Practical Procedures in Aesthetic Dentistry

Edited by

Subir Banerji BDS MClinDent(Prostho) PhD MFGDP(UK) FICOI FICD

Private Dental Practitioner;
Senior Clinical Teacher,
Programme Director, Aesthetic Dentistry MSc
King’s College London Dental Institute, UK;
Board Member of the Academy of Dental Excellence

and

Shamir B. Mehta BDS BSc MClinDent(Prostho)(Lond) MFGDP(UK)

Dental Practitioner;
Senior Clinical Teacher,
Deputy Programme Director, Aesthetic Dentistry MSc
King’s College London Dental Institute, UK;
Faculty Member of the Academy of Dental Excellence

and

Christopher C.K. Ho BDS Hons(SYD) GradDipClinDent(Oral Implants)

MClinDent(Prostho)(LON), FPFA

Prosthodontist, Sydney, Australia;
Visiting Clinical Teacher, King’s College London Dental Institute, UK;
Faculty Member of the Global Institute for Dental Education;
Board Member of the Academy of Dental Excellence

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Cover image: Courtesy of Subir Banerji.

CONTENTS

List of Contributors

Foreword

Preface

Acknowledgements

About the Companion Website

Part I Ethics

1.1 Ethics in Aesthetic Dentistry
1. Principles
2. Procedures
3. Tips
4. References

Part II Patient Assessment

2.1 Patient History and Examination
1. Principles
2. Procedures
3. Tips
4. References
2.2 Clinical Photography
1. Principles
2. Procedures
3. Tips
2.3 Evaluation of the Aesthetic Zone
1. Principles
2. Procedures
3. Tips
4. References
2.4 Clinical Smile Evaluation
1. Principles
2. Procedures
3. Tips
4. References
2.5 Digital Smile Evaluation
1. Principles
2. Procedures
3. Tips
4. References
2.6 Principles of Shade Selection
1. Principles
2. Procedures
3. Tips
4. Reference
5. Further Reading
2.7 Treatment Planning for Aesthetic Dentistry
1. Principles
2. Procedures
3. Tips
4. Further Reading

Part III Clinical Occlusion

3.1 Clinical Occlusion: Assessment
1. Principles
2. Procedures
3. Tips
4. Further Reading
3.2 Facebows: The Facebow Recording
1. Principles
2. Procedures
3. Tips
4. Further Reading
3.3 Intra-occlusal Records
1. Principles
2. Procedures
3. Tips
4. References
3.4 Semi-adjustable Articulators
1. Principles
2. Procedures
3. Tips
4. Reference
3.5 Functional Diagnostic Waxing Up
1. Principles
2. Procedures
3. Tips
3.6 Occlusal Stabilisation Splints
1. Principles
2. Procedures
3. Tips
4. Reference

Part IV Periodontology in Relation to Aesthetic Practice

4.1 Clinical Assessment of Periodontal Tissues
1. Principles
2. Dentogingival Complex (Biologic Width and Gingival Sulcus)
3. Procedures
4. Tips
5. References
4.2 Crown Lengthening without Osseous Reduction: Gingivectomy and Lasers
1. Principles
2. Procedures
3. Tips
4. References
4.3 Crown Lengthening with Osseous Reduction
1. Principles
2. Procedures
3. Tips
4. References
4.4 Management of Gingival Recession and Graft Harvesting
1. Principles
2. Procedures
3. Tips
4. References

Part V Direct Aesthetic Restorations

5.1 Adhesive Dentistry
1. Principles
2. Procedures
3. Tips
4. References
5.2 Teeth Isolation
1. Principles
2. Procedures
3. Tips
4. References
5.3 Cavity Preparation
1. Principles
2. Procedures
3. Tips
4. References
5. Further Reading
5.4 Anterior Restorations
1. Principles
2. Procedures
3. Tips
4. Further Reading
5.5 Posterior Restorations
1. Principles
2. Procedures
3. Tips
4. References
5. Further Reading
5.6 The Finishing and Polishing of Resin Composite Restorations
1. Principles
2. Procedures
3. Tips
4. Further Reading
5.7 Direct Resin Veneers
1. Principles
2. Procedures
3. Tips
4. Further Reading
5.8 Repair and Refurbishment of Resin Composite Restorations
1. Principles
2. Procedures
3. Tips
4. References

Part VI Indirect Aesthetic Restorations

6.1 Tooth Preparation for Full Coverage Restorations
1. Principles
2. Procedures
3. Tips
4. References
5. Further Reading
6.2 Tooth Preparation for Partial Coverage Restorations
1. Principles
2. Procedures
3. Cavity Design and Configuration
4. Tips
5. References
6. Further Reading
6.3 Provisionalisation
1. Principles
2. Procedures
3. Tips
6.4 Impressions and Soft Tissue Management
1. Principles
2. Procedures
3. Tips
4. References
5. Further Reading
6.5 Aesthetic Posts and Cores
1. Principles
2. Procedures
3. Tips
4. References
6.6 Appraisal and Cementation
1. Principles
2. Procedures
3. Tips
4. Reference
6.7 Adhesive Bridges
1. Principles
2. Procedures
3. Tips
4. References
6.8 Fixed Partial Dentures
1. Principles
2. Procedures
3. Tips
4. Further Reading
6.9 The Role of CAD/CAM in Modern Dentistry
1. Principles
2. Procedures
3. Tips
4. References
6.10 Ceramic Repair
1. Principles
2. Procedures
3. Tips
4. Further Reading

Part VII Indirect Ceramic Veneer Restorations

7.1 Planning for Porcelain Laminate Veneers
1. Principles
2. Tips
3. References
7.2 Tooth Preparation for Porcelain Laminate Veneers
1. Principles
2. Procedures
3. References
7.3 Provisionalisation for Porcelain Laminate Veneers
1. Principles
2. Procedures
7.4 Appraisal and Cementation of Porcelain Laminate Veneers
1. Principles
2. Procedures
3. Tips
4. References

Part VIII Partial Removable Prosthodontics

8.1 Aesthetic Removable Dental Prosthetics
1. Principles
2. Procedures
3. Tips
4. References Further Reading

Part IX Aesthetic Management of Tooth Wear

9.1 Aesthetic Management of Tooth Wear: Current Concepts
1. Principles
2. Procedures
3. Tips
4. References
5. Further Reading
9.2 The Direct Canine Rise Restoration
1. Principles
2. Procedures
3. Tips
4. References
9.3 Anterior Freehand Direct Restoration
1. Principles
2. Procedures
3. Tips
4. References
9.4 Maxillary Anterior Direct Build-up with Indices
1. Principles
2. Procedures
3. Tips
4. References
9.5 Mandibular Anterior Direct Build-up: Injection Moulding Technique
1. Principles
2. Procedures
3. Tips
4. Further Reading
9.6 Management of the Posterior Worn Dentition
1. Principles
2. Procedures
3. Tips
4. References
5. Further Reading
9.7 Evaluation and Management of the Occlusal Vertical  Dimension: Generalised Tooth Wear
1. Principles
2. Procedures
3. Tips
4. References

Part X Tooth Whitening

10.1 Assessment of the Discoloured Tooth
1. Principles
2. Procedures
3. Tips
4. References
10.2 Vital Bleaching
1. Principles
2. Procedures
3. Tips
4. References
10.3 Non-vital Bleaching
1. Principles
2. Procedures
3. Tips
4. References

Part XI Implants in the Aesthetic Zone

11.1 Pre-operative Evaluation
1. Principles
2. Procedures
3. Tips
4. References
11.2 Abutment Selection
1. Principles
2. Procedures
3. Tips
4. References
5. Further Reading
11.3 Impression Taking in Implant Dentistry
1. Principles
2. Procedures
3. Tips
4. Reference
5. Further Reading
11.4 Screw versus Cemented Implant-Supported Restorations
1. Principles
2. Procedures
3. Tips
4. References
5. Further Reading
11.5 Implant Provisionalisation
1. Principles
2. Procedures
3. Tips
4. References
11.6 Pink Aesthetics
1. Principles
2. Procedures
3. Tips
4. References
11.7 Implant Maintenance and Review
1. Principles
2. Procedures
3. Tips
4. References

Index

EULA

List of Illustrations

Chapter 2

Figure 2.2.1 Laboratory communication: use of shade guides conveyed in photograph to laboratory – note that the tabs are placed in the same vertical plane and angles as the teeth, with the incisal edge facing the incisal edges, as the ginigival portion of the tab is always shaded more like dentine.
Figure 2.2.2 Canon MR-14EX macro ring flash
Figure 2.2.3 Photo taken with a ring flash (left) compared to one with a dual-point flash (right) – note the difference in the second image, with more depth, texture and a three-dimensional effect
Figure 2.2.4 Contrasters or black cardboard can be used to provide a black background, allowing excellent display of characterisations
Figure 2.4.1 Worn anterior maxillary dentition – an intraoral mock-up has been carried out using direct resin composite from which a diagnostic wax-up is produced
Figure 2.4.2 Diagnostic wax-up
Figure 2.4.3 The wax-up has been indexed and ‘copied’ using a bis-acryl-based temporary crown and bridge material – the markings demonstrate the critical appraisal of the wax-up to verify the smile arc, axial inclination, symmetry, morphology and proportions
Figure 2.5.1 The digital facebow analysis allows fine adjustment to head position to create accurate horizontal and vertical facial references
Figure 2.5.2 Optimal height to width ratios and calibrated digital rulers provide valuable information for the technician in establishing the diagnostic wax-up and final case
Figure 2.5.3 Tooth form and arrangement are finalised to design guidelines
Figure 2.5.4 The laboratory technician is able to develop accurate changes based on the digital prescription
Figure 2.5.5 The final veneers mimic previously established and verified digital design guidelines
Figure 2.6.1 Vita Linearguide 3D-Master (VITA Zahnfabrik, Bad Säckingen, Germany)
Figure 2.6.2 Stump shade taken to determine colour of the underlying tooth preparation
Figure 2.6.3 Photographing the teeth from above the plane perpendicular to the labial surface allows less specular reflection, revealing the characteristics of the teeth
Figure 2.7.1 This patient has a failing upper right lateral incisor and the presenting complaint is the extreme mobility of this tooth
Figure 2.7.2 The tooth was extracted, root sectioned, adjusted palatally to accommodate the occlusion and immediately splinted to the adjacent tooth with composite resin to address the ‘aesthetic dental emergency’. The image here shows the area after a period of healing of the soft tissues has taken place. A more definitive alternative can now be considered after the comprehensive treatment plan has been developed

Chapter 3

Figure 3.3.1 Leaf gauge (Huffman Dental Products LLC, South Vienna, OH, USA)
Figure 3.3.2 The use of a Lucia Jig (Great Lakes Orthodontics, Ltd, Tonawanda, NY, USA)
Figure 3.3.3 Facebow record in pink beauty wax. Temp-Bond (Kerr Corporation, Orange, CA, USA) has been placed across a portion of the record; cracking of the set paste may be indicative of unwanted distortion
Figure 3.4.1 The relationship of the bite fork to the condylar head elements of the articulator, which relates the incisal edge of the maxillary teeth in the correct three-dimensional position to the condyles in the patient's head
Figure 3.4.2 The condylar guidance angle set at 30°, immediate side shift at 0.5 mm and Bennett angle (progressive side shift) at 15°
Figure 3.4.3 The upper and lower casts correctly related by a jaw relationship record, with the incised pin prior to it being adjusted to offer extra support before the programming sequence
Figure 3.4.4 The condyles positioned out of the fossa – the angled blue arrow shows the forward and downward path of movement away from horizontal that the condyle has travelled during the protrusive movement
Figure 3.4.5 Forming the Duralay pattern resin capturing the incised scheme during all eccentric movements
Figure 3.5.1 The stages of a diagnostic wax-up for a upper left central incisor tooth
Figure 3.5.2 Development of the correct emergence profile
Figure 3.5.3 The three-dimensional nature of the contact area between the upper left and right central incisors and left lateral incisor
Figure 3.6.1 A maxillary, hard full-coverage acrylic Michigan splint
Figure 3.6.2 A mandibular, hard full-coverage acrylic Tanner appliance
Figure 3.6.3 A hard, full-coverage acrylic appliance with the end-point occlusal contacts marked in articulating paper

Chapter 4

Figure 4.1.1 The periodontal tissues play a major role in the aesthetics of the smile
Figure 4.1.2 The main aesthetic parameters in periodontics: gingival exposure during smile, papillae proportions and location of gingival zenith
Figure 4.1.3 Average dimensions of different areas of the dentogingival complex
Figure 4.1.4 From thinner to thicker biotypes
Figure 4.1.5 Probing periodontal tissue to assess sulcus depth
Figure 4.2.1 Examples of gummy smiles where the main causes are maxillary vertical excess (upper left), altered eruption (upper right), short lateral incisor teeth (lower left) and secondary eruption due to wear (lower right)
Figure 4.2.2 Normal dentogingival complex and altered eruption types
Figure 4.2.3 Typical incision design for gingivectomy
Figure 4.2.4 Gingivectomy performed in a case of altered passive eruption and gingival overgrowth
Figure 4.2.5 Using a laser for a gingivectomy
Figure 4.3.1 Initial situation (top) with unpleasing gingival levels, short teeth and incorrect relative widths of anterior teeth. With an additive direct mock-up (bottom), the potential aesthetic benefits can be visualised intra-orally. The lengthening of incisal edges and their better width distribution gives an improved gingival appearance
Figure 4.3.2 Wax-up made by improving the shape and contours of a direct mock-up. From this wax-up a surgical guide was constructed
Figure 4.3.3 Although probing soft tissues and bone can be helpful, only after raising the flap can the bone levels be correctly assessed
Figure 4.3.4 Surgical procedure with bone re-contouring and soft-tissue reduction using the surgical guide as a reference
Figure 4.3.5 Restorative procedures after healing – preparations and provisionals
Figure 4.3.6 Final result after restorative procedures
Figure 4.4.1 A subepithelial connective tissue graft is harvested in the premolar area. The access is through an incision near the gingival margin and the graft is detached through internal incisions towards the midline, but avoiding the palatine artery.
Figure 4.4.2 Palatal (left) and tuberosity (right) grafts. Tuberosity grafts are more fibrous with less fat
Figure 4.4.3 Root coverage: traditional approach using vertical releasing incisions, graft and coronally advanced flap
Figure 4.4.4 Root coverage with a less invasive approach. The graft is inserted through a tunnel technique. The flap is moved by internal releasing incisions on the periosteum, allowing the tissue to advance coronally without raising the papillae
Figure 4.4.5 Initial situation with dentin hypersensitivity with Miller Class I gingival recession due to aggressive tooth brushing (left). After proper patient education concerning hygiene technique, a root coverage procedure was performed and tissues have remained stable for 5 years (right)

Chapter 5

Figure 5.2.1 The use of a rubber dam to provide effective moisture control
Figure 5.2.2 Completed resin composite restoration, where good moisture control is paramount to success
Figure 5.3.1 The patient is unhappy about the appearance of the anterior composites
Figure 5.3.2 The old composites have been removed and the cavity has been bevelled to create a smooth transition of colour
Figure 5.3.3 The new composite is seen from the distal aspect on the upper right central incisor to show the transition of colour across the labial surface
Figure 5.4.1 An example of an anterior tooth requiring a direct resin composite restoration
Figure 5.4.2 A palatal shelf has been formed using a silicone key. The figure shows the use of a Teflon-coated ‘dead-soft’ matrix to form an interproximal pillar, as seen on the lefthand side
Figure 5.4.3 Dentine layer build-up
Figure 5.4.4 Completed restoration. Subsurface resin tints have been added to mimic physiological hypoplastic areas
Figure 5.5.1 A disto-occlusal cavity; a sectional matrix has been applied supported by a metal ring, which can permit the insertion of a proprietary wedge under the beaks of the jaws
Figure 5.5.2 The interproximal wall has been formed; the matrix and ring can be removed having ‘formed’ an occlusal, Class 1 cavity. The wedge is retained in situ to avoid unwanted bleeding
Figure 5.5.3 Restoration prior to finishing and polishing
Figure 5.7.1 A discoloured upper maxillary central incisor
Figure 5.7.2 Completed direct resin veneer (3 years post-operative). Veneer was placed without any removal of tooth tissue

Chapter 6

Figure 6.1.1 Marginal finish lines with marginal configuration for porcelain fused to metal restorations: (a) shoulder with porcelain butt margin, (b) deep chamfer with metal collar, (c) shoulder with bevel (metal collar), (d) knife edge with metal margin, (e) chamfer with metal margin
Figure 6.1.2 All-ceramic crown preparation requirements
Figure 6.2.1 Onlay and inlay preparation requirements
Figure 6.3.1 Diagnostic wax-up transferred to patient for mock-up to assess aesthetic changes with provisional materials for approval and consent
Figure 6.3.2 Protemp crown (3M, St Paul, MN, USA) – malleable preformed crown that can be customised to size and adapted prior to curing
Figure 6.3.3 Silicone key developed from diagnostic wax-up. Note that a notch has been made between the central incisors to allow easy placement on the teeth. The injection of the flowable tip should always be kept within the material in order not to incorporate voids
Figure 6.3.4 Trimming of multiple provisionals may be enhanced with the use of a disc that allows simpler adjustment of embrasure spaces
Figure 6.4.1 The aim of retraction is to displace tissues away from the margin and establish a moisture free sulcus to allow impression material to flow freely in
Figure 6.4.2 Intra-oral digital implant impressions can also be acquired using special abutments called scan bodies
Figure 6.5.1 A Fibre-White ParaPost and core former (Para-Form, Coletene/Whaledent Inc., Cuyagoga Falls, OH, USA)
Figure 6.5.2 Try-in of a Fibre-White ParaPost
Figure 6.5.3 A completed resin fibre post and core restoration, with a 2 mm ferrule.
Figure 6.6.1 Assessment of crowns on the dies and unsectioned models to check fit, contact points and overall form and contour
Figure 6.6.2 PrepStart (Danville Materials, San Ramon, CA, USA) air abrasion to clean preparation prior to seating of restorations. Alternatively a pumice slurry may be used to clean the preparations
Figure 6.6.3 Clearly marking multiple restoration locations after cleaning of crowns is important so as not to confuse placement of crowns. This may be with the use of place holders or can be as simple as writing tooth numbers on a paper towel
Figure 6.6.4 Seating of the crown with a self-adhesive cement. As a dual-cure cement, after an initial gel set the excess can be removed. Alternatively the wave cure technique of waving a curing light over it for 1–2 seconds gel sets the cement, allowing simple removal
Figure 6.7.1 Upper right first premolar missing
Figure 6.7.2 A adhesive bridge has been provided
Figure 6.7.3 The adhesive bridge at the 9-year recall appointment
Figure 6.7.4 A missing lower left first molar tooth has been replaced with two cantilever adhesive bridges that have independent paths of insertion
Figure 6.8.1 Off-axis pontics may induce a torque moment
Figure 6.8.2 The ‘bucket handle’ effect of curved bridges
Figure 6.8.3 An upper left central incisor and canine repaired for a three-unit bridge
Figure 6.9.1 Phases of CAD/CAM dentistry
Figure 6.9.2 Triangulation and density distribution of data points across the varying surface of the preparation
Figure 6.9.3 Actual scan data image (left) and image corrected with algorithm (right)
Figure 6.9.4 The two lines in the box on the right show the two-dimensional digital representation, by two scanners, of the surface marked by the box on the image on the left
Figure 6.10.1 Fractured all-ceramic crown
Figure 6.10.2 CoJet air abrasion to roughen and silicoat the surface of the crown to allow adhesive bonding
Figure 6.10.3 Repaired all-ceramic crown with direct resin composite displaying satisfactory aesthetics

Chapter 7

Figure 7.1.1 Diagnostic wax-up on articulated models
Figure 7.1.2 Correction of gingival contours with measuring of biologic width and gingivectomy with diode laser
Figure 7.1.3 Complications with porcelain laminate veneer with fracture
Figure 7.1.4 Symmetry bite or stick bite – This allows the orientation of the facial vertical plane and the interpupillary line to be transfered to the dental ceramist, enabling the correct alignment of incisal edges relative to these planes in the final restorations
Figure 7.2.1 Three-plane contour of labial surface of maxillary anterior tooth Source: Wilson 2015. Reproduced with permission from Elsevier.
Figure 7.2.2 Use of depth cutting bur to initiate depth of reduction required
Figure 7.2.3 (a) Cross-sectional view of depth cuts with depth cutting bur. (b) Cross-sectional view of depth cuts. (c) Connection of depth cuts with burs; note the convex contour required. (d) Poor preparation with one plane reduction may encroach into close proximity to the pulp, with irreversible damage. Source: Wilson 2015. Reproduced with permission from Elsevier.
Figure 7.2.4 Occlusal view of the amount of reduction required to develop the arch form outlined by the orange line. It is important that you visualise prior to preparation whether the reduction of tooth structure is actually necessary to attain the final tooth position and contour. Note that one tooth would not even require preparation, as to attain the desired arch form would be purely additive
Figure 7.2.5 (a) Feather preparation. (b) Window preparation. (c) Bevel preparation. (d) Incisal overlap preparation
Figure 7.2.6 L-shaped proximal preparation to hide proximal margins. Source: Wilson 2015. Reproduced with permission from Elsevier.
Figure 7.2.7 Silicone index seen from the occlusal view
Figure 7.2.8 Silicone index assessing the vertical reduction.
Figure 7.3.1 Diagnostic wax-up
Figure 7.3.2 Spot etch of phosphoric acid applied on mid-labial of tooth. After washing off the etch, the whole prepared surface has bond applied
Figure 7.3.3 Loading of bisacryl resin into silicone template of diagnostic wax-up. Note that the template has been notched between 11/21 teeth to allow easier insertion intra-orally
Figure 7.3.4 Provisional material after removal from silicone key. Note that voids and areas of deficiency can be added with flowable composite resin to repair or modify. Any excess is removed with a no. 12 scalpel blade or multifluted carbide finishing burs. Ensure adequate contouring of the interdental spaces to allow sufficient space for access for cleaning
Figure 7.4.1 Use of a gum stimulator to remove unset excess resin cement
Figure 7.4.2 Floss should be pulled towards the palatal so as not to dislodge the veneer
Figure 7.4.3 A tacking tip on the curing light is used to tack the veneer into place
Figure 7.4.4 Veneers are tacked into place while pressure is placed towards the mesial and palatal (orange circle denotes the tacking tip position)
Figure 7.4.5 Use of no. 12 scalpel blade to remove excess cement

Chapter 8

Figure 8.1.1 The use of a portable dental surveyor with an analysing rod in clinical practice
Figure 8.1.2 Undercut depth gauges for flexible clasp (left) and non-flexible clasp (right) designs
Figure 8.1.3 Use of an undercut depth gauge for a rigid clasp design

Chapter 9

Figure 9.2.1 An example of a patient with mild posterior tooth wear, due to wear of the canine tooth
Figure 9.2.2 Post-operative view, following the placement of a direct resin composite–based canine riser restoration
Figure 9.3.1 Pre-operative view: localised anterior maxillary wear
Figure 9.3.2 Palatal surface wear
Figure 9.3.3 Freehand addition of resin composite to the maxillary central incisor teeth placed in supra-occlusion. Upon protrusion of the mandible the protrusive guidance is equally shared between the upper central incisors.
Figure 9.3.4 Separation of posterior units, by virtue of anterior  supra-occlusal restorations
Figure 9.3.5 The re-establishment of posterior tooth contacts
Figure 9.4.1 Verification of a diagnostic wax-up using a Golden Mean gauge
Figure 9.4.2 Silicone key made from the wax-up, which can be used to assist with the layering of resin composite, to augment the worn-down dentition
Figure 9.4.3 Pre-operative view of a patient with localised anterior maxillary tooth wear – facial view
Figure 9.4.4 Pre-operative occlusal view – dental caries was stabilised prior to active wear management
Figure 9.4.5 Post-operative view – resin was added to restore wear without any tooth reduction using a PVS index guide and restorations were placed in supra-occlusion
Figure 9.4.6 Post-operative view after 9 months, with occlusal contacts re-established
Figure 9.4.7 Post-operative occlusal-palatal view, centric stops marked
Figure 9.5.1 A 0.5 mm PVC stent formed on a duplicate model of a diagnostic wax-up
Figure 9.5.2 Template modified for use
Figure 9.5.3 Pre-operative view showing the tooth wear present on the lower anterior teeth.  Source: Courtesy of Dr Selar Francis.
Figure 9.5.4 Stent try-in
Figure 9.5.5 Matrices in situ
Figure 9.5.6 Warmed resin injected into stent
Figure 9.5.7 Immediate post-operative view
Figure 9.5.8 Post-operative view
Figure 9.6.1 A worn posterior occlusal surface that requires restorative intervention. A direct resin onlay has been provided, as seen in Figure 9.6.2
Figure 9.6.2 Direct resin onlay
Figure 9.6.3 An intermediate direct resin onlay placed in supra-occlusion with a flat morphology on the lower right second molar tooth. On lateral excursion there is no contact on this tooth. Following re-establishment of the occlusal contacts, the restoration has been replaced with one presenting a more favourable anatomical form.
Figure 9.6.4 The use of adhesive ceramic and Type III adhesive gold onlays to treat a worn posterior dentition
Figure 9.7.1 Pre-operative view
Figure 9.7.2 Restored anterior maxillary dentition, using direct resin composite
Figure 9.7.3 The lower anterior dentition restored in resin composite, with posterior adhesive onlays provided at the new OVD
Figure 9.7.4 Adhesive onlay restorations (left posterior quadrant)
Figure 9.7.5 Restored dentition with mutual protection

Chapter 10

Figure 10.1.1 Intrinsic, extrinsic and iatrogenic discoloration. Source: Christopher C.K. Ho, BDS MClinDent Prosthodontics. Reproduced with permission from Christopher C.K. Ho.
Figure 10.1.2 Process of extrinsic staining
Figure 10.1.3 Calcific metamorphosis leading to discoloration of the UR 1.
Figure 10.2.1 Initial presentation and after vital tooth bleaching. Source: Christopher C.K. Ho, BDS MClinDent Prosthodontics. Reproduced with permission from Christopher C.K. Ho.
Figure 10.2.2 Bleaching producing oxidation and breakdown of complex molecules
Figure 10.2.3 Tray fabrication with block-out resin utilised to create reservoirs. Source: Photo from the author’s clinical practice.
Figure 10.2.4 Application of 10% carbamide peroxide into tray reservoirs. Source: Subir Banerji, BDS MClinDent PhD Prosthodontics, London. Reproduced with permission from Subir Banerji.
Figure 10.3.1 Initial presentation and after non-vital tooth bleaching using 10% carbamide peroxide and an inside/outside technique. Source: Subir Banerji, BDS MClinDent PhD Prosthodontics, London. Reproduced with permission from Subir Banerji.
Figure 10.3.2 Inside/outside non-vital tooth bleaching using 10% carbamide peroxide.  (a) Pre-operative condition of the discoloured non-vital UR 1. (b) UR 1 after inside/outside bleaching. (c) Maxillary and mandibular dentition after continued conventional vital tooth bleaching. Source: Photos from the author’s clinical practice.

Chapter 11

Figure 11.1.1 Flow diagram for undertaking a comprehensive patient assessment. Source: Mehta, Banerji, and Aulakh, 2015. Reproduced with permission from George Warman Publications UK Ltd.
Figure 11.1.2 Evaluation of anterior tooth and gingival display. In this image, taken from the author’s clinical practice, the UL 1 is failing and requires extraction. The patient exhibits a high lip line that exposes all of the maxillary anterior and posterior teeth in addition to several millimetres of thin and highly scalloped gingival tissues with tall papillae. The aesthetic demands of the patient will be high and the rehabilitation of the UL 1 with an implant will require complex treatment.
Figure 11.1.3 CBCT scan of the maxilla taken from the author’s clinical practice, allowing for detailed surgical and prosthetic planning
Figure 11.2.1 Implant and prefabricated titanium abutment (Esthetic abutment, Nobel Biocare Services AG, Zurich, Switzerland). Note that the margins are available with different collar heights and are made to simulate the typical marginal positioning
Figure 11.2.2 Implant abutments available
Figure 11.2.3 All on Four^® Treatment Concept (Nobel Biocare) – anterior implants have straight  multi-unit abutments, while posterior implants have angulated abutments correcting the access for the prosthetic screws
Figure 11.2.4 Location jig to allow correct placement of the implant abutment
Figure 11.3.1 Open-tray impression copings – notice the square form of the coping, which is picked up in the impression
Figure 11.3.2 Customised impression coping in place, supporting and reproducing the gingival architecture developed by the provisional restoration
Figure 11.3.3 Jig constructed in the laboratory for pick-up intra-orally by splinting of copings to the jig
Figure 11.3.4 Paralleling technique used to take radiograph of implant and impression coping – note that there has been complete seating of the impression coping
Figure 11.4.1 Screw-retained crowns require an access hole on the cingulum area to enable access to the screw. The image on the right demonstrates the alignment of the implant, with the access to the screw leading to a hole on the labial surface of the crown, which would not be acceptable and necessitates a cement-on crown
Figure 11.4.2 Achieving screw retention in the anterior region may involve aligning the implant slightly more palatally in the anterior maxilla to allow screw access in the cingulum area, which may leave a ridge lap or unaesthetic crown
Figure 11.4.3 Use of a lateral set-screw to allow a bridge to be temporarily cemented, enabling retrievability if required
Figure 11.5.1 Progression from pre-operative condition to final implant restoration. Failing retained primary lateral incisor (a); resin-bonded bridge with single metal wing placed over immediate implant (b); implant-supported provisional restoration (c); definitive custom zirconia abutment and lithium disilicate crown (d)
Figure 11.5.2 Modification of interim removable partial denture pontics to prevent transmucosal loading. Pre-operative condition with congenitally missing UR 2, UL 2 and deficient soft- and hard-tissue contours (a); implant placement into the edentulous sites with simultaneous hard- and soft-tissue grafting (b); interim partial denture with modified pontics to eliminate contact with implants or grafted sites (c)
Figure 11.5.3 Laboratory-fabricated implant-supported provisional crown on definitive custom zirconia abutment
Figure 11.5.4 Chairside-fabricated implant-supported provisional screw-retained crown on temporary titanium cylinder
Figure 11.6.1 Pink porcelain between two dental implants in upper left central and lateral incisor to simulate missing papilla. Meticulous attention to oral hygiene is required to maintain the gingival health for this area. Source: Christopher C.K. Ho, BDS MClinDent Prosthodontics. Reproduced with permission from Christopher C.K. Ho.
Figure 11.6.2 Implant placed in extreme buccal position leading to severe recession and an aesthetic disaster
Figure 11.7.1 Comparison of peri-mucositis and healthy peri-implant. Gingival inflammation,
soft-tissue swelling and tissue that bleeds easily on gentle probing (a). The patient was reluctant to perform basic hygiene around the cantilevered provisional fixed partial denture (FPD) UR 2–3 on the implant in the UR 3 position. Healthy peri-implant environment on the same individual around the final cantilevered FPD UR 2–3 after non-surgical supportive therapy and patient education (b). Note the lack of swelling, inflammation and bleeding
Figure 11.7.2 Changes in tooth position over 12 years of observation. Implant restoration of the UR 4 soon after it was delivered (a); clinical presentation 12 years after initial placement of the implant restoration (b and c). Note that while the peri-implant soft and hard tissues have remained healthy around the UR 4, the contact between the UR 3 and UR 4 has opened. Source: Subir Banerji, BDS MClinDent PhD Prosthodontics. Reproduced by permission of Subir Banerji.
Figure 11.7.3 Excess cement on buccal and lingual. Excess cement retained on the abutment and crown of the implant in the UR 3 site (a and b); radiograph showing recurrent decay of the UR 2 and peri-implant bone loss around the UR 3 (c). The patient presented clinically with pain, swelling and suppuration from the implant sulcus consistent with peri-implantitis
Figure 11.7.4 Series of radiographs and photographs from the author’s clinical practice permitting evaluation of peri-implant hard and soft tissues. High-quality repeatable radiographs demonstrating the stability of the crestal bone relative to the implant over time: baseline (a), 1-year follow-up (b) and 6-year follow-up (c). Subsequent photographs depict the stability and health of the peri-implant soft tissues over the same 6-year interval (d and e).

List of Contributors

Subir Banerji BDS MClinDent(Prostho) PhD MFGDP(UK) FICOI FICD. Programme Director, MSc Aesthetic Dentistry and Senior Clinical Teacher, King’s College London Dental Institute. In private practice in London and Faculty and Board member, Academy of Dental Excellence.

Jorge André Cardoso DMD(Portugal) MClinDent(Prostho)(UK). Tutor, MSc Aesthetic Dentistry and Secretary, Portuguese Society of Esthetic Dentistry, In private practice in Espinho, Portugal and Faculty member Academy of Dental Excellence.

Brian Chee BDS MSc DClinDent(Perio) MFDSRCS(Eng). Greenhill Periodontics & Implants, Wayville, South Australia.

Tom Giblin BSc BDent(Hons) CertPros. In private practice in Sydney, Australia and Diplomate, ICOI.

Christopher C.K. Ho BDSHons(SYD) GradDipClinDent(Oral Implants), MClinDent(Prostho)(LON), FPFA. Visiting Clinical Lecturer, King’s College London, Faculty member, Global Institute for Dental Education and Faculty and Board member, Academy of Dental Excellence.

Kyle D. Hogg DDS, MClinDent (Prostho). Visiting Clinical Teacher and Postgraduate Tutor, MSc Aesthetic Dentistry, King’s College London. Previous Honorary Clinical Teacher, University of Florida College of Dentistry – Jacksonville. Faculty and Editorial Board member, Academy of Dental Excellence and in private practice, Dental Health Professionals, Cadillac, MI, USA.

Russ Ladwa BDS LDS FDSRCS MGDS DGDP FFGDP. Past Dean, Faculty of General Dental Practice (UK), at the Royal College of Surgeons of England and Past President, Odontology Section of the Royal Society of Medicine, London.

Il Ki Ricky Lee RDT. Sydney dental specialist.

Shamir B. Mehta BDS BSc MClinDent(Prostho)(LON) MFGDP(UK). Deputy Programme Director, MSc Aesthetic Dentistry; Senior Clinical Teacher, Department of Conservative and MI Dentistry, King’s College London Dental Institute; in private practice in London and Faculty member Academy of Dental Excellence.

Bill Sharpling MBA, DipCDT RCS(Eng). Director of the London Dental Education Centre (LonDec) and Senior Clinical Teacher and Associate Dean (CPD) at King’s College London Dental Institute.

Andrea Shepperson BDS(Otago). Member of the American Academy of Cosmetic Dentistry (AACD), Honorary Life Member of the New Zealand Academy of Cosmetic Dentistry (NZACD), Member of the American Academy of Oral and Systemic Health (AAOSH), Member of the New Zealand Dental Association. Digital Smile Design Instructor and Kois Center Mentor.

Charles A.E. Slade BDS LDS RCS MFGDP(UK) MClinDent(Prostho). Clinical Lecturer, London Deanery, Clinical Teacher, King’s College London Dental Institute and Faculty member, Academy of Dental Excellence. Key opinion leader Biomet 3i. In private practice, Lister House, Wimpole Street, London and No45 Dental, Chichester, UK.

Foreword

Dr Banerji is to be congratulated for assembling such an impressive, international array of co-authors, all of whom I know to be highly talented clinicians and teachers. Collectively, they bring together a wealth of clinical experience and knowledge.

This very practical work is clearly aimed at the senior dental undergraduate/newly qualified dental practitioner, but will also prove of value to more experienced clinicians. The ambition of the authors, set out in the Preface, is to supplement established standard textbooks and the many hands-on courses available to us. The combination in each chapter of concise text, practical clinical tips, high-quality illustrations, and particularly the many hours of ‘live’ video that accompany a majority of the chapters, ensures that this ambition will be achieved. A companion website is also available to complement this work.

The inclusion of high-quality ‘live’ video is a major strength and a huge advance on the static illustrations in most standard textbooks. Several of the videos show actual clinical procedures from start to finish and, along with narrated presentations from the authors, allow a level of understanding that cannot be achieved using static images alone. Their extensive clinical experience has also enabled the authors to compile a whole series of extremely helpful clinical tips. Every reader will find something to adopt here to enhance their own clinical practice.

Even today, there probably remains, in the minds of some people, a stigma associated with the terms ‘aesthetic’ or ‘cosmetic’ when applied to healthcare. The inclusion of a chapter on ‘Ethics’ is, therefore, entirely appropriate. It should also be noted that many of the procedures described are additive or minimally invasive, and fully accord with the principles of best practice.

This work covers a comprehensive range of aesthetic clinical procedures and will be a very useful addition to every library. For many clinicians, it will be a ‘must have’ book!

Stephen M. Dunne BDS LDS FDS PhD

Professor of Primary Dental Care and Advanced General
Dental Practice, King’s College London

Clinical Director, Genix Healthcare Ltd

Specialist in Restorative Dentistry

President of the European Federation of Conservative Dentistry

Preface

With changing trends associated with increased patient demands (often perpetuated by a growing wealth of ready-access, media-based and online digital information), it has become increasingly apparent that the attainment of a high-quality, predictable and desirable aesthetic treatment outcome has become an additional fundamental aim for the contemporary restorative practitioner. There is little doubt that the effective prevention, elimination and stabilisation of oral disease are essential prerequisites for successful oral rehabilitation.

Dental educators have responded to these needs by making available an array of resources, typically by means of traditional textual learning and hands-on courses. However, given the highly rapid pace of change and diverse developments in restorative dentistry, coupled with the current digital revolution (both in terms of information technology and social media), there is a need to deliver educational materials in a time-efficient, effective, user-friendly and economic manner – often at the ‘touch of a button’!

In this context, many online video presentations are widely available, for example on YouTube, which allow the dental practitioner to visualise procedures rather than simply imagining the stages between steps shown on photos supplemented by text. However, it is important that such resources meet quality assurance requirements and concomitantly boast authenticity.

I have come to realise the advantage of such assured dynamic-graphic content through my 20 years involved in educating undergraduate and postgraduate dental students as well as in my own clinical practice. In this unique publication I have been joined by an international team of highly experienced clinical educators who have, with their vast experience, put together material that aims to cover the principles and procedures for an array of clinical techniques, which we as experienced clinicians and educators strongly believe are integral to providing successful restorative dental treatment. In doing so, we have included a comprehensive range of aesthetic dental procedures commonly executed in everyday practice.

This learning resource comprises a combination of several hours of recorded video accompanied by an illustrated handbook summarising the key points, making available a source of information that we feel will help you to learn in a quick, meaningful and ‘bite-sized’ manner, and which we hope you will also find helpful and enjoyable.

While concise, this handbook is evidence based and includes references and suggestions for further reading. Additionally, it contains some relevant still photographs of crucial points in the procedures. The clinical images used throughout this resource have been taken from the contributing authors’ own dental practices and are from patients who have been treated by them.

Throughout this text, my co-authors and I have also tried to provide you with a number of useful, pragmatic clinical tips, which we feel may also help to tackle some of the minor (yet important) challenges that we as everyday practitioners encounter, but are seldom addressed.

The overall intention of this learning resource is to serve as a good accompaniment to traditional undergraduate and postgraduate learning materials, as well as to provide the general dental practitioner with a readily accessible form of relevant and appropriate information, combining the scientific and technical concepts in modern restorative dentistry.

This book is dedicated to those from whom we have learnt and to the many who continue on this journey.

Subir Banerji

Acknowledgements

Undertaking a project such as this is not possible without acknowledging the help and support of the many who have contributed towards its production, both directly and indirectly.

We would like to thank our families for their support and patience during this time when many hours were spent writing and recording the content for this unique enterprise. Our contributors have given generously and selflessly.

We would also like to extend our warm thanks to our patients who have given their permission and consent, enabling the use of images and footage that allow us to illustrate the various techniques with a practical and pragmatic approach.

We would also like to acknowledge the support extended by the Wiley production team and the publishers to make this idea into a reality.

Subir Banerji, Shamir B. Mehta and Christopher C.K. Ho

About the Companion Website

Practical Procedures in Aesthetic Dentistry is accompanied by a companion website:

www.wiley.com/go/banerji/aestheticdentistry

The website includes the following videos, corresponding to their listed chapter number:

2.2 Clinical Photography
2.3 Evaluation of the Aesthetic Zone
2.4 Clinical Smile Evaluation
2.5 Digital Smile Evaluation
2.6 Principles of Shade Selection
2.7 Treatment Planning for Aesthetic Dentistry
3.2 The Facebow Recording
3.3 Intra-occlusal Records
3.4 Semi-adjustable Articulators
3.6 Occlusal Stabilisation Splints
4.2 Crown Lengthening without Osseous Reduction
4.3 Crown Lengthening with Osseous Reduction
4.4 Management of Gingival Recession and Graft Harvesting
5.2 Teeth Isolation
5.4 Anterior Restorations
5.5 Posterior Restorations
5.6 The Finishing and Polishing of Resin Composite Restorations
5.7 Direct Resin Veneers
5.8 Repair and Refurbishment of Resin Composite Restorations
6.1 Tooth Preparation for Full Coverage Restorations
6.9 The Role of CAD/CAM in Modern Dentistry
7.2 Tooth Preparation for Porcelain Laminate Veneers
7.3 Provisionalisation for Porcelain Laminate Veneers
7.4 Appraisal and Cementation of Porcelain Laminate Veneers
8.1 Aesthetic Removable Dental Prosthetics
9.2 The Direct Canine Rise Restoration
9.3 Anterior Freehand Direct Restoration
9.4 Maxillary Anterior Direct Build-up with Indices
9.5 Mandibular Anterior Direct Build-up: Injection Moulding Technique
9.7 Evaluation and Management of the Occlusal Vertical Dimension: Generalised Tooth Wear
10.1 Assessment of the Discoloured Tooth
10.2 Vital Bleaching
10.3 Non-vital Bleaching
11.1 Pre-operative Evaluation
11.3 Impression Taking in Implant Dentistry
11.5 Implant Provisionalisation
11.7 Implant Maintenance and Review