Dr Sushil KoiralaNepal

The demand for cosmetic den-

tistry is a growing trend globally.

Increased media coverage, the

availability of free online informa-

tion and the improved economic

status of the general public has led

to a dramatic increase in patients’

aesthetic expectations, desires

and demands. Today, a glowing,

healthy and vibrant smile is no

longer the exclusive domain of

the rich and famous; hence, many

general practitioners are now be-

ing forced to incorporate various

aesthetic and cosmetic dental

treatment modalities into their

daily practices to meet the grow-

ing demand of patients.

Cosmetic dentistry is a science-based art guided by the desire of the patient. Many young clinicianswho plan to incorporate it into their practice are confused about whatthey and their patients actually wishto achieve. It is to be noted that thetreatment modalities of any healthcare service should be aimed at theestablishment of health and the con-servation of the human body with itsnatural function and aesthetics.However, it is worrying to note thatthe treatment philosophy and tech-nique adopted by many cosmeticdentists around the world tend towards macro-invasive protocols,and millions of healthy teeth are ag-gressively prepared each year forthe sake of creating beautiful smiles.

The practice philosophy adopt -ed by the clinic and the profes-

sional team members generallyguides the overall output of thepractice. Minimally invasive cos-metic dentistry (MiCD), a do noharm practice philosophy, has four fundamental components:level of care, quality of operator(dentist), protocol adopted andtechnology selected, which mustall be re-spected in daily clinicalpractice. Adopting this holisticmedical science practice philoso-phy is not an easy task, as it requiresa change in the mindset of profes-sionals.

In Parts I and II, I explain MiCD,do no harm cosmetic dentistry,based on my Vedic Smile concept,which I have been practising successfully in Nepal for the last 20 years, and advocating globallysince 2009 as the MiCD global mis-sion. It is to be noted that both partsare based on fundamental science(truth and available evidence),clinical experience and the com-mon sense required in holistic dentistry.

Cosmetic dentistry, a global trend

The prevalence and severity ofdental decay have been decliningover the last decades in many devel-oped countries and this trend isshifting towards developing coun-tries as well. With increased mediacoverage, the availability of free on-line information, public awarenesshas fuelled the demand for cosmeticdentistry globally. Now, a glowing,healthy and vibrant smile is nolonger the exclusive domain of therich and famous.1 The population ofbeauty- and oral health-consciouspeople is increasing every year anddata from various sources showsthat the coming generations of chil-dren, especially from the middle- to higher-income population, willhave fewer decayed teeth and willneed less complex restorative den-tal care as they age. These changingpatterns of dental care needs willbring about a major shift in the na-ture of dental services from tradi-tional restorative care to cosmeticand preventive services.

The increased market demandfor smile aesthetics among patientsis forcing general practitioners of today to incorporate the art and science of cosmetic dentistry intotheir practice. Cosmetic dentistry is not yet recognised as a separateclinical specialty like orthodontics,periodontics or paediatric dentistry.Cosmetic dentistry is synonymouswith multidisciplinary dentistry, asits success and failure are related to the patient’s psychology, health,function and aesthetics. Ethical,high-standard cosmetic dentistryskill training of clinicians is essen-tial for the increased global marketof cosmetic dentistry and its pro -motion. It is widely seen that thetreatment modalities of contempo-rary cosmetic dentistry are tendingtowards more-invasive procedureswith an over-utilisation of fullcrowns, bridges, dentine veneers,and invasive periodontal aestheticsurgery, while neglecting long-termoral health, actual aesthetic needsand the characteristics of the pa-tient.2 These aggressive treatment

modalities are indirectly degradingsocial trust in dentistry, owing to the trend of fulfilling the cosmeticdemands of patients without ethicalconsideration and sufficient scien-tific background and promoting the“the more you replace, the more youearn” or “more is more” mindset indentistry.2

Changing the professional mind -set of the practising clinician is notan easy task; it is just like quittingsmoking for a heavy smoker. In order to practise healthy dentistry,one must be groomed, starting fromdental school education, with moralvalues, a high ethical standard, apositive attitude and a patient-cen-tred practice philosophy. A studentreflects the mindset of his or herteachers, and a teacher or mentorwith comprehensive knowledge,clinical skills, honesty and human-ity is difficult to find in today’s business-oriented dental educa-tion. I believe that knowledge

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should be free and skill trainingmust be useful and easily affordableto our young practising cliniciansaround the world. Compromiseduniversity dental education and expensive private skill training with biased mentoring have beenpromo ting health-compromisingtreatment protocols and costly diag-nostic, preventive and treatmenttechnologies. This highly business- oriented trend will promote achange in the mindset of practisingclinicians to adopt more-aggressiveand invasive dental treatmentmodalities, leading to the practice ofunhealthy dentistry in the long term.

Aesthetic versus cosmetic dentistry

The words “aesthetics” and“cosmetic” are viewed as synonymsby many cosmetic dentists. How-ever, it is necessary to understandthe core difference in meaning. The Oxford dictionary2 defines “aesthetics” as “the branch of philosophy which deals with ques-tions of beauty and artistic taste” and“cosmetic” as “improving only theappearances of something”.

In dentistry, “aesthetics” ex-plains the fundamental taste of aperson concerning beauty, whereas“cosmetic” deals with the super -ficial or external enhancement ofbeauty. Therefore, aesthetic den-tistry falls under need-based dentalservice, and is generally guided bythe sex, race and age (SRA factors) of the patient. However, cosmeticdentistry, which is influenced byper ception, personality and desires(PPD factors), can be categorised aswant- or demand-based dental serv-ice. For example, a patient’s requestto replace old amalgam restorationswith tooth-coloured restorative ma-terials can be considered an aes-thetic requirement or demand. Therequest of an old woman for pearlywhite teeth and the ideal smile de-sign is far more than an aesthetic re-quirement, and must be considereda cosmetic demand or requirement.

In my clinical practice, I divideaesthetic and cosmetic clinicalcases into three different categories:

1. Preventive, or support based:treatment prevents or intercepts

the diseases, defects, habits andother factors that may adverselyaffect the existing or the futuresmile aesthetics of the patient.

2. Naturo-mimetic, or need based:treatment is carried out to restoreor mimic the natural aesthetics,bearing the SRA factors of the pa-tient in mind, and the treatmentgenerally enhances the healthand function of the oral tissue.

3. Cosmetic, or desire based: treat-ment is performed to enhance orsupplement the aesthetic com -ponents of the smile; hence, thetreatment outcome of cosmetictreatment may not be in harmonywith the patient’s SRA factors as innature-mimetic dentistry, andcosmetic treatment may not nec-essarily be beneficial to the healthand function of the oral tissue.

Practice philosophy in dentistry: The mindset

The majority of dental schoolsaround the world focus on teaching

knowledge and skills in dental med-icine that are based on contempo-rary dental science and art. Dentalschool education does not give dueconsideration to healthy dentalpractice philosophy owing to vari-ous factors, such as the right to choseone’s practice philo sophy and thedomination of business rather than service-oriented dental practice inthe global market. However, qualityand healthy clinical practice is al-ways a dream of a good clinician,and establishing such practice re-quires an unbiased vision, learningand serving attitudes, and dedi -cation from the dentist. We must understand that science and art indentistry have no meaning if prac-tised by an unethical operator, whodoes not respect the overall health of the patient. Any scientific ad-vancement in technology has posi-tive and negative sides; hence, if notapplied properly, it may adverselyaffect the profession and may be-come a threat.

I believe that a clinic or treat-ment centre must establish its practice philosophy according to itsobjectives. What a clinician wantsand the kind of services he or shewants to deliver to his or her patientsguides the clinic. Practically, thepractice philosophy in dentistry canbe classified into two different cate-gories, depending on the mindset ofthe operator.

Patient-centred

Clinicians with this kind ofmindset generally have a do noharm dental practice (Fig. 1). Pro-fessional honesty and humanity arethe fundamental principles of such apractice. Operators with this mind-set enjoy sharing their clinicalknowledge and skills with their professional friends and junior col-leagues to promote patient-centredclinical practice in society. Thisgroup of clinicians firmly believes in the word-of-mouth approach topractice marketing and alwaysthinks of the patient’s long-termhealth, function and aesthetics. Cli-nicians practising do no harm den-tistry are generally cheerful, happyand healthy in their professional life.

Financially focused

Clinicians with this kind ofmindset practise a financially fo-cused dentistry and adopt variouskinds of direct marketing ap-proaches to sell their dentistry like a commodity in the market ratherthan a health care service. Practi-tioners in this group generallyachieve a secure financial positionquickly; however, it is frequentlyseen that they develop chronicstress, burn-out syndrome, depres-sion, frustration and professionalguilt, leading to compromisedhealth and happiness in their pro-fessional life.

Dentistry and professional stress

Dentistry has long been consid-ered a stressful occupation. Dentistsperceive dentistry as being morestressful than other occupations.3

Dentists have to deal with many significant stressors in their per-sonal and professional lives.4 Thereis some evidence to suggest thatdentists suffer a high level of occu-pation-related stress.5–9

A study has found that 83 per centof dentists perceived dentistry as

“very stressful”10 and nearly 60 percent perceived dentistry as morestressful than other professions.11

Stress can elicit varying physiologi-cal and psychological responses in aperson. Professional burn-out is oneof the possible consequences of on-going professional stress. The effectof burn-out, although work-related,often will have a negative impact on people’s personal relationshipsand well-being.12–13 Hence, dentistsneed to take care of their staff’shealth and focus on professionalhappiness in daily practice.

A clinician has full right to adoptthe practice philosophy that he orshe prefers. However, it is always advisable to apply oneself to under-standing, analysing and comparingthis philosophy with others. I amvery fortunate to have been broughtup with the Vedic philosophy of thelaw of nature and the first, do noharm consciousness-based philoso-phy in my life at home, at school andin my society. The spiritual guidanceand mentoring I received at an earlyage at home and school have helpedme to become a professional with a firm philosophy of do no harm;hence, I started practising con-sciousness-based dentistry early inmy career. During my 21 years ofprivate practice, I have always expe-rienced happiness and joy with highpatient satisfaction, which has givenme complete confidence and faith in my practice philosophy and theMiCD treatment protocol that I ap-ply in my practice. Since late 2009, I have been promoting my practicephilosophy and clinical protocol inSouth Asia, and started the MiCDGlobal Academy in 2012 with thehelp of like-minded friends, whoalso practise a similar kind of ho -listic dentistry around the world.The MiCD Global Academy has amission to share clinical knowledgeand fundamental clinical skills freeof charge with all clinicians who de-sire to practise do no harm cosmeticdentistry for better patient care andto enhance their happiness in theirprofessional life.

Three-way test: Questionsfor your conscience

Cosmetic dentists can make er-rors in practice in two ways, first owing to a lack of the required pro-fessional knowledge and skills, andsecond owing to a lack of profes-

Trends & Applications COSMETIC TRIBUNE Asia Pacific Edition No. 5/201518

Treatment options Treatment procedures Biological cost

Non-invasive treatment: • Smile exercise Nonewhen hard and soft tissue is • Remineralisation of white spotsnot prepared during smile • Oral appliances and bruxism guardenhancement procedures • Dentures requiring no tissue preparation • Gingival mask

Micro-invasive treatment: • Cosmetic chemical treatment, such as Very lowwhen hard and soft tissue is bleaching and micro-abrasion prepared at a micro-level during • Cosmetic restorations with chemical toothsmile enhancement procedures preparation, such as direct bonding, ultra-thin veneers, adhesive pontics and overlays

Minimally invasive treatment: • Cosmetic contouring (teeth and/or gingivae) Lowwhen hard and soft tissue is • Cosmetic restorations with minimal tooth prepared at a superficial preparation, such as thin veneers, modified or minimal level during inlays and onlays, partial crowns, smile enhancement procedures partial dentures, and inlay bridges • Non-extraction conventional and MiCD orthodontic treatment • Mini dental implants (small diameter) • Gingival depigmentation

Invasive treatment: • Tooth preparation for crowns, bridge abutments Highwhen hard and soft tissue is and deep veneers prepared at a deeper level during • Orthodontic treatment with tooth extractionenhancement procedures • Dental implants • Aesthetic surgical procedures, such as periodontal, orthognathic and facial surgeries

Table I:Treatment options, treatment procedures and biological cost in cosmeticdentistry.

Sooner is better Follow early diagnosis, prevention and intervention approach

Smile Design Wheel approach Understand psychology, establish health, restore function and enhance aesthetics (PHFA—sequences of Smile Design Wheel)

Do no harm Select the most conservative treatment options and procedures to minimise the possible biological cost

Evidence-based selection Select materials, tools, techniques and protocols based on scientific evidence

Keep in touch Encourage regular follow-up and maintenance

Table II: MiCD core principles.

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sional honesty and humanity. Thefirst one can be eliminated withgood education and proper training,but the second one demands a totalshift in mindset, with a high level of consciousness in professionalethics, attitudes and respect towardsthe patient’s long-term health, func-tion and natural beauty.

I apply a simple yet very power-ful test to keep myself stress- andguilt-free and within the boundariesof professional ethics, honesty andhumanity when proposing a dentaltreatment plan to my patient. Clini-cians can apply the three-way testmentioned below just by taking adeep breath and closing their eyesfor few seconds and analysing theiranswers (the true response thatcomes to mind) with professionalhonesty and humanity. If your con-science responds positively to all the questions, then it is advisable foryou to propose the treatment planand take up the case, but if you givenegative responses to the questions,then you should rethink your pro-posed treatment plan to safeguardyour and your patient’s long-termhealth, function and aesthetics using a more sensible and less de-structive treatment approach.

The three-way test consists ofthree basic questions:

• Would I use this treatment for amember of my own family in thissituation?

• Am I competent enough to take upthe case?

• Will the patient be happy with thebiological, financial and time costsof the proposed treatment?

I have been using this simple testsince my early days of practice andenjoying every moment of my clin -ical practice without any mentalstress and post-treatment profes-sional guilt. Moreover, I have foundthat the end-result of my case has always brought happiness to me andto my entire supporting team withhigh patient satisfaction. During allmy MiCD international lectures,training, workshops and seminars, I always encourage my trainees andaudience to enhance the quality oftheir operator factors (knowledge,skills, honesty and humanity) be-cause it is the pillar of successfulMiCD. It is my personal belief that, if a clinician adopts a habit of testinghis or her treatment plan with thethree-way test before proposing it to the patient, it can certainly helphim or her to promote overall happi-ness in his or her practice with highpatient satisfaction.

Extension: Invasive dentistry If we look carefully at the history

of restorative dentistry, the word“extension” (or “invasive”) has al-ways been a point of focus amongclinicians.14 The concept of “exten-sion for prevention and retention”was pronounced by Dr G.V. Black100 years ago and it was appropriatein relation to the restorative materi-als available at that time. However,with the development of porcelain-fused-to-metal technology in thelate 1950s, the concept of “extensionfor functional aesthetics” was advo-cated, which is still very popular inclinical practice. In the early 1980s,the concept of the “Hollywoodsmile” was introduced, which estab-lished the concept of “extension forcosmetics” in dentistry.

In 2002, the FDI World DentalFederation endorsed the approachof minimal intervention dentistry,which has basically focused on theconservative management of cari-ous lesions, applying the concept of“minimal extension for decay re-moval”. History clearly shows that,since Dr G.V. Black era to the pres-ent day, we have been applying theconcept of “extension in dentistry”in the name of prevention, reten-tion, function, aesthetic need andcosmetic desire, and caries re-moval. It is a clinical fact that thisconcept will remain the focus be-cause each clinical situation is dif-ferent, as its treatment modalitiesare guided by multifactorial issuessuch as patient factors (mind, body,behaviour and surroundings), op-erator factors (knowledge, skills,honesty and humanity), protocolfactors (the truth, evidence, ex -perience and common sense),technology factors (health, reliabil-ity, affordability and simplicity).The use of science and technologyrequires consciousness in opera-tors and awareness in patients;hence, the oper ator must use his orher professional knowledge andskills with honesty and humanity toselect the least invasive procedure,protocol and technology in treat-ment, so that extension in dentistryis always minimal, safe and healthy.

The invasiveness of proceduresselected in cosmetic dentistry de-pends on the level of smile defect,type of smile design, proposedtreatment types and treatmentcomplexity. MiCD uses the mostconservative smile enhancementprocedure possible. The level of in-vasiveness in cosmetic dentistry canbe classified into four types, name-ly non-invasive, micro-invasive,minimally invasive and invasive,and the treatment options, varioustreatment procedures and their biological cost for each are pre-sented in Table I. There is only oneprinciple in selecting treatmentmodalities in MiCD: always selectthe least invasive procedure as the choice of the treatment.2 Treat-ment procedures mentioned undernon- invasive, micro-invasive andmini-invasive are used selectivelyin MiCD.

MiCD treatment protocoland clinical technique

Minimally invasive dentistrywas developed over a decade ago byrestorative experts and founded onsound evidence-based principles.15–24

In dentistry, it has focused mainly on prevention, remineralisationand minimal dental intervention incaries management and not givensufficient attention to other oralhealth problems. For this reason, I developed the MiCD concept andits treatment protocol in 2009, whichintegrates the evidence-based min-imally invasive philosophy into aesthetic dentistry in the hope that itwill help practitioners achieve opti-mum results in terms of health,function and aesthetics with mini-mum treatment intervention andoptimum patient satisfaction. TheMiCD concept and treatment pro -tocol are explained in an article titled “Minimally invasive cosmeticdentistry—Concept and treatmentprotocol”;25 hence, in the current article, I only discuss the MiCD coreprinciples (Tab. II), MiCD treat-ment protocol and clinical tech-nique briefly (Fig. 2).

MiCD clinical technique:

Rejuvenation, restoration,

rehabilitation and repair

The MiCD clinical technique focuses on the aesthetic pyramid ofthe Smile Design Wheel1 (Fig. 3).Aesthetic components in dentistryare divided in to three broad groups:

1. macro-aesthetics, 2. mini-aesthetics; and 3. micro-aesthetics.

Each aesthetic group deals withdifferent smile aesthetic compo-nents (Tab. III) and each compo-nent must be harmonised at the endof treatment. According to the smiledefect and patient’s desire, there arefour different techniques in MiCD to enhance smile aesthetics:

1. Rejuvenation: to rejuvenate inMiCD is to enhance smile aesthet-ics with minor modifications intooth position, colour and form,also known as the MiCD ABC prin-ciples, namely align, brighten andcontour (Figs. 4–9):• Align: minor discrepancies be-

tween the facial and dental mid-lines are acceptable in many instances.26 However, a cantedmidline would be more obvi-ous27 and therefore less accept-able in cosmetic dentistry. Simi-larly, the disharmony in naturalprogression of axial inclinationor the degree of tipping of ante-rior teeth affects the aestheticoutcome of a smile. The correc-tion to the midline and axial in-clination progression, and nec-essary changes to anterior toothposition are carried out usingcosmetic orthodontic proce-dures with fixed or removablealigners. Once the anterior teethare in an aesthetically accept-able position, the aesthetic con-cerns of the patient generallyshift towards the colour en-

hancement of the dentition. It isto be noted that a well-alignedtooth generally requires no orless tooth preparation duringtooth contour (shape and size)modification. This helps the clinician to achieve aestheticsmiles with micro- or minimallyinvasive procedures with a verylow biological cost.

• Brighten: tooth bleaching orcolour modification in MiCD iscarried out once teeth are in acceptable alignment but be-fore the tooth form is modified.The level of tooth colour modifi-cation depends on the quality ofthe existing colour of the denti-tion and the patient’s desire.Home and office bleaching arepopular methods for modifyingtooth colour. However, in somecases, procedures such as re -mineralisation, micro-abrasion,walking bleach and thin enamelveneers are used.

• Contour: a contour is an outlineof the shape or form of some-thing.28 In dentistry, cosmeticcontouring entails reshapingteeth or gingivae to an aestheticform. Cosmetic contouring canbe performed in two ways, ad -ditive and subtractive. Additivecosmetic contouring entailschanging the tooth form usingtooth-coloured restorative ma-terials, such as a resin composite(direct and indirect restora-tions) or ceramic (veneers), andchanging the gingival shape using graft materials. Subtrac-tive cosmetic con touring entailsremoving dental tissue by grind-ing or texturing, and gingival tissue by selective surgical procedures—which are non- reversible in nature and soproper care must be taken.

2. Restoration: restoration is aprocess of replacing missing dental tissue to enhance health,

function and aesthetics. Restora-tion is performed using micro- to mini-invasive treatment op-tions, such as direct restorations,veneers, inlays, onlays or adhe-sive pontics, depending upon theextent and severity of the smile defect (Figs. 10a & b & 11a–c).

3. Rehabilitation: rehabilitation isthe process of complete recon-struction of the smile to enhancepsychology, health, function andaesthetics using micro- or mini-mally invasive treatment optionsto minimise the possible biologi-cal cost. Direct and indirect com-posite resin and feldspathicporcelain are the materials ofchoice for rehabilitation in MiCD(Figs. 12–14).

4. Repair: the role of repair inrestorative dentistry is very im-portant. The restoration cycle oreach re-restoration process gen-erally increases the size of thesmile defect by 15 to 20 per centper re-restoration. Hence, MiCDprotocol recommends perform-ing repair wherever aestheticallyappropriate and possible usingsuitable adhesive restorative ma-terials so that the health of the oraltissue will not be compromised,while maintaining function andaesthetics (Figs. 15a–c).

MiCD summary ten

After completion of any MiCDclinical case, the patient’s overallsatisfaction and the clinical successmust be evaluated. In order to eval-uate clinical cases comprehensivelyand practically, in the MiCD proto-col, a clinician is advised to alwayssummarise his or her cases underthe ten areas listed in Table IV,called the MiCD summary ten.

ConclusionIn order to practise do no harm

cosmetic dentistry, a clinician re-quires the desire, passion, dedica-tion and will-power to become anhonest professional with humanitybecause honesty and humanity arethe pillars of do no harm cosmeticdentistry, since the mind controls allother practice factors. The clinicianmust understand that honesty andhumanity are not scientific likeknowledge and skills, which can belearned, copied and applied imme-diately in the practice. Honesty andhumanity are inner qualities of aperson and are deeply related to thelevel of a person’s consciousness,which are generally expressed ashabits and attitudes. Therefore, weneed to learn these qualities at homeand school, and from the professionand society.

Self-evaluation and the realisa-tion of the level of inner happinessthat you obtain through your dailyprofessional work are vital to under-standing and beginning to practisedo no harm cosmetic dentistry inyour practice.

Editorial note: A complete list of references

is available from the publisher.

CT

Dr Sushil Koiralais the Chairmanof and chief in-structor at theVedic Institute of Smile Aes the -

tics. He can be contacted at drsushilkoirala@gmail.com.

Author Info

Ten areas Rating

1. Smile self-evaluation Good Satisfactory Compromised

2. Smile HFA grade Normal Compromised A Compromised HFA

3. Aesthetic category Micro Mini Macro

4. Treatment complexity Simple Moderate Complex

5. Proposed treatment Accepted Modified Changed

6. Established outcome Improved No change Deteriorated

7. Enhancement category Preventive Naturo-mimetic Cosmetic

8. Biological cost None Very low Low High

9. Exit remark Excellent Good Satisfactory Below satisfactory

10. Clinical success Excellent Good Satisfactory Needs improvement

Table IV: The MiCD summary ten.

Aesthetic components Smile design parameters

Macro-aesthetics: deals with the overall structure • Facial midlineof the face and its relation to the smile. In order • Facial thirdsto establish the macro-aesthetic components • Interpupillary lineof any smile, the visual macro-aesthetic • Nasolabial angledistance should be more than 1.5 m. • Rickett’s E-plane

Mini-aesthetics: deals with the aesthetic correlation In M-position:of the lips, teeth and gingivae at rest and in smile position. • Commissure heightThe aesthetic correlation can be established properly • Philtrum heightwhen viewed at a closer distance than the visual • Visibility of the maxillary incisorsmacro-aesthetic distance. The visual mini-aesthetic distance is similar to the across-the-table distance, In E-position:which is normally within 60 cm to 1.5 m. • Smile arc (line)

• Dental midline• Smile symmetry• Buccal corridor• Display zone and tooth visibility• Smile index• Lip line

Micro-aesthetics: deals with the fine structure of dental • Maxillary central incisors (tooth size ratio)and gingival aesthetics (Fig. 8). Micro-aesthetics can • Principle of golden ratiobe established at a visual micro-aesthetic distance • Axial inclinationof less than 60 cm or within normal make-up distance. • Incisal embrasures

• Contact point progression• Connector progression• Shade progression• Surface micro-texture

Table III: Aesthetic components and smile design parameters.

Prof. Edward A. McLaren & Lee Culp

USA

Introduction: Smile analysisand aesthetic design

Dental facial aesthetics canbe defined in three ways.

Traditionally, dental and fa-cial aesthetics have been definedin terms of macro- and micro- elements. Macro-aesthetics en-compasses the interrelation-ships between the face, lips, gingiva, and teeth and the per-ception that these relationshipsare pleasing. Micro-aestheticsinvolves the aesthetics of an in -dividual tooth and the perceptionthat the colour and form arepleasing.

Historically, accepted smiledesign concepts and smile pa-rameters have helped to designaesthetic treatments. These specific measurements of form,colour, and tooth/aesthetic ele-ments aid in transferring smiledesign information between thedentist, ceramist, and patient.Aesthetics in dentistry can en-compass a broad area—knownas the aesthetic zone.1

Rufenacht delineated smileanalysis into facial aesthetics,dentofacial aesthetics, and den-tal aesthetics, encompassing themacro- and micro-elements described in the first definitionabove.2 Further classificationidentifies five levels of aesthetics:facial, orofacial, oral, dentogin-gival, and dental (Tab. I).1,3

Initiating smile analysis:Evaluating facial and orofacial aesthetics

The smile analysis/designprocess begins at the macrolevel, examining the patient’sface first, progressing to an eval-uation of the individual teeth,and finally moving to material se-lection considerations. Multiplephotographic views (e.g., facialand sagittal) facilitate this ana -lysis.

At the macro level, facial ele-ments are evaluated for form and balance, with an emphasison how they may be affected by dental treatment.3, 4 During themacro-analysis, the balance ofthe facial thirds is examined(Fig. 1). If something appearsunbalanced in any one of those

zones, the face and/or smile willappear unaesthetic.

Such evaluations help deter-mine the extent and type of treat-ment necessary to affect the aesthetic changes desired. De-pending on the complexity anduniqueness of a given case, or-thodontics could be consideredwhen restorative treatmentalone would not produce the desired results (Fig. 2), such aswhen facial height is an issue and the lower third is affected. In other cases—but not all—restorative treatment could alter

the vertical dimension of occlu-sion to open the bite and enhanceaesthetics when a patient pres-ents with relatively even facialthirds (Fig. 3).

Evaluating oral aestheticsThe dentolabial gingival re -

lationship, which is consideredoral aesthetics, has traditionallybeen the starting point for treat-ment planning. This process begins by determining the idealmaxillary incisal edge place-ment (Fig. 4). This is accom-

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Facial aesthetics Total facial form and balance

Orofacial aesthetics Maxillomandibular relationship to the face

and the dental midline relationship to the face

pertaining to the teeth, mouth and gingiva

Oral aesthetics Labial, dental, gingival; the relationships

of the lips to the arches, gingiva, and teeth

Dentogingival aesthetics Relationship of the gingiva

to the teeth collectively and individually

Dental aesthetics Macro- and micro-aesthetics,

both inter- and intra-tooth

Table I: Components of smile analysis and aesthetic design.

Smile analysis and photoshop smile design technique

Fig. 1: Three altered views of the samepatient enable analysis of what can beaccomplished to enhance facial andsmile aesthetics.—Fig. 2: Sagittal viewsbest demonstrate which specialistsshould be involved in treatment,whether orthodontists or maxillo facialsurgeons, to best aesthetically alter thefacial aesthetics.—Fig. 3: Drawing aline along the glabella, subnasale, andpogonion enables a quick evaluation ofaesthetics without the need for radio -graphs to determine alignment of ideal

facial elements.—Fig. 4:Evaluating the maxillary incisal edge position is the starting point for establishing oral aesthetics.—Fig. 5:According to the 4.2.2 rule, this patient’s smile is deficient in aesthetic elements,having only 1mm of tooth display at rest (left), minus 3mm of gingival display, and 4 mm of space between the incisal edge and the lower lip (right).

Fig. 6: Gingival symmetry in relation to the central incisors, lateral incisors and canines is essential to aesthetics. Optimal aesthetics is achieved when the gingival line is relatively horizontal and symmetricalon both sides of the midline in relation to the central incisors and lateral incisors.—Fig. 7:The aesthetic ideal from the gingival scallop to the tip of the papilla is 4–5mm.—Figs. 8–10:Acceptable width-to-lengthratios fall between 70 % and 85 %, with the ideal range between 80 % and 85 %.—Fig. 11: An acceptable starting point for central incisors is 11mm in length, with lateral incisors 1–2mm shorter than thecentral incisors, and canines 0.5–1mm shorter than the central incisors for an aesthetic smile display.—Fig. 12: The canines and other teeth distally located are visually perceived as occupying less space in an aesthetically pleasing smile.—Fig. 13: A general rule for achieving proportionate smile design is that lateral incisors should measure two-thirds of the central incisors and canines four-fifths of the lateralincisors.—Fig. 14: If feasible, the contact areas can be restoratively moved up to the root of the adjacent tooth.—Fig. 15: Photoshop provides an effective and inexpensive way to design a digital smile withproper patient input. To start creating custom tooth grids, open an image of an attractive smile in Photoshop and create a separate transparent layer.—Fig. 16: The polygonal lasso tool is an effective way toselect the teeth.—Fig. 17: Click “edit > stroke,” then use a two-pixel stroke line (with colour set to black) to trace your selection. Make sure the transparent layer is the active working layer.

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plished by understanding the incisal edge position relative toseveral different landmarks. Thefollowing questions can be usedto determine the ideal incisaledge position:• Where in the face should the

maxillary incisal edges beplaced?

• What is the proper tooth display,both statically and dynami-cally?

• What is the proper intra- and inter-tooth relationship (e.g.,length and size of teeth, archform)?

• Can the ideal position beachieved with restorative den-tistry alone, or is orthodonticsneeded?

In order to facilitate smileevaluation based on these land-marks, the rule of 4.2.2—whichrefers to the amount of maxillarycentral display when the lips areat rest, the amount of gingival tis-sue revealed, and the proximityof the incisal line to the lowerlip—is helpful (Fig. 5). At a timewhen patients perceive fullerand brighter smiles as most aes-thetic, 4 mm of maxillary centralincisor display while the lips areat rest may be ideal.2,5 In an aes-thetic smile, seeing no more than2 mm of gingiva when the patientis fully smiling is ideal.6 Finally,the incisal line should come veryclose to and almost touch thelower lip, being no more than 2 mm away.2 These guidelinesare somewhat subjective andshould be used as a starting point

for determining proper incisaledge position.

Dentogingival aestheticsGingival margin placement

and the scalloped shape, in par-ticular, are well discussed in theliterature. As gingival heights aremeasured, heights relative to thecentral incisor, lateral incisor,and canine in an up/down/up relationship are considered aes-thetic (Fig. 6). However, this maycreate a false perception that the lateral gingival line is incisalto the central incisor. Rather, in most aesthetic tooth relation-ships, the gingival line of the four incisors is approximatelythe same line (Fig. 6), with thelateral incisor perhaps beingslightly incisal.7 The gingival lineshould be relatively parallel tothe horizon for the central inci-sors and the lateral incisors andsymmetric on each side of themidline.2, 8 The gingival contours(i.e., gingival scallop) should follow a radiating arch similar to the incisal line. The gingivalscallop shapes the teeth andshould be between 4 mm and 5 mm (Fig. 7).9

Related to normal gingivalform is midline placement. Al-though usually the first issue addressed in smile design, it isnot as significant as tooth form,gingival form, tooth shape, orsmile line.

Several rules can be appliedwhen considering modifying themidline to create an aestheticsmile design:

• The midline only should bemoved to establish an aestheticintra- and inter-tooth relation-ship, with the two central in -cisors being most important.

• The midline only should bemoved restoratively up to theroot of the adjacent tooth. If the midline is within 4 mm ofthe centre of the face, it will beaesthetically pleasing.

• The midline should be verticalwhen the head is in the posturalrest position.

Evaluating dental aestheticsPart of evaluating dental aes-

thetics for smile design is choos-ing tooth shapes for patientsbased on their facial charac -teristics (e.g., long and doli -chocephalic, or squarish andbrachycephalic). When patientspresent with a longer face, amore rectangular tooth withinthe aesthetic range is appro -priate. For someone with asquare face, a tooth with an 80 %width-to-length ratio would bemore appropriate. The width-to-length ratio most often discussedin the literature is between 75 %and 80 %, but aesthetic smilescould demonstrate ratios be-tween 70 % and 75 % or between80 % and 85 % (Figs. 8–10).1

The length of teeth also af-fects aesthetics. Maxillary cen-tral incisors average between 10 mm and 11 mm in length. According to Magne, the averagelength of an unworn maxillarycentral to the cementoenameljunction is slightly over 11 mm.10

The aesthetic zone for central

incisor length, according to theauthors, is between 10.5 mm and12 mm, with 11 mm being a goodstarting point. Lateral incisorsare between 1 mm and a maxi-mum of 2 mm shorter than thecentral incisors, with the caninesslightly shorter than the centralincisors by between 0.5 mm and1 mm (Fig. 11).

The inter-tooth relationship,or arch form, involves the goldenproportion and position of toothwidth. Although it is a good be-ginning, it does not reflect na -tural tooth proportions. Naturalportions demonstrate a lateralincisor between 60 % and 70 % ofthe width of the central incisor,and this is larger than the goldenproportion.11 However, a ruleguiding proportions is that thecanine and all teeth distal shouldbe perceived to occupy less vi-sual space (Fig. 12). Another ruleto help maintain proportionsthroughout the arch is 1-2-3-4-5;the lateral incisor is two-thirds ofthe central incisor and the canineis four-fifths of the lateral incisor,with some latitude within thosespaces (Fig. 13). Finally, contactareas can be moved restorativelyup to the root of the adjacenttooth. Beyond that, orthodonticsis required (Fig. 14).

Creating a digital smile designed in Photoshop

Although there are digitalsmile design services available to dentists for a fee, it is possible to use Photoshop CS5 software(Adobe Systems) to create anddemonstrate for patients the pro-

posed smile design treatments. It starts by creating tooth grids—predesigned tooth templates indifferent width-to-length ratios(e.g., 75 % central, 80 % central)that can be incorporated into acustom smile design based on pa-tient characteristics. You can cre-ate as many different tooth gridsas you like with different toothproportions in the aesthetic zone.Once completed, you will not haveto do this step again, since you willsave the created tooth grids anduse them to create a new desiredoutline form for the desired teeth.

Follow these recommendedsteps:• To begin creating a tooth grid,

use a cheek-retracted image ofan attractive smile as a basis(e.g., one with a 75 % width-to-length ratio). Open the imagein Photoshop and create a newclear transparent layer on topof the teeth (Fig. 15). Thistransparent layer will enablethe image to be outlined with-out the work being embeddedinto the image.

• Name the layer appropriatelyand, when prompted to iden-tify your choice of fill, choose“no fill,” since the layer will be transparent, except for the tracing of the tooth grid.

• To begin tracing the tooth grid,activate a selection tool, moveto the tool palette, and select either the polygonal lasso toolor the magnetic lasso tool. In theauthors’ opinion, the polygonalworks best. Once activated,zoom in (Fig. 16) and trace theteeth with the lasso tool.

Trends & Applications COSMETIC TRIBUNE Asia Pacific Edition No. 5/201522

Fig. 28: Adjust the grid as required while maintaining proper proportions by using the free transform tool from the edit menu.—Fig. 29: Modify the grid shape as necessary using the liquify tool.—Fig. 30: Select all of the teeth in the grid by activating the magic wand selection tool and then clicking on each tooth with the grid layer activated (highlighted) in the layers palette.—Fig. 31: Use the selectionmodify tool to expand the selection to better fit the grid shape.—Fig. 32: Activate the layer of the teeth by clicking on it. Blue-coloured layers are active.—Fig. 33: With the layer of the teeth highlighted, choose“liquify”; a new window will appear with a red background called a “mask”.—Fig. 34: Shape one tooth at a time as needed by selecting “wand”.—Fig. 35: Once all of the teeth have been shaped, use the liquifytool.—Fig. 36: Tooth brightness is adjusted using commands from the dodge tool menu or image adjustments menu.—Fig. 37: Image of all the teeth whitened with the dodge tool.

Fig. 18: Image of the central incisor with a two-pixel black stroke (tracing).—Fig. 19: Image of the teeth traced up to the second premolar to create a tooth grid.—Fig. 20: Size the image in Photoshop.—Fig. 21: Save the grid as a .png or .psd file type and name it appropriately. Create other dimension grids using the same technique.—Fig. 22 To determine the digital tooth size, a conversion factor is created bydividing the proposed length by the existing length of the tooth.—Fig. 23: Select the ruler tool in Photoshop.—Fig. 24: Measure the digital length of the central incisor using the ruler tool.—Fig. 25: Measurethe new digital length using the conversion factor created earlier.—Fig. 26: Create a new transparent layer and mark the new proposed length with the pencil tool.—Fig. 27: Open the image of the chosen toothgrid in Photoshop and drag the grid on to the image of teeth to be smile designed. This will create a new layer in the image to be smile designed.

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COSMETIC TRIBUNE Asia Pacific Edition No. 5/2015 Trends & Applications 23

• To create a pencil outline of thetooth, with the transparentlayer active, click on the editmenu in the menu bar; in theedit drop-down menu, select“stroke”; choose black forcolour, and select a two-pixelstroke pencil line (Fig. 17),which will create a perfect trac-ing of your selection. Click “OK”to stroke the selection. Select(trace with the lasso selectiontool) one tooth at a time andthen stroke it (Fig. 18). Selectand stroke (trace) the teeth upto the second premolar (the firstmolar is acceptable; Fig. 19).

• The image should be sized nowfor easy future use in a smile design. In the authors’ expe -rience, it is best to adjust thesize of the image to a height of720 pixels (Fig. 20) by openingup the image size menu and selecting 720 pixels for theheight. The width will adjustproportionately.

• At this time, the tooth grid trac-ing can be saved, without theimage of the teeth, by double-clicking on the layer of the toothimage. A dialog box reading“new layer” will appear; click“OK”. This process unlocks thelayer of the teeth so it can be re-moved. Drag the layer of theteeth to the trash, leaving onlythe layer with the tracing of theteeth (Fig. 21). In the file menu,click “save as” and choose“.png” or “.psd” (Photoshop) asthe file type. This will preservethe transparency. You do notwant to save it as a JPEG, sincethis would create a white back-ground around the tracing.Name the file appropriately(e.g., 75 % W/L central).

• By tracing several patients’teeth that have tooth size andproportion in the aesthetic zoneand saving them, you can createa library of tooth grids to cus-tom design new teeth for yourpatients who require smile designs.

The Photoshop smile design technique

The Photoshop Smile Design(PSD) technique can be done onany image, and images can becombined to show the full face orthe lower third with lips on or lipsoff. This article demonstrateshow to perform the technique onthe cheek-retracted view.

The first step in the PSD tech-nique is to create a digital conver-sion of the actual tooth length andwidth, and then digitally deter-mine the proposed new lengthand proportion of the teeth.

Determining digital tooth size

To determine digital toothsize, follow these steps:• Create a conversion factor by

dividing the proposed length(developed from the smileanalysis) by the existing lengthof the tooth.

• The patient’s tooth can bemeasured in the mouth or onthe cast (Fig. 22). If the lengthmeasures 8.5 mm but needs tobe at 11 mm for an aestheticsmile, divide 11 by 8.5. The con-version factor equals 1.29, a 29 % digital increase lengthwise.

• Open the full-arch cheek-re-tracted view in Photoshop, andzoom in on the central incisor.

• Select the eyedropper palette. A new menu will appear. Selectthe ruler tool (Fig. 23).

• Click and drag the ruler toolfrom the top to the bottom of the tooth to generate a verticalnumber, in this case 170 pixels(Fig. 24). Multiply the numberof pixels by the conversion factor. In this case, 170 x 1.29 =219 pixels; 219 pixels is digitallyequivalent to 11 mm (Fig. 25).Determine the digital toothwidth using the same formula.

• Create a new layer, leave ittransparent, and mark themeasurement with the penciltool (Fig. 26).

Applying a new proposed

tooth form

Next, follow these steps:• After performing the smile

analysis and digital measure-ments, choose a custom toothgrid appropriate for the patient.Select a tooth grid based on the width-to-length ratio of theplanned teeth (e.g., 80/70/90 or 80/65/80). Open the image of the chosen tooth grid in Photoshop and drag the grid onto the image of teeth to be smiledesigned (Fig. 27).

• If the shape or length is deemedinappropriate, press the com-mand button (control button forPCs) and “z” to delete and selecta suitable choice.

• Depending on the original im-age size, the tooth grid may beproportionally too big or toosmall. To enlarge or shrink the tooth grid created (with the layer activated), press command (or control) and “t” to bring up the free transformfunction. While holding theshift key (holding the shift keyallows you to transform the object proportionally), clickand drag a corner left or right toexpand or contract the customtooth grid.

• Adjust the size of the grid so thatthe outlines of the central inci-sors have the new proposedlength. Move the grid as neces-sary using the move tool so thatthe incisal edge of the tooth gridlines up with the new proposedlength (Fig. 28).

• Areas of the grid can be individ-ually altered using the liquifytool (Fig. 29).

Digitally creating

new aesthetic teeth

Next, follow these suggestedsteps:• With the new tooth grid layer

and the magic wand tool bothactivated, click on each tooth toselect all of the teeth in the grid(Fig. 30).

• Expand the selection by twopixels in the expand menu;click “select > modify > expand”(Fig. 31). Note that the selectionbetter approximates the grid.You can expand the selection orcontract as necessary using thesame menu.

• Activate the layer of the teeth(cheek-retracted view) byclicking on it (Fig. 32).

• Next, activate the liquify filter(you will see a red mask aroundthe shapes of the proposedteeth). The mask creates a digi-tal limit that the teeth cannot bealtered beyond. This is similarto creating a mask with tape forpainting a shape (Fig. 33).

• Use the forward warp tool byclicking on an area of the exist-ing tooth and dragging tomold/shape the tooth into theshape of the new proposed out-line form (Fig. 34).

Repeat this for each tooth. If you make a mistake or do notlike something, click command(or control) and “z” to go back tothe previous edit (Fig. 35).

Adjusting tooth brightness

The following steps are rec-ommended next:• Select the whitening tool

(dodge tool) to brighten theteeth. In the dodge tool palate,click on “midtones” and set the exposure to approximately20 %. Click on the areas of thetooth you want brightened(Figs. 36 & 37).

• Alternatively, with the teeth selected, you can use thebrightness adjustment in thebrightness/contrast menu; click“image > adjustments > bright-ness/ contrast”.

Performing the changes ononly one side of the mouth allowsthe patient to compare the newsmile design to his/her original

teeth before agreeing to treat-ment.

Create a copy

To save the information youhave created for presentation tothe patient, follow these tips:• Go to “file” and select “save as”. • When the menu appears, click

on the “copy” box. • Name the file at that step. • Save it as a JPEG file type. • Designate where you want it

saved. • Click “save”.

A file of the current state of the image will be created in thedesignated area. You can nowcontinue working on the imageand save again at any point youwant.

ConclusionKnowledge of smile design,

coupled with new and innovativedental technologies, allows den-tists to diagnose, plan, create, and deliver aesthetically pleasingnew smiles. Simultaneously, dig-ital dentistry is enabling dentiststo provide what patients demand:quick, comfortable, and pre-dictable dental restorations thatsatisfy their aesthetic needs.

Editorial note: A complete list of refer-

ences is available from the publisher.

This article was originally published

in the Journal of Cosmetic Dentistry,

spring issue, No 1/2013, Vol. 29,

and the Clinical Masters Magazine

No 1/2015.

CT

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Lee Culp, CDT,is an adjunct faculty memberat the Universityof North Car-olina at Chapel

Hill School of Dentistry. He can be contacted at lee_culp@microdental.com.

Author Info

Prof. Edward A. McLaren isthe director ofthe University ofCalifornia, LosAngeles Center

for Esthetic Dentistry. He can be contacted at emclaren@dentistry.ucla.edu.

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