Global Health Nexus, Winter 2004

A Pioneer's Perspective on the Origins of the Esthetic Revolution

Dr. Ronald E. Goldstein
Dr. Goldstein, the inaugural recipient of the NYU Irwin Smigel Prize in Aesthetic Dentistry, is a cofounder and past president of the American Academy of Esthetic Dentistry, a past president of the International Federation for Esthetic Dentistry, and holds professorships at the Medical College of Georgia, the University of Southern California, Boston University, and the University of Texas Health Science Center.

Global Health Nexus (GHN): Dr. Goldstein, how did your approach to esthetic dentistry evolve?

Dr. Goldstein: After I completed the first two studies on factors motivating dentists toward esthetics in dentistry, published in The Journal of Prosthetic Dentistry in 1968, I began to map out a concept of what needed to be done in order to expand dentistry’s preoccupation with occlusion and function of the stomatognathic system in order to incorporate esthetics as well. I then spent seven years working on what would become the first comprehensive interdisciplinary textbook on esthetic dentistry, Esthetics in Dentistry (J.P. Lippincott Publishing, 1976; B.C. Decker Publishing, 1998), which addressed the role of each dental specialty, plus plastic surgery and cosmetology, in making the total face more attractive. This was followed by Change Your Smile(Quintessence Publishing, 1984), a comprehensive consumer guide written in response to a thirst for knowledge that had been stoked by the media. 

GHN: What role did consumer demand play in dentistry’s decision to embrace esthetics?

Dr. Goldstein: Beginning in the mid-1960s, consumers began to feel that gold and silver restorations were no longer attractive or natural looking, especially given the “black smiles” that silver produced. So, in order to satisfy the patient’s desire for a more attractive smile, dentists began to experiment with tooth-colored filling materials which were esthetically attractive, but which failed miserably in life expectancy. 

Then, in 1965, I received a call from Dr. Michael Buonocore, a co-inventor of the BisGMA formula, who told me that he and Dr. Raphael Bowen had developed a material that would repair fractured teeth, and they wanted to know what else it might be used for esthetically. My challenge was to come up with various esthetic techniques and to let him know specifically which ones endured over a period of time. In fact, when I received the first batches of the material, there was no manufacturer’s name attached to the labeling. (The material later became known as 3M’s Addent.) You cannot believe how excited I was to be utilizing material that enabled us to achieve immediate transformations of esthetic deformities. This is when we came up with techniques such as closing spaces, building out teeth to create the illusion of straighter teeth, and masking discolored teeth.

I still recall the excitement of dentists when I reported my five-year results, showing that not only was instant transformation possible, but that it held up as well. However, the polishability, staining, and self-curing nature of the composites were limiting factors. This motivated manufacturers to develop microfill to be used in “sandwich techniques” to make the restorations look better.

This still left the problem of the self-cured restorations, which cured too fast and were difficult for dentists to use. You had to work extremely fast to get the desired shape. So experimentation continued and in 1972 the next advance arrived: light-cured composites. This time I received a call from L. D. Caulk, announcing that they had developed a material that could be cured with an ultraviolet light, and informing me that they were sending me a prototype of the first curing light, and that I would have 90 days to evaluate it. When the light arrived, it was actually chained to a courier, and he would not take the chain off the package until he was ushered into my operatory and could release it into my personal care. This was a huge ultraviolet light, using a material called Nuvafill, but the results were spectacular. Despite a negative response from the profession, I predicted that these lights would be effective, and they have since far exceeded my predictions to become the gold standard for functional and esthetic procedures today.

: In addition to the shift in emphasis from function to esthetics in dentistry and the advent of improved materials, what other factors helped bring about the esthetic revolution?

Dr. Goldstein: The economics of esthetic dentistry also helped to popularize the field. Suddenly, people who could not afford gold restorations and did not like the appearance of silver were able to have a bonded restoration for 20 to 25 percent of the cost of a crown. And even if the restoration had to be replaced later, it was still more affordable than the cost of one crown.

Finally, the ability to show patients what they would look like prior to treatment, using computer imaging or “trial smiles,” has been a major factor in helping to convince Americans that, by giving them great smiles, dentists could enhance their appearance and self esteem — a skill previously associated mainly with plastic surgeons.

GHN: As the esthetic revolution has advanced, have there been drawbacks?

Dr. Goldstein: Once a national conversation about dental esthetics got under way, much of the information being disseminated was inaccurate, not easily accessible, or the results shown in the media were not reproducible.

Moreover, not all dentists are equally proficient in esthetics. There were and still are many costly esthetic failures, with a loss to patients of approximately $13 billion annually. In a course I teach called “Esthetic Failures,” I am adamant that as a profession we need to do a better job of referring patients for esthetic dentistry to the most skilled professionals. Indeed, I always tell consumers: “Match your desire for esthetic dentistry with the dentist’s ability to provide it for you.”

We also need to do a better job training our colleagues to recognize, and avoid, patients who are body dysmorphic — who believe that by changing their smiles, all the problems in their lives will be solved. In those cases, failure is virtually guaranteed.