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C O N T E M P O R A R Y ESTHETIC DENTISTRY C O N T E M P O R A R Y ESTHETIC D E N T I S T RY George Freedman, BSc, DDS, FAACD, FACD, FADFE 3251 Riverport Lane St. Louis, Missouri 63043 CONTEMPORARY ESTHETIC DENTISTRY 978-0-323-06895-6 Copyright © 2012 by Mosby, Inc., an imprint of Elsevier Inc. No part of this publication may be reproduced or transmitted in any form or by any means, electronic or mechanical, including photocopying, recording, or any information storage and retrieval system, without permission in writing from the publisher. Details on how to seek permission, further information about the Publisher’s permissions policies and our arrangements with organizations such as the Copyright Clearance Center and the Copyright Licensing Agency, can be found at our website: www.elsevier.com/permissions. This book and the individual contributions contained in it are protected under copyright by the Publisher (other than as may be noted herein). Notices Knowledge and best practice in this field are constantly changing. As new research and experience broaden our understanding, changes in research methods, professional practices, or medical treatment may become necessary. Practitioners and researchers must always rely on their own experience and knowledge in evaluating and using any information, methods, compounds, or experiments described herein. In using such information or methods they should be mindful of their own safety and the safety of others, including parties for whom they have a professional responsibility. With respect to any drug or pharmaceutical products identified, readers are advised to check the most current information provided (i) on procedures featured or (ii) by the manufacturer of each product to be administered, to verify the recommended dose or formula, the method and duration of administration, and contraindications. It is the responsibility of practitioners, relying on their own experience and knowledge of their patients, to make diagnoses, to determine dosages and the best treatment for each individual patient, and to take all appropriate safety precautions. To the fullest extent of the law, neither the Publisher nor the authors, contributors, or editors, assume any liability for any injury and/or damage to persons or property as a matter of products liability, negligence or otherwise, or from any use or operation of any methods, products, instructions, or ideas contained in the material herein. Library of Congress Cataloging-in-Publication Data Contemporary esthetic dentistry / [edited by] George Freedman. p. ; cm. Includes bibliographical references and index. ISBN 978-0-323-06895-6 (hardcover : alk. paper) I. Freedman, George [DNLM: 1. Esthetics, Dental. 2. Dental Bonding. 3. Dental Materials. 4. Dental Restoration, Permanent. 5. Oral Surgical Procedures. WU 100] 617.6'95—dc23 2011044457 Vice President: Linda Duncan Executive Editor: John Dolan Senior Content Development Specialist: Courtney Sprehe Publishing Services Manager: Julie Eddy Senior Project Manager: Celeste Clingan Design Direction: Jessica Williams Working together to grow libraries in developing countries Printed in the United States of America www.elsevier.com | www.bookaid.org | www.sabre.org Last digit is the print number: 9 8 7 6 5 4 3 2 1 To my parents Bella and Wilhelm Freedman, who believed in me and taught me to believe in myself Foreword Esthetic dentistry did not exist when I graduated from dental television was truly phenomenal; one show changed dentistry school. One of the most important disciplines was denture fab- completely! rication. It was assumed that beyond a certain age everyone Esthetic dentistry has transformed patients’ perspectives of would have lost their teeth and would require removable pros- dentistry tremendously. In the past, most people disliked going theses. Many simply looked awful with their dentures. When to the dentist; the dental visit was associated with fear and pain. my father needed dentures, I could not stand that they made Many deprecating jokes were told about dentists, and our pro- his features collapse and his face sink in. I repositioned the teeth fession was often symbolized by a suffering patient with a ban- more naturally and plumped the denture acrylic to support the daged head. Once esthetic dentistry came into vogue, people facial muscles. My father’s teeth looked better than ever before, realized how painless bonding was and how beautiful the results and the natural form of his face was restored; he looked like his could be. Everyone wants to look better, and patients quickly younger self, and no one knew that he had lost his teeth. The realized that dentists could be artists, improving smiles and demands of treating my father made me realize the importance appearances in very short periods of time. Within a generation, of esthetics to dentistry. the perceptions associated with dentistry were changed from In the early years of my practice, direct restorations were ugly amalgam fillings, extractions, and dentures to an art form limited to silver amalgam. Then silicate fillings were introduced. providing beauty, youth, and function. Initially they were not very retentive and tended to discolor. The Bonding was the beginning of esthetic dentistry. Veneers were introduction of composites and acid etching dramatically the next step, generating patient anticipation and demand that improved the process, and esthetic dentistry became a reality. I led to a host of more advanced appearance-related procedures. realized the potential of tooth-colored restorations and began It was now possible to use the restorations to raise the cheek- using them extensively. During this time I was a regular guest bones, soften the nasal labial lines, and fill out the lips without on a popular radio show where I discussed dental innovations. surgery, and to make the results very long-lasting. These treat- In the pre-interview I mentioned that I would talk about “acid ments were designed to provide an alternative to plastic surgery, etching”—what the technique was commonly called at the time. enhance facial esthetics, and provide touch-ups “without a The horrified host said, “You can’t say that on air. Listeners will scalpel.” Dentistry has evolved to an art that not only improves get frantic about dentists putting acid in their mouths. What smiles but changes faces in a lasting manner. else can you call it?” I responded that we were actually bonding The full scope of esthetic dentistry is just beginning to be materials to the teeth. “Then call it bonding!” he answered. And defined. Dentists are, after all, the professionals who are most that is how the term bonding began. familiar with the hard and soft tissues of the smile and the It is rarely easy to develop something brand new. Many lower face. We understand the teeth, lips, cheeks, and muscula- within the profession challenged and even ridiculed the new ture and their functions as well as their limitations. We are technique, but I knew how great bonding was. I had the good familiar with the changes caused by aging and how to overcome fortune to be asked to do a segment on That’s Incredible, a very the sagging, wrinkling, and shrinking of the face in order to popular television show at the time. The producers asked me to make a person look younger. We can offer more precise and treat a beautiful ballerina with very dark teeth, and they docu- predictable facial effects than professionals who are limited to mented every step. I bonded her teeth, changed her smile, treating the soft tissues. The public now recognizes that dentists and made her look like a different person. The exposure was are the physicians and the artists of the smile. Everyone wants extensive; dentists everywhere wanted to know more because to stay young for as long as possible. This is the future of all their patients were asking about “bonding.” The impact of esthetic dentistry. Irwin Smigel, DDS vi Preface The first materials and techniques dedicated to appearance- this text, focusing on the clinical applications of scientifically related dentistry emerged in the late 1970s. The interest from based esthetic procedures, is so opportune. It offers a compre- the dental profession and the public was very limited in the hensive and detailed guide to both routine and complex beginning. The dental profession began to recognize this innova- esthetic procedures for practitioners who seek practical direc- tive and highly desirable treatment approach and the benefits tion. The selected topics cover the vast majority of esthetic sit- for all concerned rather quickly over the next decade, however. uations that are likely to be encountered in the clinical In the early 1990s the concurrent popularization of porcelain practice. A brief but thorough review of the relevant knowl- veneers and tooth whitening created an explosive rise in interest edge base leads into a discussion of the various treatment among the public that has not abated in the slightest degree to options that are available and those that the authors believe this very day. are the best choices. Discussions of recent relevant innovations As a direct result, there was a great need and tremendous and advances are followed by illustrative clinical cases that put demand for effective professional education and the sharing of each chapter into context. The organization of the topics and clinical experience among practitioners. On the academic side, the chapters makes it easy to grasp the new concepts, tech- the Postgraduate Programs in Esthetic Dentistry (PPED) pre- niques, and materials. sented a comprehensive introduction to appearance-related dis- The field of esthetic dentistry has grown so rapidly that no ciplines at numerous university venues. More than 2200 PPED single individual can be expert in all its domains. The many graduates (1991 to 2001) began to form the cadre of the esthetic talented contributors to this definitive textbook have been revolution that was sweeping the profession. On the organiza- instrumental in the philosophy, development, and teaching of tional side, some of the earliest esthetic groups were closed: the art and science of esthetic dentistry. They are recognized attendance was by invitation only, and membership was highly internationally as the leaders in research, clinical application and restricted. There existed a tremendous need for an open forum education. It is with great and humble appreciation that I thank for dental education that welcomed all professionals with an each and every one of these authorities for his or her remarkable interest in appearance-related dentistry. efforts in acquiring basic knowledge and skills, adapting and The American Academy of Cosmetic Dentistry (AACD) was advancing these techniques to new technologies and existing founded in December 1984 by 60 dentists who converged on patient conditions, and then sharing the resulting benefits with Las Vegas for 2 days of lectures, discussions, and strategic plan- their colleagues. ning. The “Cosmetic” denomination was chosen because several Contemporary Esthetic Dentistry represents the vanguard of “Esthetic” and “Aesthetic” societies were already in operation, the transition in dental education and information transfer. The and confusion was to be avoided. The first AACD board of text is offered both in print and online, with each format associ- directors set important parameters: the Academy must be open ated with an opportunity to earn continuing education credits. to all who seek education and professional development, dental Every chapter, or part of a longer chapter, has an associated laboratory technicians must be included, and this innovative multiple choice quiz that is accessed online at the reader’s con- area of treatment must establish accessible levels of clinical rec- venience. On successful completion, an evidence-based educa- ognition (which later became Accreditation and Fellowship). tional credit is issued. This formula proved very popular; in less than a decade the Scientific textbooks have the disadvantage of becoming tem- AACD was the largest cosmetic or esthetic organization in the porally challenged shortly after publication. This is because the world and has more than 8000 members. process of developing a text can take 2 or 3 years or longer, and This successful and open prescription is applicable to all the contents represent a slice of knowledge at a particular time. forms of continuing education; the subject material and the Contemporary Esthetic Dentistry is the first “live” book wherein format must be accessible, understandable, clinically relevant, the online version can be regularly updated as the underlying and immediately applicable to everyday practice. That is why clinical science and art change and develop. Thus it will always vii viii Preface be as current as possible—a compendium of the latest informa- techniques, ongoing development, and, of course, past mis- tion at any given time. takes. I find it very gratifying to share professional experiences Gutenberg’s development of print publication made knowl- with my colleagues for our mutual benefit. Transferring and edge and education universally accessible, facilitating the Renais- distributing this information benefits our patients’ oral health, sance. Today’s Web technologies make knowledge and education improves our practices, and makes our everyday clinical tasks immediately and affordably accessible. We cannot even begin to easier and more predictable. Most important, an open exchange imagine the progress that will be unleashed in the next few is a great advantage for the younger members of the profession, decades. who can use the established knowledge base to achieve ever I am often asked why I make the effort, and spend the better treatment concepts and modalities. To teach is to touch time, to write and to lecture about innovations, materials, the future. George Freedman, BSc, DDS, FAACD, FACD, FADFE Acknowledgments When I first agreed, reluctantly, to undertake the task of devel- journey in organized dentistry. Dr Geza Terezhalmy was the oping this definitive text on the topic of esthetic dentistry, I had Dean of Case Western Reserve University School of Dental a fair concept of the work that was involved. Or at least I Medicine in 1991. During a discussion about the lack of esthetic thought that I did. As we progressed, I realized the myriad dentistry training available to dentists, he challenged me to concepts, techniques, and materials in the field of Esthetic Den- develop a suitable course of study. This conversation resulted in tistry had grown exponentially since I first became involved in my organizing the first Post-graduate Program in Esthetic Den- its earliest days. The task was daunting but the outcome extremely tistry 6 months later. Within a decade, more than 2200 dentists important. had graduated from these programs in the United States and The knowledge base for esthetic dentistry is so vast and around the world. Dr Irwin Smigel, founder and president of varied, and the expertise so broadly distributed, that it was the American Society for Dental Aesthetics, has been a mentor incumbent upon me to involve world-renowned authorities on and a shining light to all of us in the profession. His energy, his many of the areas under discussion in the development of this vision, and unabashed love for dental esthetics are standards that textbook. I humbly thank each and every one of the contributors we can live and grow by. for their tremendous efforts, sincere commitment, and invalu- At Elsevier, John Dolan (Executive Editor) was the first to able contribution to the progress of dentistry. envision the Contemporary Esthetic Dentistry textbook and was I hold Jennifer Murphy largely instrumental in developing this project, both with me and with responsible for cajoling me to accept Elsevier. He shepherded the project through the many gauntlets the burden of writing Contemporary that are part and parcel of every book that publish. He prodded Esthetic Dentistry. On the other when necessary, and commiserated over wine when appropriate. hand, she has also been the indi- Most significantly, he was open to the many innovative concepts vidual who has responsibly held all that are the hallmarks of this publication. The successful conclu- the loose ends of this massive project sion of this project has been made possible by the tireless dedica- together, and enabled it to come to tion and professional contributions of Courtney Sprehe (Senior fruition. Developmental Editor), Celeste Clingan (Senior Project Every long-term project takes its Manager), Brian Loehr (Senior Development Editor) and Kari toll on family life, and I extend my Terwelp (Editorial Assistant) through a very long and extensive heartfelt thanks and sincerest apolo- project. gies to Dr. Fay Goldstep, my wife, and our daughter, Judy. It is also important to thank the dental manufacturers who Many dental professionals have contributed to my personal have supplied and permitted the use of images which add much development over the years, but the following individuals to the practical relevance of a clinical text. These same companies deserve a special mention. I first met Dr Jack Kammer in 1984. are largely responsible for funding and driving the research and He was the founding president of the American Academy of development that has propelled esthetic dentistry so rapidly to Cosmetic Dentistry, and he helped me to begin my exciting the forefront of the dental profession. George Freedman, BSc, DDS, FAACD, FACD, FADFE ix