Comprehensive

ESTHETIC

Dentistry

A CIP record for this book is available from the British Library.

ISBN:
978-3-86867-294-7 (ebook)
978-1-85097-278-5 (print)

Quintessence Publishing Co Ltd

Grafton Road, New Malden, Surrey KT3 3AB

Great Britain

www.quintpub.co.uk

Incursiune în Estetica Dentară

Copyright © 2013
SSER (Societatea de Stomatologie Estetică din România)

Editing: Quintessence Publishing Co Ltd, London

Index: Indexing Specialists (UK) Ltd

Production: Quintessenz Verlags-GmbH, Berlin, Germany

Foreword

In our modern society, the value of a smile is becoming increasingly important. Smiling is one of our most powerful communication tools and can influence people’s first impressions significantly. It has a fundamental impact, not only on esthetics, but also on facial expressions, masticatory function, phonetics, and verbal expression.

A healthy smile showing bright white teeth represents a combination of the perception of “beauty” and “health.” A common request from patients all over the world nowadays is for dental treatments that optimize esthetics and function in order to help them enhance their self-esteem and improve their professional and personal relationships.

The challenge for the modern dentist is to balance the esthetic and functional objectives, and seek to achieve the best result through minimally invasive dental procedures that respect the biological parameters.

The authors of this book have made a valuable contribution to our profession by putting together, in a clear, efficient, understandable, and logical way, all the concepts related to dental esthetics, explaining them from both an academic and a practical point of view.

The entire dental community will benefit greatly from the contents of this book.

Mauro Fradeani, MD, DDS

Acknowledgments

I could not have imagined, a decade ago, that the Romanian Society of Esthetic Dentistry would have reached such a high standing and be so widely appreciated. Through our activity over the 10 years of our existence, we have succeeded in putting together, step by step, a solid organization, whose anniversary we are now celebrating in a distinctive way. The motto describing us is associated with the name of our society and is meant to be a constant reminder of our duty: “Dedicated to excellence in esthetic dentistry.” Our entire activity has revolved around this motto. Everything we have undertaken, from the organization of conferences and courses, to editing books, guidelines, newspapers, or special journals, to setting up campaigns or press conferences, has been related to the promotion of the values of esthetics in dental medicine.

This book represents the pinnacle of the work done by the Romanian Society of Esthetic Dentistry. It is a great achievement; the result of passion, knowledge, skill, dedication, and days and nights of hard work. I coordinated a team of extraordinary authors, who placed quality above all, and who aimed to share their knowledge, accumulated through years of work and study. I wish to thank all the authors, as well as all those involved in producing this book.

This English edition follows a Romanian edition of 10,000 published and distributed copies, which represents a solid foundation for the education of Romanian dentists in the field of esthetic dentistry.

This publication represents the first Romanian book published in English by the prestigious Quintessence Publishing, and this is both a great honor and a great responsibility.

I would like to express my gratitude to Dr George Freedman and Dr Mauro Fradeani, as well as other true leaders in esthetic dentistry, for their friendship and continuous support.

Many thanks to Ovidiu Tabacaru, who helped me with the photographs and figures, and who succeeded in setting such a high standard for the imagery in this book.

And finally, a very special thank you to my parents, who taught me the moral values and opened up for me the path to knowledge, then helped me to remain straight on it, always looking ahead. And, of course, many thanks to my “girls”, Magda and Alexandra, from whom I stole big chunks of dedicated time.

Florin Lăzărescu, DMD

Comprehensive Esthetic Dentistry

Preface

The idea of this book appeared five years ago, when we undertook the task of publishing a medical specialty book with a print run of 10,000 copies to be distributed throughout Romania. The budget for producing so many copies of a book is huge, and only by accessing non-refundable co-financing was this project possible.

The success of the Romanian edition propelled us into a partnership with the prestigious Quintessence Publishing, the English version being, in accordance with the wishes of ourselves and the editors, the first in a series of translations from various national editions.

The content covers the entire range of esthetic dentistry, including all the information a dental surgeon would require to be able to practice esthetic dentistry on a daily basis.

In choosing the co-authors, we intended maintaining a balance between academics – who are implicitly highly professional when writing for their specialty, and whose experience is extremely valuable – and practitioners, who have a rich store of case records, and who have been trained in international centers by top specialists. Their contribution offers a fresh and clear outlook, interesting cases, and a straightforward writing style acquired through their daily activity in the dental office.

The book mainly addresses dental practitioners who want to improve their work and put a beautiful smile on their patients’ faces as a guarantee of quality. By integrating the information in this book into your daily practice, you can become a dentist oriented toward dental esthetics. We are also sure that even the more experienced among you, with vast experience in esthetic dentistry, will be able to find useful information that will help improve your daily work.

The book is composed of 15 chapters, divided into two parts by an invisible line. The first part includes information and data that lay a solid foundation for the clinical activities described in the second part. Thus, the first eight chapters comprise introductory elements and general principles of dental and dentofacial esthetics, such as photographic examination, communication with the patient in the esthetic assessment, integration of the provisional esthetic rehabilitation into the therapeutic plan, materials used in esthetic restorations, minimally invasive procedures in esthetic dentistry, principles of adhesion to particular dental structures, and tooth discoloration.

Chapter IX to XV cover the practical aspects of esthetic dentistry, such as the esthetic restorations of the anterior and lateral teeth, the protocol for adhesive fixations in esthetic restorations, CAD/CAM systems, and techniques in the dental office.

The final three chapters introduce a modern, interdisciplinary, prosthetic-orthodontic-periodontal approach, consisting of complex cases that require teamwork for a successful outcome.

We conclude by wishing you success in your professional activity, and wonderful smiles on the faces of all your patients.

The authors

COSMIN ULMAN

SMARANDA BUDURU

RAREŞ BUDURU

Chapter I

ESTHETIC DENTISTRY IN THE MODERN DENTAL PRACTICE

Consequently, as dental estheticians, we can certainly enter our patients’ lives and change them for the better, forever. An amusing story from a dental practice describes a female patient who had had her smile reconstructed by applying 10 maxillary dental veneers, after an almost complete body makeover. After finishing the dental esthetic treatment, she declared that everybody had noticed a change in her for the better, while the esthetic modifications of her body had remained unobserved by her close friends and relatives.

Frequent discussions during esthetic dental congresses refer to the following questions: “Is there an esthetic dentistry and an unesthetic one?” and “Do I want to make an esthetic restoration today and a non-esthetic one tomorrow?” We do not want to believe that these contrasts exist, but definitely the final results differ from dental practice to dental practice and from patient to patient. The difference between a dentist who specializes in esthetic dentistry and a general dentist is that the former, before starting a treatment, will make an evaluation of the smile and of the type of patient. This will assume solid knowledge regarding facial, dental, and periodontal esthetics, as well as good communication skills, in order to understand what the patient wants and expects. In conclusion, the dentist must be not only first and foremost a professional, but also a fine psychologist.1,2

This is why we thought of systematizing the factors that differentiate between a dental practice with exceptional esthetic results and one with more modest results. These factors are related to the dentist, personnel, equipment, patients, and management.3–5

Let us say we have a dental practice, new or old, and we would like to change its profile and concentrate more on dental esthetic treatments. Where should we begin? How should this transformation take place? Once, during a congress where several esthetic cases were presented, I heard some dentists in the room talking and complaining that they did not have patients who “would ask for such treatments”. This idea is totally wrong! Never, or extremely rarely, will a patient ask the dentist for a certain type of treatment. The algorithm we should follow is: information; knowledge; practice; proposal; persuasion; and, finally, undertaking the treatment. In other words, the dentist must have state-of-the-art information and must undertake as many continuing medical education courses as possible, and dedicate a good part of his/her free time to accumulating new esthetic dentistry knowledge. We consider that anyone can become a successful esthetician, the only question is: What should one give up for this purpose? Mainly, a great deal of free time needs to be dedicated to study.6–8

For this training to be successful in daily practice, dentists should make an informed choice regarding the types of courses that could offer them these skills. We consider that, in addition to esthetics courses in prosthetics, dental occlusion, color, dental photography, periodontology, and implantology would be necessary. The knowledge acquired during courses and congresses should be permanently added to and developed by reading reference books in the field and subscribing to various publications in order to be continually updated about new trends and technologies.9,10

The personnel of the esthetic dentistry practice must always be trained, according to their position, in the treatments that are carried out in the dental practice. The patient’s first contact is the person who answers the phone at the reception desk. This person plays a major role because s/he offers the first impression, which can be defining for the whole office. S/he should be a pleasant and extremely professional person, who will win the patient’s trust and offer enough information about treatments in a way that will persuade the patient to make an appointment. Subsequently, the meeting with the receptionist must strengthen this first good impression. Moreover, the receptionist should be able to offer relatively complex information regarding the different treatments. The details of the treatments will be offered, of course, by the dentist.

The dentist’s personal assistant is one of the most important people, as s/he is closest to the dentist, knows the treatment stages in detail, and can provide the patient with valuable information. The personal assistant can also confirm the dentist’s professionalism and qualities by telling the patient about successful cases completed by the dentist. Very often patients trust information offered by a team member because that team member does not have a direct material interest in the case.11

Dentists are at the top of this ladder and, until they meet the patient, their image must be enhanced each time the patient meets with other team members. This is why the way the auxiliary staff talk, as well as their smiles and general appearance, influences the dentist’s image. When meeting the patient, the dentist must be able to listen to the patient’s wishes, to inspire trust and confidence, and to explain all possible treatments in such a way that the patient can easily understand. S/he must present all treatment types that may meet the patient’s needs, instead of waiting for the patient to suggest his/her own ideas for treatment.

The esthetic dentistry practice must be congenial, clean, nicely perfumed, and have an attractive atmosphere. There should be numerous photos showing wonderful smiles, albums with “before” and “after” cases, explanatory videos, and brochures, which will encourage the patients’ interest and their wish to obtain more information.

In addition, the practice should be equipped with all that is necessary for performing the esthetic treatment correctly: an esthetic analysis sheet; a very good camera and everything that has to do with photos and case documentation; large-screen computers and smile design software; a large range of composites to form the mock-ups; rotary instruments (turbines, multiplication pieces, reduction pieces, finishing pieces, precalibrated mill sets, and specific forms for making precise preparations); augmentation optical instruments (dental microscopes or loupes); quality materials for making the provisional works, in color ranges with pigments and glazes; precision impression materials, preferably with automatic mixing for increased quality; specific materials and instruments for expanding the sulcus; equipment for optical impression; colorimeter and spectrophotometer for colored maps; materials for bonding; airborne particle-abrasion instruments; ultrasound baths; isolation systems; several adhesive cement systems; and finishing systems.

The patient entering the esthetic dental practice has specific wishes and the dentist must be a good psychologist in order to make a correct selection of the patients who can be treated. Generally, the patients who want to increase their self-esteem and their self-confidence are looking for better social, personal, and professional perspectives. They have real personal complexes, or are people who have been influenced by the beautiful images reported in the media, or by acquaintances who have successfully changed their appearances – the thereby their lifestyles – in their search for eternal youth.

The patients to be avoided are those who have visited several esthetic practices, have changed many of their treatments over a short period of time and for whom no treatment has been good enough, and who have a totally unrealistic vision of what they could look like. The patients who are going to be treated will become very close to the esthetician because s/he must understand their wishes and visions about this image change. Treatment will start only after patients have understood the procedure, and accepted, by signing a consent form, the medical team that will take care of their case, as well as the timespan and the specified costs involved.

After the treatment ends, the patient will have to be monitored and educated in order to maintain the correct dental hygiene and relevant lifestyle. Besides having regular checkups, patients should receive information periodically regarding new treatments as they appear (this should be done only with the patient’s consent). We suggest that patients should also be sent greeting cards for their birthdays or at Christmas or Easter, in order to show them that they are important to the practice.

The dentist may become an exceptional esthetician as long as s/he is passionate about beauty in general and about esthetic dentistry in particular. We also believe that the dentist’s smile, and those of his/her team, is an additional argument for the patient to choose an esthetic solution. Knowledge regarding the materials and techniques, as well as how to achieve esthetic results, will make estheticians believe in what they are doing, and thus they will be able to easily convince their patients of the quality of their treatments. If the dentist believes in the treatments offered, so will the patient. Let’s not forget that we have the chance to change our patients’ lives, to give them back their self-esteem and to make them happy, and this is absolutely extraordinary!

1.2 INTERDISCIPLINARY COMMUNICATION AND RELATIONSHIP

The remarkable progress made by dental medicine in the past decade has led to an extremely large number of available therapeutic options. To reach optimal performance in so many aspects of dental treatments, the dentist should be continuously in touch with the vast amount of information that appears (courses, presentations, specializations, etc). This is why it is ideal for complex cases to be approached and solved by a team of specialists. These specialists should work together like an orchestra, led by the esthetician dentist, who is the “conductor”.

A possible scenario would be the following: the patient arrives at the esthetic dental clinic and is met by the case coordinator, who is the dentist who will write the case history, conduct the examination, establish the patient’s needs and wishes, and decide which esthetic problems should be resolved by carrying out the prosthetic procedures.

At that moment, the dentist will be able to decide, after making a complex analysis, the final plan, ie, what the final result should be. Knowing the starting point (the patient’s initial situation) and the end point (the final situation with the approved esthetic result), the coordinator can propose the treatment stages. In other words, an actual treatment, assumed both by the dentist and the patient, requires that the final result is known in detail and with certainty. This final point will allow previous stages to be seen, and allow a decision about what in the initial situation has to be changed.

Most of the time the dentist has a vague idea regarding the final result, and subsequently most of the stages of the case are decided as s/he is working, sometimes in an empirical manner. The patient does not know the final result and creates his/her own vision and idea, which is often completely unrealistic. Many of the tensions and problems that occur between the dentist, the patient, and the technician are caused by different visions. Without knowing the final result precisely, the dentist is in the awkward position of “selling” a final product to the patient without actually showing him/her anything. To draw an analogy, it is like a situation where someone wants to buy a car, but after arriving at the sales office, finds that there is no car inside, no possibility of a test-drive, and no photo; only the car dealer describing a potential acquisition. Would you invest a large sum of money in a car without seeing it? Highly improbable!

This is why we always start a complex esthetic treatment just as one would the construction of a house: first the outside facades are drawn (the final esthetic project), then the internal division of the house (treatment stages), then the loadbearing elements, the installations, etc (the pre-prosthetic treatment itself), and thus working back to the foundation (the patient’s initial situation).

After taking all these steps, and knowing precisely the final image of the patient, we suggest a meeting of the team of specialists who will be involved in resolving the case. The team can meet physically, or a videoconference can be scheduled.

At this moment, the treatment coordinator will present the case to the team (photos, models, radiographs, computed tomography scans, the final project) and they will decide on the correct staging of the case and what work each specialist has to do.

This is a very important moment because all those involved will have an image of the final result and will be able to assess if the proposed intermediary stages can be finalized successfully. Each specialist will be able to explain to the coordinator exactly how each stage will be realized, how much time will be needed, and what the period required will be. The coordinator can provide exact details about the projected result, and thus all those involved can be in agreement. At this moment, the final treatment plan can be written, the approximate costs can be evaluated, an estimation of the period of time required can be made, and appointments can be scheduled for the patient.

In our experience, dentists from several fields can be involved, eg, restorative therapy, orthodontics, endodontics, periodontics, surgery-implantology, in order to resolve a complex case.12,13 Now we shall examine each specialty.

1.2.1 Restorative therapy

It is preferable when a prosthetic treatment is required on vital teeth that have old fillings, that these fillings should be redone, even if they seem to be correct at clinical or radiological examination. We suggest this because it is possible that when, for example, one is making the ceramic veneers on the maxillary anterior teeth, these may have proximal fillings. These fillings can produce a pulpitis after finalizing the veneers, which the patient might erroneously assume were created by the prosthetic treatment. By remaking the fillings we ensure that the teeth were treated by us, and in the case of failure, we can assume responsibility for the problem on the basis of our treatment, not that of other dentists.

Another reason is that it is possible when removing the old fillings that complications of existing dental caries that were not suspected by the patient (an asymptomatic tooth) or by the dentist could be discovered.

There are situations where the patient has teeth with caries, on which prosthodontic treatment should be carried out for esthetic purposes. Even if they do not seem extensive, they should be treated before starting the esthetic treatment. We suggest this because the clinical and radiological examinations do not always provide precise information regarding the extent of the decay. Thus, the margin of the prosthetic restoration at the end of the treatment can be modified: it is known, for example, that the ceramic veneer should preferably have the margins on the enamel. Also, the color of the restorations must sometimes be changed (more often in the case of a lighter shade) in order not to influence the final result (eg, that of a thin veneer) or for the color to be matched with the bleached teeth.

1.2.2 Whitening therapy

There are a series of dental whitening procedures that involve the use of thermoformed trays in which an active substance of different concentrations is applied, and which the patient can use either at home or under medical supervision. There are also whitening procedures that take place in the dental office and can be performed with the help of a polarized light lamp or a laser. These procedures have the advantage of being quicker and less painful before and after the intervention through better control of the whitening substances and of the marginal periodontium (see Chapter VIII).

The whitening treatment should be scheduled in advance, as it takes some time until the color stabilizes. Also, studies show that a specific period of time between the whitening and the bonding of the veneers should be allowed in order not to compromise the quality of the adhesion.14-16

1.2.3 Occlusal therapy

Occlusal therapy is one of the key factors in ensuring final success. The initial occlusal examination is vital before starting the treatment. The main objectives are occlusal stability in maximum intercuspation (MI) and centric relation (CR) and providing the functional guides (in anterior and lateral movements).

Screening the active and passive interferences in the mandibular kinematics protects the dentist from future failures. The analysis of the anterior guidance is extremely important, especially for esthetic restorations in the maxillary anterior region. For example, patients frequently have dental crowding in the mandibular anterior area. This may determine active protrusive interferences, which will produce fractures of the veneers, uneven abrasion of the incisal edges, and debonding of the classically cemented crowns. Also, inferior dental crowding requires initial orthodontic treatments or leveling of the occlusal area by selective grinding or coronoplasty, in order to make a correct upper guidance.

These modifications must be explained to the patient at the beginning of the treatment and not at the stage when the ceramic reconstructions have been tried-in and signs of occlusal dysfunction appear. In this situation, we have to modify the treatment plan while carrying it out, which leads to higher costs and extra time, including the patient’s lack of compliance and compromise. Let us not forget that the passive protrusive interferences, especially in the last molars, may determine modifications in the anterior teeth (dental diastema, protrusions, extrusions, mobility), a situation which is also known as the Thielemann phenomenon.17

The lack of mandible stability in MI and CR may cause it to slide sagittally or transversally, with microshocks in the restorations and the development of complications, either in the reconstructions or in the dentomaxillary apparatus: dental (abrasions, pulp complications), periodontal (gingival recessions with the exhibition of the dental-prosthetic junction, position modifications, mobility), muscular (pains, spasms, contractures), and articular (blockages, pain, modifications in dynamics, articular noises). In global esthetic restorations, the CR position will be the only reference point.18 This is why the dentist must know mandible manipulation and CR recording techniques. In this situation, the vertical dimension of occlusion (VDO) should be considered as well. It can be modified only in CR, and by choosing an optimum VDO, the dentist can gain extra space for restorations.19

In conclusion, dental occlusion is the key factor that provides both the functional esthetic restorations and the health of the dentomaxillary apparatus. It is the esthetician’s wish that the patient should enjoy not only an improved esthetic image, but also the ability to function well with the esthetic restorations. Our patients should not only look good, but also eat well (correct mastication), speak well (correct phonation), and be able to express their satisfaction with the restorative work.

1.2.4 Orthodontic therapy

Orthodontics has been (and sometimes still is) underevaluated as it is considered a treatment only for children and teenagers. But this type of treatment is an extremely important tool in esthetic dentistry. Sometimes, without preliminary orthodontic treatment, the positive results of the esthetic treatment are improbable, or even impossible. We have tried to summarize some indications for orthodontic treatments for esthetic purposes:20,21

• Dental vertical movements: these refer to the intrusion of extruded teeth that exceed the occlusion plane and prevent the prosthetic restoration of the antagonistic arch (the correction of the occlusal sagittal curves), the intrusion of a central incisor for the symmetry of the gingival margins if a periodontal intervention is not wanted. A tooth with incomplete eruption, or the entire anterior group, can be modified in order to correct the incisal curve to be parallel with the line of the inferior lip.22

• Retrusions or protrusions of the anterior teeth whose initial position would modify the prosthetic solution or would involve a deeper tooth preparation.

• In cases of diastemas that are too large, dental movements can be made in order to redistribute the interdental spaces for better proportions between width and length.

• Remaking the contact points by modifying the dimensions of the interdental papillae.

• Straightening the rotated teeth by opening the spaces for the dental implantations and correcting the distribution of the mastication forces in the teeth axes.

• The orthodontic extraction of an untreatable tooth in order to create bone for implants.23,24

• Solving dental crowding by correcting the arch forms and the active centric line and functionally esthetic lines.

• Remaking the guidances (especially in solving anterior crowding) and the occlusal stability by re-establishing the multiple contact points in MI and CR.25,26

• Slightly correcting the gingival smile orthodontically, more in connection with orthognathic and periodontal surgery.27

• Modifying the dental axes and correcting the width of the smile.

All these modifications are extremely important because they aim to outline the dental, periodontal, and facial esthetics criteria, and finally help to perform a minimally invasive treatment.

1.2.5 Endodontic therapy

The current trend in dentistry is called “minimally invasive”. This means a minimal preparation for veneers with a minimal sacrifice of dental structure.

It is obvious that in this situation, endodontic treatment appears to be a therapy that is far away from this viewpoint.

However, there are a series of situations that would indicate this therapy:28

• Extensive carious decay that compromises the pulp or is in close proximity to the pulp chamber, which would cause problems during prosthetic treatments.

• Incorrect endodontic treatments.

• A vital tooth that has insufficient dental tissue to ensure the retention of future crowns.

• Orthodontically unrecovered dental malpositions that need a large sacrifice of dental substance.29–31

1.2.6 Implant therapy

Implant therapy is an area that is continually gaining more ground in current dental practice. However, esthetics based on anterior implants requires special care. These particular aspects refer to:

• Non-traumatic extractions with special instruments to allow immediate implantation.

• The stability of the esthetic results, for which the area should be augmented with connective tissue graft.

• The positioning of the implant, which is vital both for correct esthetics and for the prevention of subsequent vestibular recessions.

• Cases where the CT shows enough bone to make a flapless implant insertion in order to avoid gingival scars in the anterior area.32–35

1.2.7 Periodontal therapy

Another very important trend in dentistry nowadays is represented by the increased attention paid to the connection between periodontal and prosthetic treatments. This connection is the weak point (“Achilles’ heel”) and the place where patients most often notice that “the tooth is a fake”.

Any successful esthetician should ideally have a skilled periodontist as a very good friend. More and more emphasis is being placed on pink esthetics and the junction between the tooth and the gum. The aspects in which periodontics for esthetic purposes can be of great assistance are:36–43

• Making correct gingival outlines with the symmetry of the central incisors and the gingival level of the lateral incisors below the tangent between the canines and the centrals.

• Making the correct gingival zeniths.

• Obtaining correct dental proportions.

• Obtaining more thickness in the fixed gingiva in order to mask the dark color of the dental root through a thin periodontium.

• Remaking the outline of the vestibular cortical bone, both for implants and for the edentulous ridge in the anterior area.

• Covering the gingival retractions.44

• Reconstructing the papillae.45

• Treating gingival excess.

• Preparing the site for the ovate pontic in the edentulous ridge.

Some clinical cases are now presented, which exemplify the idea of interdisciplinarity in esthetic treatments (Figs 1-1 to 1-24).

1.3 THE RELATIONSHIP BETWEEN THE ESTHETIC DENTAL CLINIC AND THE LABORATORY AND DENTAL TECHNICIAN