Esthetic Dentistry In Clinical Practice - Internet Archive

xContributorsRobert Hepps DDS, BSRobert Hepps is an assistant professor in the Department of Restorative Dentistry at the University of the Pacific. He is a 1971 graduate of the Ohio State University School of Dentistryand has lectured and directed programs on esthetics, practice growth, and development of thecomprehensive practice in New York, Florida, and California. He is founder and director ofthe California Academy of Aesthetic Dentistry and maintains a private practice in SanFrancisco.Parag R. Kachalia DDS, BSParag Kachalia is an assistant professor in the Department of Restorative Dentistry and codirector of the Pre-doctoral Fixed Prosthodontics Program at the University of the Pacific. He alsomaintains a private practice in San Ramon, California, with a focus on restorative and cosmeticdentistry.Brian J. Kenyon DMD, BABrian Kenyon completed his undergraduate studies at Brown University and graduated fromTufts University School of Dental Medicine in 1982. He was in private practice in Smithfield,Rhode Island, for seventeen years prior to accepting a full-time faculty position at the University of the Pacific. Dr. Kenyon is currently an associate professor in the Department of Restorative Dentistry and maintains a private practice in San Francisco, California.Kenneth G. Louie DDS, MA, BADropBooksDropBooksKenneth Louie completed his undergraduate studies at the University of California–Berkeleyand graduated from the University of the Pacific in 1988. Dr. Louie is the codirector of Preclinical Operative and teaches in the senior clinic generalist model. He maintains a privatepractice in San Francisco, California, in restorative and esthetic dentistry.Richard G. Lubman DDSRichard Lubman is a graduate of the Loyola University School of Dentistry in Chicago, Illinois,and has practiced esthetic and restorative dentistry for over thirty years in California. Followingretirement from private practice, he joined the faculty as an assistant professor of restorativedentistry at the University of the Pacific.Mark Macaoay DDS, BSMark Macaoay graduated from the University of the Pacific, Arthur A. Dugoni School of Dentistry, and completed an Advanced Education in General Dentistry residency at the NavalDental Center in San Diego, California. He currently is an assistant professor in the Departmentof Restorative Dentistry at the University of the Pacific and maintains a private practice in theSan Francisco Bay Area.James Milani DDS, BAJim Milani received a DDS degree from the University of the Pacific in 1982. He is an assistantprofessor in the Department of Restorative Dentistry and maintains a private practice in Lakeport, California.

ContributorsxiJeffrey P. Miles DDSJeff Miles graduated from the University of California–San Francisco in 1980. Following twentyone years of private practice in the San Francisco Bay Area, he joined the faculty at the University of the Pacific, Arthur A. Dugoni School of Dentistry.James B. Morris DDS, BSBrad Morris graduated from the University of the Pacific with a degree in dentistry in 1991.He continued his education at Columbia University and graduated in 1995 with a certificate inthe specialty of prosthodontics. Dr. Morris currently has a practice in Mill Valley, California,and is an assistant professor in the Department of Restorative Dentistry at the University ofthe Pacific.Warden Noble DDS, MS, BSWard Noble graduated from the University of California at San Francisco with a degree inDentistry in 1965, and he obtained a master ’s in education in 1968 as well as a master ’s inrestorative dentistry in 1970. Dr. Noble is a certified prosthodontist and has worked in privatepractice for more than thirty years. He is currently a professor in the Department of RestorativeDentistry at the University of the Pacific.Donnie G. Poe, CDTDonnie Poe has been a certified dental technician since 1974. He has served the dental laboratory profession since 1981 at the local, state, and national levels. Since 1987 Mr. Poe has givenclinics and lectured nationally on waxing, casting, and use of the stereo microscope in dentaltechnology, and he is now on staff at the University of the Pacific.Gitta Radjaeipour DDS, EdDGitta Radjaeipour is an assistant professor of restorative dentistry at the University of the Pacificand has practiced esthetic and restorative dentistry for seventeen years in Northern California.She graduated from Pacific’s dental school in 1992 and has been on faculty continuously sinceher graduation.Laura Reid DDS, BSLaura Reid is an assistant professor in the Department of Restorative Dentistry at the Universityof the Pacific. She has taught dental anatomy and fixed prosthodontics for the past eight yearsand practices in Santa Rosa, California.Eugene Santucci DDS, MA, BSEugene Santucci is full-time faculty in the Department of Restorative Dentistry and director ofthe second-year restorative curriculum. He is a frequent lecturer in the Predoctoral Occlusioncourse and directs the Occlusion Plus postgraduate program. He maintains a private practicewith his wife in Atherton, California.

xiiContributorsNoelle Santucci DDS, MA, BSNoelle Santucci is an assistant professor in the Department of Restorative Dentistry at theUniversity of the Pacific, Arthur A. Dugoni School of Dentistry. She maintains a private practicewith her husband in Atherton, California.Karen A. Schulze DDS, PhDKaren Schulze graduated in 1992 from the dental program and in 1998 from the PhD programat the University of Leipzig, School of Dentistry in Germany. She is currently an assistant professor and director of the Restorative Research Division in the Department of RestorativeDentistry at the University of the Pacific and maintains a private practice in San Francisco,California.Ai B. Streacker DDS, BSAi Streacker graduated from the University of the Pacific School of Dentistry in 1979, and in2002 retired from a successful two-decade-plus private practice in San Francisco specializingin esthetic and reconstructive dentistry. He is now an assistant professor in the Department ofRestorative Dentistry at the University of the Pacific School of Dentistry. He is the recipient ofthe Mark Hagge award and the Lucien Schmyd memorial award for excellence in teaching.Bina Surti DDSBina Surti graduated from the University of Detroit Mercy School of Dentistry and completeda residency in Advanced Education in General Dentistry and a fellowship in Implant Restoration at Case Western Reserve University School of Dentistry. She is currently an assistantprofessor at University of the Pacific in the Department of Restorative Dentistry.DropBooksDropBooksJessie Vallee DDS, BSJessie Vallee is an assistant professor in the Department of Restorative Dentistry at the University of the Pacific. She is a 2004 graduate of Pacific who served three years in the United StatesNaval Dental Corps upon graduation. She is currently an instructor of Occlusion, Pre-ClinicalFixed Prosthodontics, Integrated Clinical Sciences and maintains a part-time private practicein San Francisco, California.Marina Wasche DDS, BSMarina Wasche graduated with honors from the University of California–Davis where shereceived her Bachelor of Science in biological sciences. She received her Doctor of DentalSurgery with honors from the University of the Pacific and has since become full-time facultyat the Arthur A. Dugoni School of Dentistry. She was recently appointed the director of NewTechnologies for the Department of Restorative Dentistry.Richard H. White DDS, BARichard White is an assistant professor in the Department of Restorative Dentistry at the University of the Pacific. He has a BA from Albion College and is a graduate of the University ofMichigan School of Dentistry. He completed a Dental General Practice residency with theUnited States Public Health Service, where he continued for a twenty-seven-year career andachieved the rank of dental director. He currently lectures in the occlusion course and restorative dentistry courses at the University of the Pacific.

ESTHETIC DENTISTRY IN CLINICAL PRACTICE

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Chapter 1Introduction to Concepts inEsthetic DentistryMarc Geissberger DDS, MA, BS, CPTGeneral Principles of EstheticsEsthetics (also spelled aesthetics) is a subdisciplineof value theory or axiology, which is a branch of philosophy that studies sensory values, sometimes calledjudgments of sentiment or taste. Esthetics is closely associated with the philosophy of High Art. Estheticsincludes art as well as the very purpose behind it. Esthetics as a branch of philosophy studies art, the methods ofevaluating art, and judgments of art. Art has existedthrough all recorded human history. Art is unique tohuman beings because of our innate ability to abstract.Esthetics is important because it examines the reasonswhy art has always existed and attempts to bringclarity to a vastly complex intellectual human need(Manns 1997).The term aesthetics is derived from the Greek“aisthetike” and was coined by the philosopher Alexander Gottlieb Baumgarten in 1735 to mean“the science of how things are known via the senses.”The term was used in German, shortly after Baumgartenintroduced its Latin form (Aesthetica), but it did not comeinto popular use in English until the beginning of thenineteenth century (Kivy 1998). However, much thesame study was called studying the “standards of taste”or “judgments of taste” in English, following the vocabulary set by David Hume prior to the introduction of theterm aesthetics (Hume 1987).It has been said that “beauty is in the eye of thebeholder.” This very concept suggests that there maynot be universal agreement on what constitutes art orbeauty. Look at the two images that follow (figs.1-1 and1-2). Both are paintings, one abstract and one realistic.Do both appeal to you as a viewer? If so, why? If not,why not? By nature, all esthetic undertakings will elicitan emotional response from its creator, the receipient ofthe esthetic work, and the larger viewing audience. Successful art must not only appeal to its creator but to therecipient and larger viewing audience as well. Additionally, what one group or society may deem esthetic,another may dismiss as overtly unappealing. Estheticsand art do not necessarily cross cultural, political, generational, or societal boundaries. This being said, canthere be a set of guidelines that increase the likelihoodof art being deemed esthetic?Although esthetics studies the broader context of artand may be difficult to fully conceptualize, principles doexist within the field of art that can dramatically enhancethe aesthetic appeal of any piece of artwork. This textbook will provide dental practitioners with several toolsdesigned to enhance the beauty of the dental restorations they create. Throughout this text, practitioners willbe introduced to several guiding principles, techniques,and methods that, when followed, can dramaticallyincrease the esthetic appeal of their efforts. The goal ofthis text is to organize and define concepts of estheticsinto tangible, meaningful tools that can be applied to thepractice of esthetic dentistry.Esthetic (Cosmetic) DentistryFor years, the focus of the practice of dentistry was primarily the prevention and treatment of dental disease.This has been loosely described as “need”-based dentistry (Christensen 2000). In the mid to late twentiethcentury, dentistry evolved as a highly organized profession with advanced treatment methodologies and protocols enabling dentists to successfully treat dentaldisease. As tooth-colored restorative materials weredeveloped, both dentists and the public began to recognize the esthetic improvements that could be obtainedwith these advances. During the later part of the twentieth century, practitioners began to see a shift in thetype of dentistry the public was seeking. The public wasno longer forced to select between metallic restorativematerials that restored function but presented estheticcompromises. With the rapid improvements in toothcolored restorative materials, the discovery of toothwhitening agents, and the American preoccupation withappearance, patients were suddenly seeking selectiveprocedures that focused on the esthetic improvement of3

4Esthetic Dentistry in Clinical PracticeFigure 1-1. Abstract artwork, watercolor on paper, artist unknown.Figure 1-3. Schematic representation of the left and right hemispheres ofthe brain.To be successful, the practitioner must be able to putaside personal bias and allow the patient to guideesthetic decisions. Once this occurs, the likelihood ofesthetic success dramtically increases. If the dentist istoo controlling of the process, superimposing his or heresthetic preconceptions over those of the patient, chancesof success will decrease.DropBooksDropBooksWhy Is Esthetic Dentistry Stimulating?Figure 1-2. Scrub jay, guache on paper. Artist: Marc Geissberger.their dentitions. The age of “want”-based dentistry wasborn (Christensen 2000).Esthetic (cosmetic) dentistry is a discipline withindentistry in which the primary focus is the modificationor alteration of appearance of a patient’s oral structures,in conjunction with the treatment and prevention ofstructural, functional, or organic oral disease. Throughcosmetic dentistry, the appearance of the mouth isaltered to more closely match the patient’s subjectiveconcept of what is visually pleasing. Under thisdefinition, successful cosmetic dentistry adheres to theprincipal that “beauty is in the eye of the beholder.”Furthermore, it requires the practitioner, as the artist,to recognize the subjective nature of all estheticundertakings.Under this principle, the dentist is the artist and thepatient is the recipient of the artwork. Both individualshave an emotional investment in the process and results.Roger W. Sperry PhD, a professor of psychobiology,won a Nobel Peace Prize for Physiology or Medicine in1981 for his discoveries concerning the functional specialization of the cerebral hemispheres, namely, definingthe different function of the left and right hemispheresof the brain. His work led to the belief that the left brainis associated with verbal, logical, and analytical thinking. It excels in naming and categorizing things,symbolic abstraction, speech, reading, writing, andarithmetic. The right brain, on the other hand, functionsin a nonverbal manner and excels in visual, spatial, perceptual, and intuitive information (Sperry 1973; fig. 1-3).Dentistry, as a profession, is a relatively left-brain activity where facts rule, strategies are formed, and detailoriented behavior is commonplace. A well-constructed,logical plan and implementation of any surgical procedure or treatment is essential for clinical success. Esthetics and art are largely right-brain functions, whereimagination is prevalent, spatial perception abounds,and possibilities are explored. Success in this arearequires imagination, vision, and flexibility.The successful practice of esthetic dentistry capitalizeson a combination of left-and right-brain behavior. The

Introduction to Concepts in Esthetic Dentistryleft-brain behavior allows practitioners to developsound, logical, and predictable treatment plans. Additionally, they can accomplish the detail work that isrequired for successful clinical outcomes. The artisticmindset required for esthetic dentistry allows practitioners to engage the right brain in visual, spatial, andintuitive behavior. This total brain engagement mayhelp explain why esthetic dentistry is so appealing andprofessionally rewarding for dental professionals.Esthetic dentistry can provide a highly stimulating bodyof work, requiring the practitioner to balance logic,facts, and the known with feeling, perception, and theunknown.A Brief History of Esthetic DentistryAncient EstheticsExamples of prehistoric art exist, but they are rare, andthe context of their production and use is not very clear,so we can little more than guess at the esthetic culturethat guided their production and interpretation. Ancientart was largely, but not entirely, based on the six greatancient civilizations: Egypt, Mesopotamia, Greece,Rome, India, and China. Each of these centers of earlycivilization developed a unique and characteristic stylein its art. Greece had the most influence on the development of esthetics in the West. The period dominated byGreek art saw a veneration of the human physical formand the development of corresponding skills to showmusculature, poise, beauty, and anatomically correctproportions.Greek philosophers initially felt that estheticallyappealing objects were beautiful in and of themselves.Plato felt that beautiful objects incorporated proportion,harmony, and unity among their parts. Similarly, in theMetaphysics, Aristotle found that the universal elementsof beauty were order, symmetry, and definiteness(Ahmad 2005). These “mathematical” theories of esthetics have been used to establish many of today’s conceptsin esthetic dentistry. It must be noted that althoughseveral mathematical principles can be applied to beautyand esthetics, they are merely tools and do not constituteabsolutes; they will be discussed in greater detail in laterchapters.In twenty-first century United States, dental estheticsmay be simplified to include a full dentition consistingof straight, white teeth. The so-called “Hollywood”smile, popularized by American cinema and television,can be recognized worldwide. History shows us thatthroughout the world, this may not have always beenthe case. There are several examples of tooth modification for esthetic reasons that do not adhere to the stan-5dard of the “Hollywood” smile. Recognizing that therehave been and still remain many different concepts ofesthetic dentistry helps illustrate that dental beauty istruly in the eye of the beholder. Furthermore, what isappealing to one group may be unappealing to another.So Much for White Teeth: The JapaneseTradition of Tooth BlackeningAn examination of skeletal remains and art from theAsuka to the Edo period (from the seventh to the nineteenth century) reveals a tradition of intentional toothblackening as a practice among both women and men.The custom, an esthetic symbol from ancient times inJapan called ohaguro, became popular among marriedwomen as a way of distinguishing themselves fromunmarried women and providing contrast to their whitepainted faces. The artwork pictured here depicts womenfrom this era with intentionally blackened teeth (fig. 14). The black dye was an oxidized mixture of iron shavings melted in vinegar and powdered gallnuts. Thetradition of ohaguro became popular among males,especially court nobles and commanders. Among samurais, the custom of ohaguro was a symbol of loyalty toone master within a lifetime. In the case of men, thecustom is said to have ended around the Muromati Era(1558–1572) and was far less popular and short-livedcompared with the female tradition (Hara 2001). Withits origin in Japan, this tradition spread throughout Asia.Figure 1-4. Japanese art depicting a woman with blackened teeth, circasixteenth century.

6Esthetic Dentistry in Clinical PracticeFigure 1-5. Modern version of ohaguro depicting Asian female with ceremonially blackened teeth.Figure 1-6. Cast reproduction of a Bantu tribesman depicting typical toothmodification. Courtesy Dr. Scott Swank, curator, the Dr. Samuel D. HarrisNational Museum of Dentistry.DropBooksDropBooksThe tradition of blackening of teeth can still be seen insmall pockets of Asian culture today (fig. 1-5).African Tooth ModificationThe Bantu people of Africa have a myth that holds thatdeath enters the human body through the teeth. Due tothis longstanding belief, the Bantu file teeth into pointsin an attempt to create a portal trough which death mayexit the body (Favazza 1996). Figure 1-6 is a photographof cast reproduction of a Bantu tribesman de

Richar d Lubman is a graduate of the Loyola University School of Dentistry in Chicago, Illinois, and has practiced esthetic and restorative dentistry for over thirty years in California. Following retirement from private practice, he joined the faculty as an assistant professor of restorative dentistry at the University of the Pacifi c