sis" indicating "high clinical performance" and Mair's10-year data'" showing "adequate clinical service for10 years," which would appear to indicate that theperformance of materials used in these studies is bet-ter than the early materials that suffered from extremewear. Furthermore, the American Dental Associationrecently published a list of applications for resin com-posites,'' by the current scientific literature, indicatingtheir suitability in Class 1 and 2 medium-sizedrestorations,'^ but not supporting the use of resincomposite materials for teeth with heavy occlusalload or teeth that cannot be isolated.'^ However, themajority of the above studies'^-'* were carried out indental school environments, without fhe pressures of

time and economics, which prevail in general dentalpractice. In this respect, the operator may play atnajor part in longevity of RBC restorations.

Patients should also be aware that RBC restorationsare more time consuming, and potentially more diffi-cult, to place than amalgam restorations, and aretherefore unlikely to be cost effective.̂ " Nevertheless,clinical evaluations cannot always compare like withlike, given that composite restorations may requireless tooth substance loss. Furthermore, compositerestorations may be more readily repaired than amal-gam restorations, possibly improving their cost effec-tiveness. Cracks and fractures may be found beneathold and corroded amalgam restorations, with suchrestorations potentially expanding at a rate of 2 to 5pm per day.̂ ' Patients requiring restoration of a poste-rior tooth should be provided with this information sothey may make an informed choice. Perhaps the bestevidence of success is for the clinician to present dataon the effectiveness of restorations placed in his/herpractice. Good information of this type is a key to suc-cessful practice and optimum patient information. Forlarger restorations in posterior teeth, tooth-colored in-lays have demonstrated reasonable longevity in somestudies,"-'*

Patients should be aware of the longevity of esthetictechniques before making an informed choice, espe-cially if the esthetic materials and techniques are not aslong lasting or cost effective as "traditional" techniques.

Are good-looking teeth important to patients'healfh? If so, is esthetics part of health? It has beenconsidered that the psychologic benefits of an oral es-thetic improvement are potentially more important toa patient than traditional dental procedures.^^ Workcarried out on orthodontic patients demonstrated thatconcern with dentofacial appearance often providedthe main motivation for parents to seek orthodontictreatment for their children. Over 70% of those ques-tioned considered such treatment impotiant to theirchild's future success.'^ Furthermore, it has beenshown that young adults with a normal dental appear-ance will be judged more socially attractive.^^ Poordental esthetics has been linked to a personality lack-ing in self-confidence, and thus, disadvantaged in so-cial, educational, and occupational settings.^' Linn^*reported that dental appearance is very important forthose running for public office. Therefore, the patient'sesthetic health may be considered an increasingly nec-essary aspect of overall patient satisfaction followingtreatment.

It may be concluded that esthetic health is impor-tant to a person's well-being. The converse of this maybe that poor dental appearance may be bad for self-es-teem, and that the general health of some individualscould be adversely affected by poor dental appearance.

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A further conclusion may be that people of different so-cial groups may have different aspirafions regarding es-thetic health, given that the achievement of an estheticresult may be time consuming and costly, although thissuggestion is by no means absolute: For example, acomposite buildup of a peg-shaped lateral incisor mayprovide a low-cost improvement in esthetics.

Is the US a trendsetter in esthetic dentistry? Isthere a difference in esthetic perception in differentcountries? A review of the literature demonstratesthat a majority of esthetic techniques originated in theUS. However, while RBC materials were derived fromwork carried out in the US, much of the early work onposterior composites was carried out in a clinical trialin both the US and Europe.'^ Esthetic dentistry is notinexpensive denfistry and, therefore, is carried out inmore affluent locations. However, the procedures ap-pear to have been adopted worldwide where patientscan afford to pay.

It may be surmised that the different cultural back-grounds of different countries will lead to different de-mands. For example, patients requesting veneers inEurope may not wish to receive restorations as whiteas those requested in the US, where manufacturershave reacted to demands for white teeth by producingnew "extra-white" shades of RBC materials. However,there is no evidence from the literature that this is so.

In conclusion, although many esthefic techniquesoriginated in the US, esthetic dentistry is now a globalphenomenon.

Is there a difference in the perception of estheticsby clinicians and the general public? There are fewreports on this subject, especially since the widespreadacceptance of porcelain veneers by the dental profes-sion and the public. However, work carried out in1980 by Brisman^ indicated that clinicians' viewscould differ from those of the public. Research carriedout in 1991 from The Netherlands^" showed that thepublic's percepfion of dental appearance differed fromthose of the clinician in > 45-year-old age groups,with clinicians identifying more esthefic "problems" inthe older age groups of which the patients were notaware.̂ **

Ultimately, the idea of esthetic health may be differ-ent for different people, different age groups, and dif-ferent cultures.

Is esthetic dentistry need driven or want driven?Esthetic dentistry must be led by a patient request: Itis, therefore, "want" driven. By comparison, treatmentof a caries lesion should be "need" driven. However,the latter may also be "want" driven if the patient re-quests an esthetic restoration. Patients should be pro-vided with the information on what treatments are po-tentially available, and if they "want" it enough, andthe clinician can jusfify this "want" in the context of,

for example, removal of tooth substance, then thetreatment can be justified. Above all, however, thetreatment should not harm the patient. In this respect,the clinician must be able to provide the treatmentthat the patient wants. This will require the clinicianto undertake postgraduate education in order to re-main updated in current techniques.

What is the role of the insurance system in theesthetic equation? Third party insurers use sub-scribers' or taxpayers' monies to pay for treatment:They must, therefore, be ahle to justify their spendingto shareholders, taxpayers, or government. There is noquestion that orthodontics is beneficial to the patient'slifelong self-esteem, and payment through a third partyinsurer (such as the National Health Service [NHS] inthe UK) can be justified. However, whether treatmentswith a more short-term chance of success may be jusfi-fied by a third party insurer is questionable, given thatfailure of short-term treatment invariably leads to a fu-ture treatment need, with the attendant costs to the in-surer. One insurance system may therefore find itself"picking up the bill" for a failed esthetic treatmentoriginally funded under a different scheme.

Other matters are involved too. People are increas-ingly attending shops for tongue piercing, but has theattendant risk of cracked teeth been discussed withthe patient? Should an insurance system pay for thedamage so caused? The dental professional is awareof the potential for periodontal damage by smoking:Should the insurance system pay for the periodontaltreatment made necessary by the patient's habit?Insurance organizations and companies are increas-ingly discussing what is and what is not necessary forhealth. Surely the concept of esthetic health mustnow be brought into this equation. The clinician isnot following fashion changes by painting differentcolors on a patient's teeth, but is achieving a long-lasting effect on teeth that may be discolored or unes-thetic. If esthetics is important for the health of a per-son, and if the person is esthetically unhealthy, thenthe dental surgeon may help that person and provideesthetic health. There would appear to be a strongcase for insurers to pay for such treatment, given that,increasingly, there is a psychosocial necessity for es-thefic health.

In conclusion, while esthetic treatment may oftenbe justified for the patient's self-esteem, it is unlikelyto be readily funded by tbird party insurers. An indexof treatment need for esthetic dentistry may be a wayforward.

How about cutting healthy teeth to make themlook better? Tbe placement of an RBC restoration torestore caries in a posterior tooth may require the re-moval of less tooth substance than the placement of anequivalent amalgam restoration. However, incorrectly

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placed RBC restorations tnay cause pulpal problems ordamage to the supporting tissues by poor approximalcontacts. Poor patient selection may lead to prematurefailure of these restorations in bruxing patients.

Esthetic treatments may require the removal ofsound tootb substance. For example, when veneerswere originally proposed, they were considered to bea nonpreparation treatment modality. However, toothpreparation is necessary for veneers in order to pro-duce the correct emergence profile and to provide thetechnician with sufficient space to produce an estheticrestoration. Incorrect preparation-too httle or toomuch-may lead to damage lo the supporting tissuesor pulp. Inadequate knowledge of the use of dentin-and enamel-bonding agents may cause significant pul-pal probicms. The placement of crowns for estheticreasons requires more tooth reduction than veneers.Porcelain-fused-to-metal restorations have been con-sidered to have good longevity but may cause gingivalirritation due to insufficient tooth preparation {Hereis the quandry for the restorative clinician-iceep theperiodontists happy or the puip biologists?). Goodcommunication between clinician and patient, andvice versa, is essential to successful esthetic treatment.The patient's informed consent is needed, and thisshould serve to raise the consciousness of the patientto the proposed treatment. The patient's judgmentshouid be honored unless the proposed treatment isdeemed harmful to their well-being. However, it is ul-timately the clinician who must take responsibility forthe treatment and execute it with care and to thehighest possible standard. In this respect, training isimportant. Less invasive options should be encour-aged. For exampie, it may be perceived as easier toplace four or six anterior veneers rather than attemptthe difficult restoration of one discolored tooth.However, the true professional should be able to takeon the chaiienge of the one unesthetic tooth.According to Croll,̂ ^ bleaching should be attemptedbefore treatment of discolored teeth. Esthetic treat-ment should not be carried out in isolation of a fulloral examination and a treatment plan individualizedfor each patient, with an interdisciplinary team if nec-essary, and with a full risk/benefit assessment alsobeing carried out

In conclusion, only those techniques with a pub-lished satisfactory longevity should be attempted foresthetic reasons. Better still, the clinician should beable to produce evidence of satisfactory longevity ofthe chosen technique. Only when the patient hasweighed the disadvantages of tooth preparation andthe need for replacement restorations in due course,should the treatment proceed. The clinician should al-ways remember that there is no dentistry better thanno dentistry.

Are there special ethical considerations in thecommunication between dinician and patient deal-ing with esthetic dentistry? The clinician has a dulyto inform patients about all aspects of all treatment,but for esthetic treatment, the elinician should provideinformation on the long-term sequelae to treatmentand compare this with no treatment. Written detailsshould be provided and a workup made of the treat-ment, ideally in the form of an intraoral mocktip.Patients may demand treatment, but the clinician mustfeel justified in terms of the psychosocial beneñts to thepatient before commencing any form of tooth prepara-tion. There are likely to be differing considerations fordifferent patients. For example, the actor may feel thatgood-looking teeth are essential for employment

The clinician is responsible for fully informing pa-tients seeking esthetic treatment, especially in terms ofthe eñect of tooth preparation on long-term viability.

Does the manufacturer have a roie in estheticdentistry? Given the raised profile of esthetic treat-ments in recent decades, manufacturers have an im-portant role in producing esthetic materials that arereliable, repairable, and cost-effective. At the time ofwriting, no materials are an absolute substitute forenamel and dentin. The era of esthetic dentistry forposterior teeth will truly arrive at the same time as aneasy-to-use, non-technique-sensitive, tooth-coloredrestorative material that is repairable and permanent.

Manufacturers and clinicians sbould liaise eloseiy onwhat is required in terms of esthetic dental materials.

CASE REPORT 1

A 25-year-old woman presented requesting a newporcelain veneer for her maxillary right lateral incisor.The resin veneer on this tooth had been placed 6 yearspreviously to cover a white spot lesion, and the patientfound the veneer of poor color match (Fig la). The pa-tient also expressed dissatisfaction with the appear-ance of the gingival tissue associated with this tooth.Following discussion with the patient, it was decidedthat a crown-lengthening procedure with minimalremoval of bone would be carried out, and the diseol-ored veneer would be replaeed. Enamel microabrasionwould be condueted to remove or reduce the whitespot lesions on the other anterior teeth.

The gingival surgery was carried out (Fig lb), andafter healing, the resin composite veneer was removedfrom the maxillary right lateral incisor {Fig lc). Thecrown lengthening made the patient's lateral incisorfooth appear larger, the shade match was satisfactory,and the minimal lingual displacement of this toothwas not of concern to the patient Aceordingly, it wasdecided not to replace the veneer, and the tooth was

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llary left central and lateral incisors, (f and g) Sm\\e at pre-and posttreatmeni

treated with a fluoride gel and polished. Enamel mi-croahrasion was carried out on the remaining maxil-lary anterior teeth (Figs Id to Ig),

Comment

The treatment carried out was of low cost, of minimalintervention, and of good durahility. Had a replace-ment veneer been chosen for treatment, it would haveheen necessary to prepare the tooth, and during thepatient's lifetime, it would have been necessary to re-place the veneer several times. Moreover, when teethare reprepared, tooth substance is lost. The enamel

microahrasion treatment is without risk of relapse.The treatment carried out was estheticaily sound andof certain prognosis, with minimal intervention.Sometimes the most simple option for treatment mayhe overlooked.

CASE REPORT 2

A 39-year-old female singer presented with a requestfor esthetic improvement of her anterior teeth. Herprincipal esthetic complaint was that spaces werepresent between her maxillary premolar and canine

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Fig 2 ¡a) Case 2 pretreatment. (b and c) Teelh upon completion.

teeth in the maxillary arch and that the cuspids werepointed (Eig2a).

Following discussion with the patient, a treatmentplan was created, which consisted of orthodontic cor-rection, followed by porcelain laminate veneers if sodesired by the patient.

However, the patient was unwilling to wear ortho-dontic appliances because of potential interferencewith her singing and television performances, A re-vised treatment was therefore developed. This con-sisted of correction of the misaligned teeth withdentin-bonded, all-ceramic crowns and/or veneers.The patient was informed of the potential for damageto her teeth as a result of their preparation and wastold that there was little information concerning thelong-term success rate of the proposed restorations.However, she was given details of satisfactorymedium-term success rates in a retrospective evalua-tion." The patient, so informed, elected to proceedwith the revised treatment plan that did not involveorthodontics.

The length of the cuspids was functionally correct,so that it was necessary to lengthen the central incisorand weaken the pointed cuspid teeth without shorten-ing them. An all-ceramic laboratory technique wasused with dentin bonding (Scotchbond 1 and Rely XARC Dual Cure Cement, 3M Dental Products).

An additional challenge was that the crowns/ve-neers had to be completely finished from Monday toFriday because of the patient's busy work schedule.The results are shown in Figs 2b and 2c.

Comment

It is the clinician's responsibility to effectively treat thepatient while causing as little harm as possible. The aimmust therefore be to create a restoration that will belong lasting and which causes as little damage as possi-ble to the periodontal and pulpal tissues, Porcelain-fused-to-metal crowns vtith subgingival margins requireextensive removal of tooth substance and may be detri-mental to the periodontium. Dentin-bonded crownsand veneers require minimal preparation and thereforemay be considered the treatment of choice for esthetictreatment." The patient was provided with all availableinformation regarding her proposed treatment, and,thereby informed, decided not to seek orthodontic in-tervention. Rather, she chose the restorative route, de-spite the fact that tooth preparation, albeit minimal,was required- The benefit of this treatment to the psy-chologic well-being of the patient and, thus, to hersinging career cannot be underestimated.

CASE REPORT 3

A 30-year-ol(i woman presented requesting removal,for esthetic reasons, of an amalgam restoration in hermandibular left first molar tooth (Fig 3a). The patientwas initially counseled that there were no physical rea-sons for the replacement of the amalgam restoration^''and that the potential longevity of a tooth-colored re-placement restoration could be less satisfactory,"

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Fig 3 (a) Mandibular first molar with amalgam restoration: inferproximal caries diagnosed, lb> Teeth were isolated with rubber dam, ahdthe old amalgam restoration was removed, (c> Cavity outline ih ¡irsf molar determined by existing amalgam restoration and estent of canes.Minimal cavity prepared in occlusai aspeot of mandibular second molar, (d) Enamel and dentin etched, (e) Deniin-bonding agent applied¡Prime & Bond NT. Dentsply). Sectional matrix (3M Dehtal Products) was applied and wooden wedge inserted, Interprosimal contact im-proved by the placement of the separating ring (f) Flowable composite applied to the floor of the cavity (Filtek Flow, 3M Dental Products).fg^lncremenfalburldupof the distal wall with composite (Esthet-X, Dentsply) fhj After enamel shades were placed and adapted (A2, At.and CE) in 2-mm increments, final increment was placed and tiie matrix band removed, (i) With the restoration tinished and polished, therubber dam was removed and discs and points were used lor final finish, (i) Postoperative view.

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However, the patient elected to proceed, and a bitew-ing radiograph was taken. This showed the presence ofinterproximal caries affecting the first molar tooth.Caries was also diagnosed on the occiusal suriace ofthe mandibular second molar tooth. Both teeth wererestored with resin composite as illustrated in Figs3b to 3j.

Comment

Replacement of functional, satisfactory, amalgamrestorations at a patient's request may present a diffi-cult ethical problem, given that the potential for suc-cess of resin composite restorafions in posterior teethmay be less than for amalgam.'^ This is all the morelikely if inadequate attention is paid to the details ofthe restoration placement, given that the placement ofresin composite restorafions has been considered to be"technique sensitive." In the case described, this ethi-cal dilemma first seemed to be present, although theradiographie discovery of caries meant that restora-fions were Indeed indicated. With regard to resin com-posite restorations in posterior teeth, there is evidencethat good success rates may be obtained under opti-mum conditions,"" and in the case described, stepswere taken to ensure isolafion and meficulous place-ment technique. It is necessary to build restorationsincrementally and to take steps to ensure that poly-merization contraction stresses do not build up witbinthe restoration or at its margins. Accordingly, in therestorations illustrated, a flowable composite wasplaced at the base of the restoration. Rubber dam iso-lation was used to prevent moisture contamination,and great care was taken to ensure a good interproxi-mal contact. Attenfion to such detail is paramount if asuccessful restoration is to be achieved.

DISCUSSION AND CONCLUSION

Esthetic dental health is increasingly sought after,globally, for reasons of patient self-esteem. It is oftenimportant to a person's well-being. However, noready-made definition of esthetic health exists. It maymean different things to different persons, as illus-trated in the cases described. When patients requestan esthetic treatment, the clinician can make the pa-tient aware of what the clinician may be able toachieve. It is then for the patient to decide-esthetictreatment should be patient led, but clinician guided.Patients should be aware of the longevity of esthetictechniques before making an informed choice, espe-cially if the esthetic materials and techniques are notas long lasting or cost effective as "traditional" tech-

niques. Esthetic treatment may or may not be cost iri-tensive. At all times, treatment must be of the opti-mum quality; this is especially relevant to elective pro-cedures of an esthetic nature.

Finally, there would appear to be an increasing argu-ment for insurers to include such treatment in theirschemes, provided that the psychosocial need can beidentified and the longevity of the treatment guaranteed.

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