Esthetic Dentistry: A Clinical Approach to Techniques and Materials pdf

Kenneth W. Aschheim,
DDS, FACD
Assistant Clinical Professor, Department of Dentistry
Mount Sinai School of Medicine of New York University
Assistant Attending Dentist, The Mount Sinai Hospital
Private Practice
New York, New York
Barry G. Dale,
DMD, FACD
Assistant Clinical Professor, Department of Dentistry
Mount Sinai School of Dental Medicine of New York University
Assistant Attending Dentist, The Mount Sinai Hospital
New York, New York
Private Practice
Englewood, New Jersey
SECOND EDITION
With 975 illustrations
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SECOND EDITION
Copyright© 2001 by Mosby, Inc.
Previous edition copyrighted 1993.
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Library of Congress Cataloging in Publication Data
Esthetic dentistry : a clinical approach to techniques and materials / [edited by] Kenneth
W Aschheim, Barry G. Dale 2nd ed.
p. ; cm.
Includes bibliographical references and index.
ISBN 0-323-00162-9 (hard cover)

1.
Dentistry-Aesthetic aspects.

I.
Aschheim, Kenneth W

II.
Dale, Barry G.
[
DNLM:

1.
Esthetics, Dental.

2.
Dental Materials.

3.
Dental Restoration, Permanent.
WU 100 E79 2000]
RK54 .E88 2000
617.6-dc21

00-048046
01
02 03
04 05 OW / KPT 9 8 7 6 5 4 3 2 1
Fred B. Abbott,
DDS, MDS, FACD
Life

Member, American College of
Prosthodontics
Former Associate Professor
Northwestern University
School of Dentistry
Chicago, Illinois
Practice Limited to Prosthodontics
Salisbury, Maryland
Nellie Abbott,
PhD, RN
Former Associate Administrator
Nursing Hospital of University of
Pennsylvania
Former Associate Dean
Nursing Practice
University of Pennsylvania
School of Nursing
Philadelphia, Pennsylvania
Milton B. Asbell,
DDS, MSc, MA
Clinical Associate Professor
Department of Community
Dentistry
Temple University
School of Dentistry
Staff, Department of Dental
Medicine
Einstein Medical Center
Philadelphia, Pennsylvania
Jerry B. Black,

DMD, MS, FACD
Private Practice
Birmingham, Alabama
Phillip Bonner,
DDS
President
Bonner Communications, Inc.
Atlanta, Georgia
Daniel Buchbinder,
MD, DMD
Professor of Oral, Maxillo-Facial
Surgery and Otolaryngology
Department of Dentistry
Division of Oral, Maxillo-Facial
Surgery
Mount Sinai School of Medicine
Head, Division of Oral, Maxillo-
Facial Surgery
Department of Dentistry
Mount Sinai Medical Center
New York, New York
Trudy M. Burke,
DDS, MS
Clinical Assistant
Department of Restorative and
Prosthodontic Sciences
New York University
College of Dentistry
New York, New York
Vincent Celenza,

DMD
Diplomate
American Board of Prosthodontics
Private Practice
Manhattan, New York
Charles 1. Citron,
DDS, MScD
Director of Pediatric Dentistry
Dental Department
New York Hospital Medical Center
of Queens
Queens, New York
David R. Federick,
DMD, MScD
Adjunct Associate Professor
Department of Fixed Prosthodontics
University of Texas
School of Dentistry
Houston, Texas
Adjunct Clinical Assistant Professor
Department of Restorative Dental
Sciences
Boston University, Goldman School
of Dental Medicine
Boston, Massachusetts
Mark Edward Jensen,
BS, MS, DDS,
PhD, FACD, FADM, CBGD, DABFD
Director
Minnesota Dental Research

Associates
St. Paul, Minnesota
Mark P King,
DDS, MS
Assistant Professor
University of Texas, Dental Branch
Houston, Texas
Richard J. Lazzara,
DMD, MScD
Assistant Professor
Department of Periodontics and
I
mplant Regeneration
University of Maryland
Baltimore, Maryland
Enrique Lenchewski,
DDS
Assistant Clinical Professor
Department of Implant Dentistry
New York University
New York, New York
Assistant Attending
Department of Dentistry
Mount Sinai Medical Center
New York, New York
Charles Andrew Lennon,
DMD
Assistant Attending Dentist
(Prosthodontict)
Oral and Maxillofacial

Reconstructive Department
New York Hospital
New York, New York
Vi
CONTRIBUTORS
Edward C. McNulty,
DMD, MDS,
FACD, FICD
Clinical Associate Professor
Chairman, Orthodontic
Department
New York University
College of Dentistry
New York, New York
Co-Chief, Orthodontic Division
Department of Surgery (Dental)
Lenox Hill Hospital
New York, New York
Senior Attending Staff
Dental Clinic
Greenwich Hospital
Greenwich, Connecticut
Richard D. Miller,
DDS, FICD
Former Associate Clinical Professor
Division of Restorative and
Prosthodontic Sciences
New York University
College of Dentistry
New York, New York

Attending Staff
Department of Surgery-Section of
Oral Surgery
Greenwich Hospital
Greenwich, Connecticut
Ross W. Nash,
DDS
Clinical Instructor
Department of Restorative
Dentistry
Medical College of Georgia
School of Dentistry
Augusta, Georgia
Francis V Panno,
BS, DDS, FACP,
FICD, FACD
Professor and Head
Division of Restorative and
Prosthodontic Sciences
New York University
New York, New York
Professor and Chairman
Department of Prosthodontics and
Occlusion
New York University
College of Dentistry
New York, New York
Mitchell S. Pines,
DDS
Clinical Professor

Department of Dental Materials
Science
Graduate School of Arts and
Sciences
New York University
New York, New York
Burton R. Pollack,
DDS, MPH, JD
Dean and Professor
School of Dental Medicine
SUNY at Stony Brook
Stony Brook, New York
Stephan S. Porter,
DDS, MSD, MS
Director of Clinical Dentistry
I
mplant Innovations
Palm Beach Gardens, Florida
Gregory E. Rauscher,
MD
Professor
Department of Plastic Surgery
Hackensack University Medical
Center
Hackensack, New Jersey
Professor
Department of Plastic Surgery
University of Medicine and Den-
tistry of New Jersey
University Hospital

Newark, New Jersey
Edwin S. Rosenberg,
BDS,
H.Dip.Dent., DMD
Professor
Department of Implant Dentistry
New York University
School of Dental Medicine
New York, New York
Bruce A. Singer,
BS, DDS
Clinical Assistant Professor
Department of General Restorative
Dentistry
University of Pennsylvania
School of Dental Medicine
Philadelphia, Pennsylvania
Albert Einstein Medical Center,
North Division
Jenkintown, Pennsylvania
Robert A. Strauss,
DDS
Associate Professor and Chief, Resi-
dency Training Program
Department of Oral and
Maxillofacial Surgery
Medical College of Virginia
Virginia Commonwealth University
Richmond, Virginia
Van P Thompson,

DDS, PhD
Associate Dean for Research
Department of Prosthodontics and
Biomaterials
University of Medicine and Den-
tistry of New Jersey
Newark, New Jersey
James Torosian,
DMD
Assistant Professor
Department of Periodontics
Temple University
School of Dentistry
Philadelphia, Pennsylvania
Richard D. Trushkowsky,
DDS,
FAGD, FADM
Director of Operative Dentistry
Dental Department
Staten Island University Hospital
Staten Island, New York
Michel G. Venot,
DCD, DDS,
MScD, FICD
Adjunct Associate Professor
Department of Restorative
Dentistry
Case Western Reserve University
School of Dentistry
Cleveland, Ohio

Staff Maxillofacial Prosthodontist
Department of Dental Service
Veteran Administration Medical
Center
Cleveland, Ohio
Morton Wood,
DDS, MEd
Chairman
Department of Restorative
Dentistry
University of Maryland
Dental School
Baltimore, Maryland
Ira D. Zinner,
DDS, MSD
Diplomate, American Board of
Prosthodontics
Fellow, American College of
Prosthodontists
Clinical Professor
Division of Restorative and
Prosthodontic Sciences
New York University
College of Dentistry
New York, New York
at this time is elective. Much of this treatment is what
would be considered to be esthetic dentistry including
bleaching, bonding, veneers, tooth-colored inlays and
onlays, nonmetallic crowns and fixed prostheses, ortho-
dontics, surgical procedures, and many other procedures.

Dentists and their staff must be proactive in their pa-
tient educational activities to stimulate patients to desire
these elective procedures. If dentists wait for patients to
ask for the procedures, practice activity can be influenced
negatively.
Many of the procedures in current esthetic dentistry
are not taught or are taught minimally in dental schools
because of the shortage of curriculum time. Practitioners
must learn many of these clinical concepts and tech-
niques independently after dental school graduation.
This book will assist interested persons in becoming
updated in the broad scope of esthetic dentistry. Self-
instruction is perhaps the best way to cope with the ex-
panding area of esthetic dentistry.
GORDON J. CHRISTENSEN, DDS, MSD, PhD
In memory of my parents, David and Edith Aschheim; together they
pointed me in the right direction. And to my wife, Susan, her parents,
Herb and Edith Margulis, and my children, Sara and Joshua, without
whom I could not continue to find the way.

KWA
To my parents, Jack and Frances Dale, who built a strong foundation,
and to my wife, Ellen, my son, Adam, and my daughter, Chelsea,
who assure me the stars.

BGD
Vii
cally since the education of most practitioners, or the in-
formation was simply unavailable during their formal
dental training. In fact, the myriad choices of techniques

and materials available initially may appear overwhelm-
ing. In reality, when properly organized, this body of
knowledge is easily managed. This, then, was the chal-
lenge in preparing this book: to create a definitive, all en-
compassing, single source of information presented in a
clinically relevant, easy-to-use format.
Resolution of a cosmetic dental problem requires the
practitioner to determine a diagnosis, formulate a treat-
ment plan, and select the appropriate instruments and
materials. Treatment must then be performed in an or-
derly fashion with an understanding of proper clinical
technique and specific material manipulations. The com-
petent clinician approaches any cosmetic dilemma in this
manner. We therefore organized this text to duplicate this
sequence of thought processes and clinical operations.
A troubleshooting guide (Section I) quickly directs
the practitioner to appropriate information in this text-
book. It permits diagnosis and treatment planning at a
glance and provides cross-references to more detailed dis-
cussions of material selection and clinical technique.
Section II, "Principles of Esthetics," lays the founda-
tion of basic esthetic principles. A detailed discussion of
the fundamentals of esthetics and the relevancy to den-
tistry is presented. The principles are referred to through-
out the textbook to link clinical relevancy to basic theory.
Section III, "Esthetic Materials and Techniques," aids
i
n selecting the correct materials for a specific clinical sit-
uation. The concise discussion of basic material science
enables the clinician to fully understand the ramifications

of using the various materials currently available. Further,
this serves as a basis of comparison, enabling an effective
evaluation of new materials as they are introduced. De-
tailed step-by-step clinical techniques delineate appropri-
ate armamentarium and include specific procedural nu-
ances and numerous highlighted Clinical Tips. This
facilitates a sound clinical approach. Also included is a
comprehensive discussion of special considerations, indi-
cations, and contraindications for each technique and ma-
terial presented, as well as numerous case presentations.
Section IV, "Esthetics and Other Clinical Applica-
tions," is a specialty-oriented section that presents an
overview of other clinical applications by eminent practi
tioners. Included are such dental specialties as orthodon-
tics, periodontics, and oral and maxillofacial surgery. Also
i
ncluded are emerging fields such as implantology, implant
surgery, and laser surgery as well as other clinically rele-
vant topics such as dental photography and plastic surgery.
The clinical relevance to the esthetic dentist is stressed by
using case studies, sample laboratory prescriptions, office
forms, and clinical techniques. Advanced techniques and
criteria are presented to aid the dentist in determining
when to refer a patient for specialty care.
Section V, "Esthetic Practice Management," details
i
mportant patient psychology, marketing, and jurispru-
dence information. Today's clinician will find this section
helpful in meeting the challenges facing dentistry and in
managing a successful dental practice.

As our profession enters the twenty-first century, es-
thetic dentistry offers a new era of doctor and patient sat-
isfaction and excitement.
We hope we have shared our
own enthusiasm in the pages of this text.
KENNETH W ASCHHEIM, DDS, FACD
BARRY G. DALE, DMD, FACD
ix
We
are grateful to the pioneers of esthetics
who have pre-
ceded us. We owe an enormous debt to the gifted clini-
cians of today who seek to expand the envelope of knowl-
edge. These people are our contributors.
Without their
willingness and ability to surpass all expectations and
their sharing in the common goal of creating a "state-of-
the-art" text, this volume would not be possible.
First and foremost, we wish to thank our esteemed
contributors. Their enormous effort is greatly appreciated.
We feel privileged to have had the opportunity to work
closely with such talented individuals.
We are grateful to
Dr. Rella Christensen and the Clinical Research Associ-
ates Staff for generously providing the resource list.
We
also would like to extend special thanks to Dr. Gordon
Christensen for honoring us by contributing the foreword.
We were particularly impressed with each and every
one of the individuals we had the pleasure of working

with at Mosby/Harcourt. They all exhibited the highest
degree of professionalism, while at the same time main-
taining a sense of humor and good will during this ardu-
ous task.
We are greatly indebted to Penny Rudolph and
Linda Duncan and the executives at Mosby/Harcourt for
agreeing to undertake the second edition.
We also want
to thank Kimberly Frare, our developmental editor, and
Rene Saller, our production editor, who kept us on track
after we were continuously faced with the realization that
in 6 years we had forgotten just how much work went
into producing a textbook.
We would also like to thank
Amy Buxton, our designer, and the entire production de-
partment who took a manuscript and some photographs
and created a true work of art. In addition, we wish to
thank everyone else at Harcourt, from Marketing to Pro-
duction, from the Art Department to the Editorial De-
partment, without whose efforts this book could not have
been a success.
We also wish to thank all the laboratory technicians
and manufacturers' representatives who supplied us with
much of the necessary technical information. We must
extend a special thank you to Adrian Jurim at Jurim Den-
tal Studios; the late Jack Karp, Beth Karp, and Arthur
Saltzman at Americus Dental Labs; Zwe Padeh at Studio
46; and Steven Pigliacelli and Eva Pop of Marotta Dental
Studio, our reservoirs of information for some of the lab-
oratory aspects of dental esthetics. An additional thank

you goes to Barry Mermelstein and Fred Gebert of Patter-
son, Inc., and Benco, Inc., and Cliff Marsh of J and B
Dental Services and Supply for providing us with infor-
mation about many of the products in this textbook.
A special note of gratitude goes to Debbie Baer, Eve-
lyn Rosa, Wandee Gonzales, Diane Korn, Catherine Hill,
Rachelle DiMaso, and Millie Errante, as well as former
and present dental assistants
and office managers who
helped "mind the store" while we worked on the book
and also aided us in compiling many of the clinical cases
necessary for this text.
We also owe particular gratitude to
Dr. Jack Hirsch, who, despite seeing his office overrun
twice with "bookwork," was still able to provide much ap-
preciated insight and guidance. An additional thank you
to Ellen Horowitz Dale and Eric Zaidins, Esq., for their
advice and counsel.
We owe much to our colleagues at the Department of
Dentistry of The Mount Sinai/NYU Medical Center for
their continued support and guidance, especially Dr. Jack
Klatell,
Dr.
Daniel Buchbinder, and the attending and
support staff for providing the resources and encourage-
ment necessary to produce this text.
A note of appreciation must be extended to our med-
ical illustrator, Caroline Meinstein, whose first edition illus-
trations stood the test of time. Her good spirits, combined
with her excellent technical skills, were an integral part of

conveying many of the techniques illustrated in the book.
Finally, we wish to thank our families. After 4 years of
work on the first edition, they still gave us 4 more years of
support and encouragement to allow us to update this text-
book. Their unwavering love, encouragement, and moral
support not only made our lives easier but was ultimately
the most important force ensuring a successful result.
This is not merely a book of our experiences with
dental esthetics but a work of the combined experiences
of all of the above. Through their efforts, we hope we
have been able to describe the state of esthetic dentistry
today and perhaps lay a basic framework for the esthetic
dentist of tomorrow.
Kenneth W. Aschheim, DDS, FACD
Barry G. Dale, DMD, FACD
SECTION ONE

TROUBLESHOOTING
TROUBLESHOOTING GUIDE,
1
SECTION T
WO

PRINCIPLES OF ESTHETICS
1

I
NTRODUCTION TO ESTHETICS,
23
Milton B. Asbell

2

FUNDAMENTALS OF ESTHETICS,
27
Bruce A. Singer
SECTION THREE

ESTHETIC MATERIALS
AND TECHNIQUES
3

DENTIN BONDING AGENTS,
41
Mark E. Jensen
4

COLOR MODIFIERS AND OPAQUERS,
53
Jerry B. Black
5

COMPOSITE RESIN: FUNDAMENTALS AND DIRECT
TECHNIQUE RESTORATIONS,
69
Richard D. Trushkowsky
6

COMPOSITE RESIN: INDIRECT TECHNIQUE
RESTORATIONS,
97

Ross Nash
7

CERAMOMETAL: FULL COVERAGE
RESTORATIONS,
113
Ira D. Zinner
Francis V. Panno
Richard D. Miller
Mitchell S. Pines
Trudy M. Burke
xi
8

PORCELAIN: FULL COVERAGE
RESTORATIONS,
137
Vincent Celenza
Charles A. Lennon
9

PORCELAIN LAMINATE VENEERS AND OTHER
PARTIAL COVERAGE RESTORATIONS,
151
Kenneth W Aschheim
Barry G. Dale
10

ADHESIVE RESIN BONDED CAST
RESTORATIONS,

185
Morton Wood
Van Thompson
11

ACRYLIC AND OTHER RESINS: PROVISIONAL
RESTORATIONS,
199
David R. Federick
12

ACRYLIC AND OTHER RESINS: REMOVABLE
PROSTHESES,
227
Michel G. Venot
13

BLEACHING AND RELATED AGENTS,
247
Barry G. Dale
Kenneth W Aschheim
SECTION
FOUR
ESTHETICS AND OTHER
CLINICAL APPLICATIONS
14

ESTHETICS AND ORAL PHOTOGRAPHY,
269
Kenneth W. Aschheim

Mark P. King
15

ESTHETICS AND ELECTROSURGERY,
289
Mark P. King
16

ESTHETICS AND IMPLANT PROSTHETICS,
301
Richard J. Lazzara
Stephan S. Porter
xii
CONTENTS
17

PEDIATRIC DENTISTRY, 329
Charles I. Citron
18

ESTHETICS AND PERIODONTICS, 349
Edwin S. Rosenberg
James Torosian
19

ESTHETICS AND ORTHODONTICS, 379
Edward C. McNulty
20

ESTHETICS AND ORAL AND MAXILLOFACIAL

SURGERY, 411
Daniel Buchbinder
21

ESTHETICS AND IMPLANT SURGERY, 429
Enrique Lenchewski
22

ESTHETICS AND LASER SURGERY, 441
Robert A. Strauss
23

ESTHETICS AND PLASTIC SURGERY, 451
Gregory E. Rauscher
24

ESTHETICS AND ADVANCED TECHNOLOGY, 459
Kenneth W Aschheim
SECTION FIVE

ESTHETIC PRACTICE
MANAGEMENT
25

ESTHETICS AND PSYCHOLOGY, 485
Fred B. Abbott
Nellie Abbott
26

ESTHETICS AND DENTAL MARKETING, 499

Phillip Bonner
27

ESTHETICS AND DENTAL JURISPRUDENCE, 509
Burton R. Pollack
SECTION Six

APPENDIXES
App A
CUSTOM STAINING, 523
Kenneth W Aschheim
Barry G. Dale
App B
NINETY-SECOND RUBBER DAM
PLACEMENT, 531
Barry G. Dale
App C
SMILE ANALYSIS, 541
Barry G. Dale
Kenneth W Aschheim
App D
SAMPLE LEGAL FORMS, 543
App E
LIST OF MANUFACTURERS, 555
I
NDEX, 583
TROUBLESHOOTING GUIDE
1
Size and Shape Problems

•

Abrasion, 3
•

Aged teeth-worn, 3
•

Anterior tooth-chipped or fractured, 3
•

Attrition, 3
•

Chipped tooth, 3
•

Erosion, 4
•

Extruded tooth, 4
•

Feminine teeth-excessive, 4
•

Fractured tooth, 4
•

High smile line, 5

•

Large tooth, 5
•

Long tooth, 5
•

Malformed teeth-mild, 5
•

Malformed teeth-severe, 6
•

Masculine teeth-excessive, 6
•

Narrow tooth, 6
•

Peg lateral incisor, 6
•

Short tooth, 6
•

Small tooth, 7
•

Wide tooth, 7

Position Problems
•

Anterior flared teeth-major, 7
•

Anterior flared teeth-minor, 7
•

Crowding, 7-8
•

Diastemata, 8
•

Excessive spacing, 8
•

Extruded tooth, 8
•

High smile line, 9
•

Long tooth, 9
•

Midline disharmony, 9-10
•


Migrated teeth, 10
•

Multiple diastemata, 10
•

Open bite-mild, 10
•

Open bite-severe, 10
•

Overbite/overjet, 10
•

Spacing, 10-11
•

Traumatic injury-luxation, 11
2

SECTION
I
TROUBLESHOOTING GUIDE
Coloring Problems
•

Aged (dark) teeth, 11
•


Coloration, 11
•

Congenital discoloration, 11
•

Discoloration, 11-12
•

Endemic fluorosis, 12
•

Endodontic discoloration, 12
•

Fluorosis, 12
•

Post-endodontic discoloration, 12-13
•

Staining, 13
•

Tetracycline discoloration, 13
•

Tooth color-too dark, 13
•


Tooth color-too light, 13-14
•

Traumatic discoloration, 14
•

White spots, 14
Missing Teeth
•

Migrated teeth-multiple, 14
•

Migrated tooth-single, 15
•

Multiple missing teeth, 15
•

Single missing tooth, 15
•

Traumatic injury-avulsion, 15
Caries
•

Carious restoration margins, 15
•

Carious tooth, 15

Repairs
•

Acrylic veneer facing-dislodgment, 16
•

Carious restoration margins, 16
•

Porcelain fractures-ceramometal-full
coverage restorations, 16
Non-Tooth-Related Problems
•

Gingival inflammation, 16
•

Gingival recession, 16
•

High frenum attachment with or without
diastema, 16
•

High smile line, 16
•

Mobile teeth, 16
Dermatologic Problems
•


Aging, 17
•

Bruising, 17
•

Scars, 17
•

Wrinkles, 17
Facial Contours and Skeletal Problems
•

Asymmetry, 18
•

Bimaxillary prognathism/protrusion, 18
•

Excessive lip support, 18
•

Facial asymmetry, 18
•

Hypogenia, 18
•

Insufficient lip support, 18

•

Macrogenia problem, 18
•

Mandibular prognathism/protrusion, 18
•

Mandibular retrognathism/retrusion, 19
•

Maxillary prognathism/protrusion, 19
•

Maxillary retrognathism/retrusion, 19
•

Open bite-mild, 19
•

Open bite-severe, 19
•

Orthodontic therapy, 19
•

Orthognathic surgery, 19
•

Prognathism, 19

•

Protrusion, 19
•

Retrognathism, 19
•

Retrusion, 19
Periodontal Problems
•

Gingival asymmetry, 16
•

Gingival hypertrophy, 16
Clinical conditions that are common to more than one category are
appropriately repeated.
TROUBLESHOOTING GUIDE

3
4

SECTION
I
TROUBLESHOOTING GUIDE
TROUBLESHOOTING GUIDE

5
6


SECTION
I
TROUBLESHOOTING GUIDE
TROUBLESHOOTING GUIDE

7
8

SECTION
I
TROUBLESHOOTING GUIDE
TROUBLESHOOTING GUIDE

9
10

SECTION
II
SECTION TITLE
TROUBLESHOOTING GUIDE

11
12

SECTION
I
TROUBLESHOOTING GUIDE
TROUBLESHOOTING GUIDE


13
14

SECTION
I
TROUBLESHOOTING GUIDE