Được đan xen vào truyền thống của nền văn minh phương Tây, từ người Hy Lạp cổ đại đến Aquinas và Kant, vẻ đẹp đã trở thành trung tâm của mọi tư tưởng triết học, bắt rễ sâu trong bản chất con người. Việc đánh giá cái đẹp, không liên quan đến chủ quan của thị hiếu cá nhân, đòi hỏi đào tạo thẩm mỹ để thúc đẩy cảm xúc cá nhân, phù hợp với các tiêu chí khách quan. Mục đích của cuốn sách này là đưa ra các tiêu chí khách quan để đánh giá cái đẹp, để có thể đưa ra sự phân biệt phê phán giữa cái đẹp và cái xấu. Một loạt các yếu tố mang lại vẻ đẹp cấu trúc của thành phần nha khoa, răng hàm mặt và khuôn mặt, cũng như các biện pháp điều trị bao gồm các thủ thuật phục hồi, phẫu thuật hoặc chức năng được thiết kế để tái tạo tự nhiên. Thực tế thẩm mỹ của con người bao hàm sự cần thiết phải có sự kết hợp hài hòa giữa các yếu tố nha khoa với môi trường và đòi hỏi khả năng hiểu và giải thích các đặc điểm tâm lý biểu hiện của cá nhân mà chúng ta được kêu gọi điều trị. Nha khoa hiện đại, bị ảnh hưởng bởi công nghệ vì lợi ích của công nghệ, đã quá thường xuyên bỏ qua thực tế này. Các nguyên tắc được nêu trong công việc này sẽ cung cấp cho các học viên các phương tiện để đảm bảo hoặc cải thiện sức khỏe thẩm mỹ răng hàm mặt của bệnh nhân, trong khuôn khổ của quá trình lão hóa
www.ajlobby.com Claude R Rufenacht Fundamentals of Esthetics With contributions by Robert P Berger, CDT Robert L Lee, DDS, MS Robert L Nixon, DMD Giana Ricci, MD, DDS, MScD Harlod M Shavell, DDS www.ajlobby.com Fundamentals of Esthetics Dr Claude R Rufenacht Medecin Dentiste Geneva, Switzerland With the contribution of Robert P Berger, CDT Chatsworth, California Robert L Lee, DDS, MS Private practice, Grand Terrace, California Robert L Nixon, DMD Private practice, Los Angeles, California Giano Ricci, MD, DDS, MScD Private practice, Florence, Italy Harold M Shavell, DDS Private practice, Chicago, Illinois Quintessence Publishing Co, Inc www.ajlobby.com Chicago, Berlin, London, São Paulo, Tokyo, and Hong Kong www.ajlobby.com Library of Congress Cataloging-in-Publication Data Rufenacht, Claude Fundamentals of esthetics/Claude Rufenacht p cm Includes bibliographical references ISBN 0-86715-230-3 Dentistry–Aesthetics I Title [DNLM: Esthetics, Dental WU 100 R922f] RK54.R84 1990 617.6–dc20 DNLM/DLC 90-8621 for Library of Congress CIP © 1990 by Quintessence Publishing Co, Inc, Chicago, Illinois All rights reserved 1st reprinting, 1992 This book or any part thereof must not be reproduced by any means or in any form without the written permission of the publisher Lithography: Scantrans, Singapore Printing and binding: Toppan Printing Co Pte., Ltd., Jurong Town, Singapore Printed in Singapore www.ajlobby.com Contents Part I Fundamentals of Esthetics Chapter Introduction to Esthetics Claude Rufenacht The philosophy of beauty The origins of esthetics and its perception Esthetic principles Personality Chapter Morphopsychology Claude Rufenacht Introduction Typologic classifications Biodynamic conception of the personality Laws of adaptation to the environment Facial morphopsychology Morphopsychologic interpretation Affective and sentimental zone Cerebral zone Instinctive and physical zone Mouth and lips www.ajlobby.com Chapter Morphopsychology and Esthetics Claude Rufenacht The evaluation of human beauty Youth factor Integration and sublimation Chapter Structural Esthetic Rules Claude Rufenacht Facial components Dental components Gingival components Physical components Part II Intraoral and Extraoral Means to Rejuvenation Chapter Esthetics and Its Relationship to Function Robert Lee Natural permanent crown morphology Physiology of occlusion Mastication Occlusal loading Clinical aspects in bioesthetic function Chapter Facial Sculpture Claude Rufenacht Striated muscles: Physical and physiologic characteristics Muscular activity Facial muscle characteristics Perioral anatomy Muscle retraining exercises www.ajlobby.com Part III Esthetic Restoration of the Smile Chapter Esthetic Management of the Dentogingival Unit Claude Rufenacht The dentogingival unit Passive eruption Delayed passive eruption Tooth lengthening Chapter Gingival Recessions Giano Ricci Historical rationale and treatment techniques Therapeutic possibilities Chapter Ridge Pontic Relationship Claude Rufenacht Prevention of ridge collapse Morphology of the ridge Correction of an increased available space Graft material and donor site Implant material Improved techniques for localized ridge augmentation Pontic Chapter 10 Mastering the Art of Tissue Management Harold Shavell Periodontal esthetics Gingival displacement methods Biologic final impression Globalism and the perioprosthetic gestalt Coda: The search for excellence www.ajlobby.com Chapter 11 Metal Ceramic Framework Design Robert Berger Marginal fit Planning for esthetics, physiologic form, and strength Interproximal connectors: Design for strength Interproximal design: Esthetics Pontic-tissue relationship Lingual metal band design Chapter 12 Porcelain Veneers: An Esthetic Therapeutic Alternative Robert Nixon Case evaluation Indications for porcelain veneers Contraindications for porcelain veneers Stratification method Tooth preparation and impression taking Tooth preparation sequence: Maxillary teeth Tooth preparation sequence: Mandibular teeth Laboratory communication Veneer try-in for individual and collective fit Chairside try-in sequence for individual and collective fit Veneer try-in for color/color modification Cementation and finishing Maintenance of porcelain veneers www.ajlobby.com Preface Woven into the tradition of Western civilization, from the Ancient Greeks to Aquinas and Kant, beauty has been central to all philosophical thought, deeply rooted in human nature The appreciation of beauty, far from being related to the subjectivity of individual taste, requires esthetic training for the promotion of individual feelings, in accordance with the objective criteria The purpose of this book is to set forth objective criteria for the appreciation of beauty, so that critical discrimination between the beautiful and the ugly may be made A variety of elements bearing on the structural beauty of the dental, dentofacial, and facial composition will be presented, as well as therapeutic measures including restorative, surgical, or functional procedures designed to reproduce nature The reality of human esthetics implies the necessity for a harmonious integration of dental elements with the environment and requires a capability of understanding and interpreting the morphopsychological features manifested by the individual that we are called upon to treat Modern dentistry, influenced by technology for technology's sake, has all too often neglected to take this reality into consideration The principles outlined in this work will provide practitioners with the means to ensure or improve the patient's dentofacial esthetic well-being, within the framework of the aging process 10 www.ajlobby.com Fig 12-58 Cementation and finishing—seating a veneer with incisal edge in porcelain is accomplished by means of an incisofacial pivot First, the incisal porcelain contacts the incisal edge of the prepared tooth and acts as a vertical stop Then, the veneer is seated proximally and cervically with gentle finger pressure Fig 12-59 Cementation and finishing—appearance of a veneer that has been completed seated Observe the generous amount of excess resin cement at the margins 581 www.ajlobby.com Fig 12-60 Cementation and finishing—systematic removal of the gross, uncured resin cement excess, before light curing, simplifies postcementation finishing For medium viscosity resins, a thin-bladed instrument is effective Fig 12-61 Cementation and finishing—gross resin cement excess is reduced considerably along the gingival margin by a second passage of the thin-bladed instrument 582 www.ajlobby.com Fig 12-62 Cementation and finishing—while the veneer is held in place on the distal one half of the facial surface, the thin metal strip is drawn lingually to remove resin cement excess interproximally Normally, this midline, mesioproximal metal strip would be pulled lingually until it was removed Then, the left central incisor veneer, loaded with resin cement, would be placed on the left central incisor, as has just been described This would allow the veneers to be placed and cemented by light-curing in pairs This ensures accurate placement at the midline and expedites the cementation process However, for the sake of precise illustration, the right central incisor veneer will be used to demonstrate all of the cementation and finishing sequence, rather than both central incisors together, as would be done normally Remove gross resin cement from the linguoincisal margin with a thin-bladed instrument (Fig 12-63) Be sure to leave a thin bead of excess resin cement in this area to prevent possible voids along this area of the margin 583 www.ajlobby.com Fig 12-63 Cementation and finishing—excess resin cement is removed from the lingual margin with the same instrument shown in Figs 12-60 and 12-61 Care must be taken to avoid removing all excess resin cement in this area particularly, because marginal voids will readily result Tack the veneer in place by light-curing it at the mesioincisal edge for 20 seconds (Fig 12-64) This step will ensure that a veneer will not move or dislodge while the remaining resin cement excess at the margin is thinned out Pull the metal strip on the distoproximal suface lingually to remove gross cement excess there (Fig 12-65) Before completely light-curing the remaining part of the veneer, feather out the remaining gross cement excess cervically and interproximally with a pigtail explorer (Fig 12-66) The gingival and interproximal portions of the facial surface of the veneer are now cured for 40 to 60 seconds To prevent possible incomplete cure, the incisal edge is also cured for 30 seconds from the lingual (Fig 12-67) This should cure all material, but if the veneer is thick and opaque and the resin cement is dark, a longer cure time may be necessary Porcelain resin cements cannot be overcured 584 www.ajlobby.com Fig 12-64 Cementation and finishing—while the veneer is held firmly in the distal area of the facial surface, the veneer is "tacked" by light curing a small segment of the facial surface at the mesioincisal edge This stabilizes the veneer during additional uncured resin cement removal Fig 12-65 Cementation and finishing—with the veneer now partially bonded for stability, the thin metal strip is drawn lingually with a college pliers to remove resin excess along the distal proximal surface 585 www.ajlobby.com Fig 12-66 Cementation and finishing—additional removal of excess resin cement is accomplished along the gingival finish line with an explorer tip A small bead of excess resin should always remain before curing to prevent voids Fig 12-67 Cementation and finishing—facial and incisal surfaces of the veneer are light-cured with two wide angle tips for 60 seconds to ensure complete polymerization After complete curing of the resin cement through the porcelain veneer, the interproximal metal strips are removed The placement of these strips interproximally during light-curing ensures the passage of finishing disks and strips to remove excess resin cement Using scalers or interproximal carvers, remove excess resin cement from the gingival margin and the interproximal margins The porcelain-glazed surface will permit easy "flicking off" of the excess porcelain resin cement in most areas (Fig 12-68) 586 www.ajlobby.com Fig 12-68 Cementation and finishing—light-cured resin cement excess can be removed, to a large extent, at the gingival margin with a scaler or curette Interproximal finishing is initiated with medium finishing disks, followed by medium gapped finishing strips, and graduated to fine or superfine disks and strips If binding occurs initially, preventing the passage of even the fine or superfine strips, lightly separate the contact by torquing the adjacent tooth with a metal instrument while a dental auxiliary slides an ultrafine metal strip through a couple of times (Fig 12-69) Infrequently, it may be necessary to resort to controlled separation An anterior separator is superb for this purpose Cautiously activate the separator to avoid porcelain veneer fracture A sound precaution in preventing interproximal "splinting" with resin cement is to always cover the interproximal surfaces of adjacent teeth with metal strips when etching If the resin cement is lodged against unetched enamel, it will not bond to it Fig 12-69 Cementation and finishing—if the interproximal resin cement flash inhibits finishing with disks and strips, a thin, diamond-coated abrasive strip can be used initially to remove the flash 587 www.ajlobby.com It is imperative that the interproximal margins be void of excess porcelain resin cement and smooth to allow complete seating of the adjacent veneers and to avoid undesirable plaque accumulation Finalize interproximal polishing with fine or superfine finishing disks and strips, flexible rubber polishing cups, and porcelainpolishing pastes Determine that all margins are undetectable with a sharp, finetipped explorer (Fig 12-70) If resin cement flash is still present, remove it entirely as previously described (Fig 12-71) Fig 12-70 Cementation and finishing—cervical resin cement excess should be completely removed, as carefully determined with an extremely sharp, fine-tipped explorer If not removed, the undetected excess can cause gingival inflammation Fig 12-71 Cementation and finishing—if thin resin cement flash is present, a flexible aluminum oxide disk with a back action motion should be used to feather it away The abrasive material is on the underside of the disk in this illustration If porcelain "ledging" requires adjustment, use micro-fine diamonds with a 588 www.ajlobby.com copious water spray at slow speed, sharp-edged rubber and silicone wheels, 30 fluted carbide burs without water spray at high speed, and porcelain-polishing paste to renew the glaze (Fig 12-72) Normally, if this case were not planned for sequence photography to illustrate the fine points of the technique, both central incisor veneers would have been cemented simultaneously The remaining veneers of a multiple unit case are cemented in contralateral pairs, ie, lateral incisors, canines, and premolars Fig 12-72 Cementation and finishing—academic research substantiates the need for microfine diamond burs and 30 fluted carbide burs to remove small porcelain overhangs at the margin and to polish the porcelain This 30 fluted carbide bur should be utilized at high speed with no water mist to avoid overheating the resin or porcelain It should be used with a feather touch and should be used only for light polishing, never finishing Once all the veneers are cemented and finished completely at the margins, evaluate the veneers collectively Check centric occlusion and all excursive contacts with fine articulating paper If the occlusion requires adjustment, make corrections with an appropriate fine diamond bur followed by microfine diamond burs and 30 fluted carbide burs under copious water spray to prevent crazing of the porcelain Avoid removing the porcelain glaze on facial surface if possible, except where a deflective contact occurs at the facioincisal line angle Eight maxillary porcelain veneers have been placed to improve the color of the brownish teeth used for technical discussion (Fig 12-73) The positive emotional reaction, improved self-image, enhanced feeling of well-being that the patient experiences subsequent to these esthetic makeovers are difficult to put into words It is wisely stated that "if a picture is worth a thousand words, then a radiant smile must be worth at least twice as many." 589 www.ajlobby.com Fig 12-73 Cementation and finishing—posttreatment appearance of the maxillary anterior teeth used for the technical sequences is shown Six maxillary porcelain veneers have been placed to brighten the teeth considerably Figures 12-74 and 12-75 portray one of many patients who have had a new dimension of beauty added to their appearance through the exciting, new medium of porcelain laminate veneers Fig 12-74 A portrait of an attractive young woman whose smile is an injustice to her 590 www.ajlobby.com overall beauty Fig 12-75 A vibrant transformation in her appearance has resulted from the "magic" of a porcelain veneer makeover Dramatic results like this can become routine with mastery of the porcelain veneer technique Maintenance of porcelain veneers Maintenance of porcelain veneers consists of periodic reexamination of the veneers as well as the contiguous hard and soft tissue Patient receptivity to oral hygiene instruction and posttreatment monitoring is optimal It is a golden opportunity for the dentist and staff to translate this heightened oral consciousness into a progressive program for the future, including prevention, nutritional counseling, definitive restorative dentistry, and maintenance of the veneers It is beneficial to contact a patient within 30 days of initial veneer placement The soft tissue around the veneers is frequently irritated from finishing procedures This inflammatory reaction is usually transient, assuming the periodontal tissues were healthy before porcelain veneering However, if the veneer margin has a porcelain "ledge," the veneer is 591 www.ajlobby.com overcontoured, the porcelain surface has been roughened, or extraneous resin cement flash is still present, a localized gingivitis may persist The causative factor(s) for any such residual gingivitis should be diagnosed and eliminated at this follow-up appointment by recontouring and polishing of the porcelain or removal of the excess resin cement The patient should continue to be followed up at 2-week intervals until the gingival tissue is healthy A naturally glazed porcelain surface, with the correct emergence profile and an undetectable butt margin, is arguably the most biocompatible surface in the oral cavity Consequently, if repeated attempts to resolve a localized gingivitis around a veneer fail despite performing the aforementioned corrective measures and verifying correct soft tissue management on the part of the patient, then the veneer should be removed and replaced At the initial follow-up appointment, all veneer margins should be carfully checked with a sharp explorer, not only along the gingival margin but also proximally and incisally If a perceptible catch occurs, a microfine diamond bur and a 30 fluted carbide bur, followed by porcelain-polishing paste, should be used to eradicate it If a marginal void is detected, a small diamond bur should be used to make a shallow penetration into the void The enamel surrounding the void is then etched for 30 seconds, and a polishable resin, which color matches the veneer, is placed to repair the void The resin "patch" should be polished to a high luster If a small amount of resin cement flash is discovered, it can be delicately milled away with a microfine diamond bur or a multifluted carbide bur and polished to a high luster with appropriate disks, strips, and resin-polishing pastes Any occlusal prematurities should be adjusted to prevent porcelain checking of natural tooth wear Centric occlusion, straight protrusive, lateral protrusive, and lateral excursion should be checked with fine articulating paper As a general rule, unless a canine is missing or an abnormal occlusion is present, anterior guidance should be canine-protected without veneer interferences If any interferences are present, they should be removed, and the porcelain glaze restored with polishing procedures In recall appointments subsequent to veneer placement, the dental hygienist should not routinely polish the porcelain surface with any form of pumice (even fine pumice) to avoid altering the surface glaze and roughening the porcelain If polishing of porcelain is necessary, due to surface abrasion, a silicone polishing wheel followed by a porcelain-polishing paste should be used at conventional speed with the surface kept moist If any porcelain is discovered around any veneer, it should be brought to the dentist's attention, and a correction of the problem should be instituted Scaling around the veneer margin should be performed as with a natural tooth 592 www.ajlobby.com However, indiscriminate scaling of the facial surface of a veneer, due to carelessness, is to be condemned The porcelain facial surface is inherently smooth and will remain stain-free if the porcelain was properly fabricated and finished Therefore, there is no justification for arbitrarily manipulating it like natural teeth because the surface should be optimal after placement and finishing In addition to avoidance of mechanical abrading of the porcelain surface during prophylaxis procedures, the dental hygienist should not use acidulated fluoride solutions on any porcelain surface Several reliable research studies have shown that the glaze is marred and the surface progressively roughened Nonacidulated fluoride solutions are acceptable for porcelain Finally, the Prophy-Jet is contraindicated for porcelain veneers because of the possibility of surface disturbance of the glaze or porcelain stains Porcelain veneers that are correctly fabricated, placed, and finished are essentially self-maintaining for the foreseeable future References Pincus CR Building mouth personality J South Calif Dent Assoc 1938;14:125–129 Buonocore MG A simple method of increasing the adhesion of acrylic filling materials to enamel surfaces J Dent Res 1955;34:849–853 Bowen RL Properties of a silica-reinforced polymer for dental restorations J Am Dent Assoc 1963;66:57–64 Faunce FR, Myers DR Laminate veneer restoration of permanent incisors J Am Dent Assoc 1976;93:790– 792 Fleming JE, Bayne SD, Spence P, Taes CG Forty-five month clinical evaluation of extracoronal laminate veneer performance J Dent Res 1984;63:1082 Abstract Cannon M Surface resistance to abrasion of performed laminate resin veneers J Prosthet Dent 1984;52:323– 330 Simonsen RJ, Calamia JR Tensile bond strength of etched porcelain J Dent Res 1983;62:297 Abstract Horn HR Porcelain laminate veneers bonded to etched enamel Dent Clin North Am 1983;17:671–684 Calamia JR, Simonsen RJ Effect of coupling agents on bond strength of etched porcelain J Dent Res 1984;63:162–362 10 Hsu C Stangel I, Nathanson D Shear bond strength of etched porcelain J Dent Res 1985;64:296 Abstract 11 Haywood VB, Heymann HO, Andreaus SB Polishing porcelain veneers: An SEM analysis J Dent Res 1987;66:289 Abstract 12 Haywood VB, Heymann HO, Scurria MS Experimental instrumentation for polishing porcelain intraorally J Dent Res 1988;67:377 Abstract 13 Haywood VB, Heymann HO, Scurria MS Efficacy of stones for polishing porcelain intraorally J Dent Res 1989;68:395 Abstract 14 Christensen GC Veneering of teeth: State of the art Dent Clin North Am 1985;29:373–391 593 www.ajlobby.com 15 Garber DA, Goldstein RE, Feinman RA Porcelain Laminate Veneers Chicago, III: Quintessence Publ Co; 1988 16 Nixon RL The Chairside Manual for Porcelain Bonding Wilmington, Del: BA Videographics; 1987 594 www.ajlobby.com Learn more about Quintessence Publishing Co., Inc www.quintpub.com 595 ... and spiritual The origins of esthetics and its perception Esthetics What is esthetics and what is the significance of esthetics and dental esthetics? Are the roots of esthetics hidden in a world... Singapore www.ajlobby.com Contents Part I Fundamentals of Esthetics Chapter Introduction to Esthetics Claude Rufenacht The philosophy of beauty The origins of esthetics and its perception Esthetic... interpretation of clinical results is possible by reason of scientific knowledge, the comprehension of esthetic principles should permit a logical evaluation of the fundamentals of beauty This