DT UK No. 4, 2015

UK News / World News / Business / Graduation: A minefield for the younger generation of dentists / Interview: “Patients tend to go to court more often nowadays” / Cosmetic Tribune United Kingdom Edition No. 4 - 2015

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DTUK0415_01_Title 15.09.15 10:26 Seite 1

DENTAL TRIBUNE
The World’s Dental Newspaper · United Kingdom Edition
www.dental-tribune.co.uk

Published in London

Vol. 9, No. 4

INTERVIEW

GRADUATION

COSMETIC TRIBUNE

Dr Stefanos Morfis about the situation of dentists in Greece and
the reasons he has chosen to leave
his home country in order to start
working in the UK.
” Page 6

Dental Tribune contributor Aws
Alani explains why entering the
field has become a minefield for
the younger generation of dentists.
” Page 10

Read the latest news and clinical
developments from the field of
cosmetic dentistry in our specialty section included in this very
issue.
” Page 17

Introducing a treatment coordinator:
The Bridge to case acceptance
By Lina Craven, UK

Filling the role:
An internal solution?

You might think that in financially
challenging times the last thing
you need is a new member of staff.
For a practice to thrive and prosper
in a difficult financial climate, however, it has to become more efficient,
more competitive and more profitable. One way to do that is to introduce a treatment coordinator (TC)
into the team or if you already have
one then to offer appropriate training. This is a relatively new role to
the European market, but in the US,
where the role is a central part of
any practice, it has proven to dramatically add value to the patient
experience, reduce in chair time and
increase case acceptance.
The introduction of a welltrained TC will change your entire
approach to new patient care, as
well as increase profitability. While
many practices know how to attract patients, their case acceptance ratio is low. The first contact,
first visit and follow-up are the
most important elements of the
new patient process, yet they frequently represent a wasted opportunity because of a lack of skill,
focus, time or all three.
In my experience, a major downfall of practices is the unwillingness
of practitioners to delegate the new
patient process to staff, or what we
call the TC role. This is often due to
a wide range of factors, including
the practitioner’s perception that
the patient wants communication
on his or her treatment to come
from the practitioner, the perception that patients pay to see the
practitioner, a lack of trust to empower staff or time to train staff,
and the financial implications of
introducing the new role.
Relinquishing new patient management to well-trained staff is not
a new trend, although its application has been limited in Europe.
However, patients’ expectations,
competition for private work and
the team’s demand for career progression and job satisfaction are
key drivers for introducing the
TC role.

There are no hard and fast rules.
It depends upon the size and aspirations of your practice and the
qualities of existing members of
your team. If you have a team member who fulfils the characteristics
of a TC and he or she wants the challenge, then the answer is yes. Keep
in mind that you may well need to
fill that person’s current position.

The TC concept
A TC is someone in your practice
who, with the right skills and training, will facilitate the new patient process. He or she bridges the
gap between the new patient, the
practice and the staff. The TC promotes and sells the practice and its
services by demonstrating their
true value to prospective patients,
frees up the practitioner’s time,
increases case acceptance ratios
and, resultantly, increases practice
profits.
Consider the time spent by the
practitioner with the new patient
and calculate how much of that
time is non-diagnostic. A TC can often reduce up to 60 per cent of practitioner–patient time. Rather than
this being a barrier to patients—
which is indeed what many practitioners perceive to be the case—
in my experience, patients actually
feel much more at ease with the TC
and therefore better informed.
Doctor time is not always doctor time. As a typical example: if
an new patient appointment is
30 minutes, but the clinical part
is actually only 15 minutes, there

is potentially 15 minutes still available. Think about the impact an
additional 15 minutes for every new
patient in the appointment diary
could have.
A good TC will manage all aspects
of the patient journey, from referral to case start, and potentially increase your case starts. He or she is
the first point of contact. People
buy from people, so the development of a relationship and establishing of rapport between the TC
and the new patient are crucial to
the success of your conversion
from referral to start of treatment.
The TC informally chats to the new
patient prior to consultation. This
helps not only to foster rapport but
also to gain a better idea of the
patient’s needs and wants.
I recommend to all my TCs to be
present at the consultation to listen
and understand clinically what is
and is not possible in order to allow
the TC to determine how he or she
will conduct a top-notch case presentation.
The TC carries out the case presentation, reiterates the treatment

options available to the patient,
discusses these, answers any questions the patient may have, and
clarifies proposed treatment. He or
she also discusses the informed
consent, shows before and after
photographs of similar cases, and
addresses any barriers or concerns
the patient may have.
The TC also explains the financial
options and determines the most
suitable payment method for the
patient’s needs, as well as prepares
the walk-out pack. The value of a
walk-out pack should not be underestimated and should reflect the
values of the practice, including
all information the patient needs,
the finance agreement or contract,
diagnostic report, photographs of
the patient (an excellent marketing
tool), informed consent and anything else the practitioner feels
adds value to the consultation.
Too many new patients are lost
due to lack of follow-up. A good TC
follows up and provides monthly
information on patient conversions to assist with strategic planning. All practices should have a
patient journey tracker.

Some practices streamline job
descriptions allowing them to create the new role without having
to hire another staff member.
Whether it is a full-time role or not
depends upon various factors, including the size of the practice; the
number of practitioners, chairs
and patients; and the profit aspirations. Many practices implement the role and monitor its
progress and impact. This often
helps the team to accept the change
and gives the practitioner the opportunity to assess any training
needs of the TC and to access how
remuneration will be affected.
The role of your TC should fit in
with your practice’s culture and aspirations for patient care. However
you choose to implement the role,
the only guarantee is that you will
benefit enormously. Augmenting
your team with a well-trained TC
can reap tremendous rewards for
you, the team and your patients.
A TC’s tailored and personal approach to care, follow-up and communication with patients fosters
trust and increases patient satisfaction and retention.

Lina Craven is
founder and Director of Dynamic Perceptions,
an orthodontic
m a n a g e m e nt
consultancy and
training ﬁrm in
Stone in the UK,
and has many
years of practice-based experience. She
can be contacted at info@linacraven.com

[2] =>

DTUK0415_02_News 23.03.16 17:36 Seite 02

UK NEWS

Dental Tribune United Kingdom Edition | 4/2015

BDA calls for radical action to
lower Britain’s sugar intake

IMPRINT

By DTI

ONLINE EDITOR:
Claudia DUSCHEK

LONDON, UK: Lately, there have
been increasing efforts to curb
Britain’s high sugar consumption.
Although the British Dental Asso-

progress, but these symbolic gestures should not disguise the fact
supermarkets are still banking
on the nation’s sweet tooth,” Dr
Mick Armstrong, Chair of the BDA,
said.

Tesco’s plans echo recent recommendations in the Carbohydrates
and Health report, published by
SACN on 17 July, which advises
reducing the daily energy intake
of sugars from 10 to 5 per cent.
The report also recommends that
consumption of sugar-sweetened
drinks be minimised and of fibre be
increased.
According to the health experts,
5 per cent of daily energy intake is
the equivalent of 19 g or five sugar
cubes for children aged 4–6, 24 g
or six sugar cubes for children aged
7–10, and 30 g or seven sugar cubes
for those aged 11 and over, based on
average diets.

ciation (BDA) has welcomed Tesco’s
recent announcement that it is
banning high-sugar drinks from its
shelves, the association has called
for action that goes further than
“symbolic” concessions and urged
government to follow the recommendations of the report by the
Scientific Advisory Committee on
Nutrition (SACN).
“Finally we’re seeing big retailers
waking up to the sugar crisis. That’s

“The recent obituaries for Capri
Sun, Ribena or Percy Pigs are designed first and foremost to fill up
column inches and Twitter feeds.
PR stunts should not blind government, parents or health practitioners to the need for real, co-ordinated
action to address Britain’s addiction to sugar,” remarked Armstrong
on Tesco’s plans to take addedsugar drinks out of the children’s
juice department starting in September.

The SACN findings, established by
a group of independent experts that
advises government on matters relating to diet, nutrition and health,
offer the first wide-ranging look at
the relationship between sugar consumption and health outcomes in
the UK since the 1990s.
Other national statistics have
shown that British children especially are consuming unhealthy
amounts of free sugars—the
nutrient-free refined sugar added
to products such as sweetened
drinks—in their daily diet. At 30 per
cent, soft drinks accounted for
the majority of sugar in the diet of

4- to 10-year-olds, the 2014 National
Diet and Nutrition Survey found.
Soft drinks and juices are especially harmful to the teeth, since
they tend to be very acidic, which
makes the teeth particularly vulnerable to both dental decay and tooth
erosion. Aside from posing oral
health risks, a diet rich in free sugars
has been linked to obesity and Type
2 diabetes, among other conditions.
With reference to the SACN recommendations, the BDA has called
for radical measures to cut Britain’s
sugar intake, including lowering the
recommended daily allowance, and
action on marketing, labelling and
sales taxes. The BDA has launched an
online petition addressed to Prime
Minister David Cameron, inviting
both health professionals and patients to lend support to SACN’s
proposals at Change.org.
“We have an historic opportunity
here to end Britain’s addiction to
sugar. The government now has the
evidence and a clear duty to send the
strongest possible signal to the food
industry, that while added sugar
might be helping their sales, it is hurting their customers,” Armstrong said.
The complete SACN report can
be accessed at https://www.gov.uk/
government/publications/sacncarbohydrates-and-health-report.

PUBLISHER:
Torsten OEMUS
GROUP EDITOR/MANAGING EDITOR DT AP & UK:
Daniel ZIMMERMANN
newsroom@dental-tribune.com
CLINICAL EDITOR:
Magda WOJTKIEWICZ

ASSISTANT EDITORS:
Anne FAULMANN, Kristin HÜBNER
COPY EDITORS:
Sabrina RAAFF, Hans MOTSCHMANN
PRESIDENT/CEO:
Torsten OEMUS
CFO/COO:
Dan WUNDERLICH
MEDIA SALES MANAGERS:
Matthias DIESSNER
Peter WITTECZEK
Maria KAISER
Melissa BROWN
Weridiana MAGESWKI
Hélène CARPENTIER
Antje KAHNT
MARKETING & SALES SERVICES:
Nicole ANDRAE
ACCOUNTING:
Karen HAMATSCHEK
BUSINESS DEVELOPMENT:
Claudia SALWICZEK
EXECUTIVE PRODUCER:
Gernot MEYER
AD PRODUCTION:
Marius MEZGER
DESIGNER:
Franziska DACHSEL
INTERNATIONAL EDITORIAL BOARD:
Dr Nasser Barghi, Ceramics, USA
Dr Karl Behr, Endodontics, Germany
Dr George Freedman, Esthetics, Canada
Dr Howard Glazer, Cariology, USA
Prof. Dr I. Krejci, Conservative Dentistry, Switzerland
Dr Edward Lynch, Restorative, Ireland
Dr Ziv Mazor, Implantology, Israel
Prof. Dr Georg Meyer, Restorative, Germany
Prof. Dr Rudolph Slavicek, Function, Austria
Dr Marius Steigmann, Implantology, Germany

Rare case of amnesia linked to
root canal treatment
By DTI
LEICESTER, UK: In March 2005,
a 38-year-old British soldier stationed in Germany lost his ability
to form new memories after undergoing a regular root canal treatment. To this day, he is unable to remember anything for longer than
90 minutes, although his brain is
completely intact and he suffered no
trauma that could have caused the
amnesia, according to his doctors.
“I remember getting into the
chair and the dentist inserting the
local anaesthetic,” the man, who
wishes to remain anonymous, told
the BBC. Since that moment, he remembers nothing. Every morning,
he wakes up thinking that he is still
a soldier stationed in Germany in
2005, waiting to visit the dentist
for root canal surgery.
The German dentist only realised after the treatment, which
was without complications, that
something was wrong with the patient. He was pale, disoriented and

struggled to stand up. As his condition did not improve, he was brought
to hospital where he stayed for several days. In the beginning, he was
not able to remember anything for
longer than a few minutes.
The doctors’ first suspicion was
that a bad reaction to the anaesthetic had caused a brain haemorrhage. However, they could not find
any evidence of injury. Finally, the
patient and his family returned to
England, where Dr Gerald Burgess,
a clinical psychologist from Leicester, took over the case.
According to Burgess, a form of
anterograde amnesia would have
been the most obvious explanation for the man’s condition. In this
case, the hippocampi, the brain regions responsible for the consolidation of information from shortterm memory to long-term memory, are damaged so that memories
can no longer be formed and stored
correctly. Yet, the man’s brain scans
showed no abnormalities. Thus, another possible explanation would

have been a psychogenic illness.
Burgess conducted detailed psychiatric assessments in order to
determine whether the man had
suffered any trauma. However,
Burgess found that his patient was
emotionally healthy and his wife
confirmed that there had not been
any traumatic events in the man’s
life prior to his dentist visit in 2005.
Burgess continues to research
his patient’s rare case of amnesia,
currently suspecting that the
brain’s synapses might play an important role. Each time a memory
is formed and transferred to longterm memory, the synapses are rebuilt, which involves the production of new proteins. This protein
synthesis might be blocked in the
case of Burgess’ patient, keeping
him from generating any new longterm memories. In order to further
research his hypothesis, Burgess
is examining five similar cases of
mysterious memory loss without
brain damage from the medical literature. These cases might provide
an answer to why the root canal

treatment appears to have triggered the man’s memory loss. All
of the cases are in some way related
to a period of psychological stress
during a medical emergency. “It
could be a genetic predisposition
that needs a catalyst event to start
the process,” Burgess told the BBC.
“One of our reasons for writing
up this individual’s case was that we
had never seen anything like this
before in our assessment clinics,
and we do not know what to make
of it, but felt an honest reporting of
the facts as we assessed them was
warranted, that perhaps there will
be other cases, or people who know
more than we do about what might
have caused the patient’s amnesia,”
Burgess stated.
The case report by Burgess, titled
“Profound anterograde amnesia
following routine anesthetic and
dental procedure: A new classification of amnesia characterized by
intermediate-to-late-stage consolidation failure?”, was published online
in the Neurocase journal on 15 May.

Published by DTI.
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DTUK0415_04_News 10.09.15 15:04 Seite 4

UK NEWS

Dental Tribune United Kingdom Edition | 4/2015

Research uses virtual reality
technology to train dental surgeons
By DTI
HUDDERSFIELD, UK: A University of
Huddersfield researcher is harnessing the latest virtual reality technolAD

ogy to help oral and maxillofacial
surgical trainees practise complex
dental surgeries. His project aims to
provide accurate 3-D visualisations
of human anatomy and surgical

procedures using Oculus Rift, a virtual reality head-mounted display.
Indian-born Yeshwanth Pulijala
is a qualified dental surgeon. Dur-

ing his training, he was confronted
with the problem of poor visualisation of dental procedures in the
operating room. Being aware of
these shortcomings in surgical

training, as well as passionate
about 3-D design and technology,
he relocated to the UK to pursue
postgraduate research on the use of
advanced technology to improve
health care.
During his master’s studies on
3-D medical visualisation at the
University of Glasgow, Pulijala created a mobile app called SurFace
that provides patient education
in corrective jaw surgery. This inspired him to explore the potential
of virtual reality for surgical education, using Oculus Rift. A commercial version of the device is
expected to be released in the first
quarter of 2016. However, Pulijala,
who is currently studying for a PhD
at the University of Huddersfield,
was able to obtain the developer
version for his research.
Learning through observation
and hands-on participation is an
important part of the education
of surgical trainees, and medical
and dental students, according to
Pulijala. “During these sessions the
trainees learn by observing the procedures in real time,” he stated. “But
the problem is that not everybody
can see what is happening. This
is especially the case in crowded
operating rooms where surgical
trainees perform multiple duties.
Also in surgeries confined to
oral and maxillofacial zone, as the
structures are complex and densely enclosed in a confined space, it
is very hard to observe and learn.
Further, a reduction in surgical
training hours is severely affecting
the training of surgeons,” Pulijala
pointed out.
As a result, he continued, four
out of ten surgical trainees are not
confident in performing a procedure. Therefore, he is developing
a tool that enables them to participate virtually in an operation. His
PhD project aims to provide trainee
surgeons with close-up, unrestricted 360-degree views of a surgical
procedure, yielding the potential
to improve surgical training substantially.
“If you are a trainee surgeon,
wearing an Oculus Rift, you will
see the surgical procedure in an
operating room environment and
also be able to ‘touch’ the skull of
the patient and interact with it,”
Pulijala said. He is currently developing the project concept and producing working prototypes. In the
longer term, he envisions a system
that will enable surgical trainees
to practise and perform virtual
operations. “But at the moment it
is about creating a high-quality
visualisation, interacting with the
patient’s data and seeing their
anatomy in great detail,” he concluded.

[5] =>

[6] =>

DTUK0415_06_Morfis 10.09.15 15:05 Seite 06

WORLD NEWS

06

Dental Tribune United Kingdom Edition | 4/2015

“I do not see how the situation can improve”
An interview with Dr Stefanos Morﬁs, Greece
Educated in Manchester and a
dentist at heart, Dr Stefanos Morfis
opened his first practice in Athens
five years ago, right at the beginning of the debt crisis in Greece. Five
years later, he is selling it owing to
the economic circumstances and is
planning to register with the General Dental Council in order to start
working as a dentist in Britain.
Dental Tribune had the opportunity
to speak with him recently about
the situation of dentists in his home
country and the reasons he has
chosen to leave.
Dental Tribune: Dr Morfis, with the
recent referendum on the austerity
measures proposed by the EU and
the resignation of Minister of Finance
Yanis Varoufakis, the debt crisis in
Greece has heated up again. Can you
describe what impact the crisis has
had on dentistry in your country?
Dr Stefanos Morfis: When one
looks back 10–15 years, dentistry
actually used to be quite a prosperous business in Greece. Since many
dentists received their education
in countries like England, Germany
or the Netherlands, the level of den-

Dr Stefanos Morﬁs

tistry was quite high. What we have
seen during the last ten years or so
is that fewer people are visiting the
dentist because of their financial
situation and they only go when
they are already in pain.
You have to know that, unlike in
the UK or other European countries,
most dental care here is private.
Since many cannot afford treatment in Greece, they travel to other
countries, like Macedonia, where
they receive cheaper, but lower
quality, treatment. Recently, I heard

of two patients who died after undergoing a tooth extraction there.

fessionally and ensure quality for
patients at these prices?

Owing to the lack of money for
treatment, caries levels are very
high and, although we are fully
aware of its benefits, there is very
little money for any kind of preventative dentistry. This is only done
at university level.

With having to compete at such low
prices, can you actually live on your
income as a dentist in Greece?
Ten years ago, our income was
almost double what it is now and
the cost of living, materials and
education were much cheaper.
Living in Athens now is like living
in London, but with five times less
income. That is why many now
meet their educational needs
online by attending free webinars.
What is really troubling is that
more and more dentists are being
forced to sell their practice for
half the price. That includes me.
Ironically, my practice will be taken
over by a dentist from Britain.

Consumer prices in Greece are soaring owing to the strict regulations.
Have prices for dental treatment
also gone up?
In contrast to everything else in
Greece, prices for dental treatment
have actually gone down in the last
five years. While one could charge
€50 or more for a composite filling in 2003/2004, today there are
quite a number of dentists who are
performing fillings for just €20.

You are planning to work in the UK.
When are you going to leave?
I am currently in the process of
registering with the General Dental
Council and planning to leave Greece
in November. I did my postgraduate
studies at the University of Manchester’s School of Dentistry and I have
worked in several practices over there.

This trend is facilitated by the
majority of patients, who are only
looking at price and not at what
kind of material is being put in
their mouth. Do not ask even me
what kind of fillings they use sometimes! But how can one work pro-

AD

R

R

R

The austerity measures will allow
Greece to stay in the EU. In your
opinion, is there any possibility of
the situation improving?
There are positive examples,
like Ireland and Portugal who were
able to recover from the recession
a few years ago. I hope to be proven
wrong, but I do not see how the
situation can improve in Greece.
Politicians come and go, but the
people remain the same. If we do
not drastically change how things
are run in this country, in a few
years I guess it will be impossible to
recover.
Would you go back if things start to
improve?
I would like to, but I think it will be
very difficult. I have a family to look
after now and I want the best for my
little son. At 35, I am at the best age
to be productive and achieve things
in my live. I have always felt a love
for the dental profession and therefore want to dedicate my life to it.
Thank you very much for taking
the time and all the best for your
future.

[7] =>

DTUK0415_07_Amalgam 15.09.15 15:51 Seite 1

AD

Dental Tribune United Kingdom Edition | 4/2015

Update on
dental amalgam
guidelines
European Commission recommends use
of alternative materials for ﬁllings
By DTI
BRUSSELS, Belgium: Many countries around the world, European
countries in particular, have seen
a shift away from the use of dental
amalgam in oral health care and an
increase in the use of alternative
materials over the past years. The

European Commission recently
acknowledged this trend and published an updated version of its
opinion on the safety of dental
amalgam and alternative restoration materials.
The new document is an update
of the 2008 opinion and aims to
assess the safety and effectiveness
of dental amalgam and current
alternative materials by evaluating
the latest scientific evidence.
While in 2008 the European
Commission and the Scientific
Committee on Emerging and
Newly Identified Health Risks concluded that both types of material
are generally considered safe to
use, they now recommend that
the choice of material be based on
patient characteristics. In accordance with the objectives of the
Minamata Convention on Mercury,
the committee now recommends
using alternative materials in children and pregnant women.
The committee further stated
that the systemic effects of elementary mercury are well documented
and it has been identified as a
neurotoxin, especially during early
brain development by a number
of studies. Mercury has also been
associated with adverse health effects in the digestive and immune
systems, and in the lungs, kidneys,
skin and eyes. Nevertheless, the

evidence for such effects due to
dental amalgam is weak, according
to the committee.
The new recommendation is
also based on the findings that
dental amalgam fillings may cause
mercury poisoning in genetically
susceptible populations. Some

genetic variants appear to impart
increased susceptibility to mercury toxicity from dental amalgam.
Studies involving dental health
care personnel have indicated that
mercury exposure from dental
amalgam during placement and
removal may cause or contribute
to many chronic illnesses, as well
as depression, anxiety and suicide.
However, exposure of both patients
and dental personnel could be minimised by the use of appropriate
clinical techniques, the committee
stated in its opinion report.
However, current evidence does
not preclude the use of either
amalgam or alternative materials
in dental restorative treatment.
The committee acknowledged
that there is a need for further research, particularly with regard to
neurotoxicity of mercury from
dental amalgam and the effect of
genetic polymorphisms on mercury toxicity. In addition, the
committee concluded that there
is a need for the development of
new alternative materials with a
high degree of biocompatibility.
The full report, titled “The safety of
dental amalgam and alternative
dental restoration materials for
patients and users”, can be accessed
on the website of the Scientific
Committee on Emerging and Newly
Identified Health Risks.

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DTUK0415_08_Shah 10.09.15 15:05 Seite 1

BUSINESS

Dental Tribune United Kingdom Edition | 4/2015

“Bring more patients
into practices”
An interview with Crown 24 Directors Rupa Shah and Sandy Shapira, London
Crown 24 UK has made a significant impact in the UK dental laboratory market since it started three
years ago. Dental Tribune had the
opportunity to speak with Rupa
Shah and Sandy Shapira, directors of the company, about their
unique marketing concept and
how they manage to assure the
highest quality at a significantly
lower price.
Dental Tribune: With Crown 24 UK,
you promise that dentists and patients are able to have dental prostheses fabricated at much lower
costs. How do you achieve this price
advantage?

Rupa Shah: Our concept is very
simple. While we offer the premises of a fully equipped dental laboratory based in London, all the
manufacturing is done in China.
The production there allows us to
offer a better price to dentists and
patients. If the benchmark for the
UK is £250, for example, we are
able to provide laboratory work
that is up to 60 per cent cheaper
than comparable work done here
in the UK.
How do you assure quality that is
comparable to UK standards?
Sandy Shapira: Since Crown 24 UK
is the daughter company of a busi-

ness that started in Switzerland five
years ago, our dental laboratory
in London can offer proven Swiss
standards of control.
Based on that, we have implemented a strict monitoring and
evaluation process for each phase
of manufacturing. The finished
products sent from China are
subject to final quality control
inspection by our UK-based senior technicians registered with
the General Dental Council.
This process allows us to provide
a five-year guarantee to all our
customers.

What kind of laboratory work does
Crown 24 UK offer at present, and
do you cover CAD/CAM too?
Rupa Shah: We currently carry
out crown and bridge work, implantology and prosthetics. We
even provide a CEREC machine free
to dentists, so they can send us their
digital data as they are used to.
What are the prospects for your
business?
Rupa Shah: You probably know
better than I that dentistry, particularly in the UK, is a struggling
business. Many practices are having difficulties sustaining their
business owing to the lack of pa-

tients. At Crown 24, we advertise to
both dentists and prospective patients, so patients first contact us
directly and we can then pass their
information on to the dentists.
The general goal is to bring more
patients into practices.
Thank you very much for the interview.

Crown 24 UK Ltd
Rowlandson House
289–293 Ballards Lane
London, N12 8NP
Tel.: 0800 1522338
info@crown24uk.co.uk
www.crown24uk.co.uk

Photos showing production in China. © Crown 24 UK

UK spin-out launches crowdfunding
campaign for no-drill tooth repair tech
By DTI
PERTH, UK: Teeth restored without
drilling is the dream of almost
every dental patient. A new
approach developed in Britain that utilises an electrical
current to remineralise the
tooth promises exactly that.
Reminova, the developer of
the technology, has now announced the start of an equity
crowdfunding campaign for
UK and the US in an effort to
raise £0.5 million to bring it to
market.

panies interested in selling the
technology, Reminova executives
said. Initial clinical studies are also
planned.

Reminova expects a potential
market for the device of 700,000
dentists worldwide. In a press note
released at the start of the cam-

It will be the first fundraising campaign of its kind to
target shareholders in both
countries simultaneously. If
reached, the sum will be used
to expand the company’s development and operational
team and to seek strategic
partnerships with dental com- Left to right: Professor Nigel Pitts, Dr Chris Longbottom and Dr Jeff Wright of Reminova.

paign, the company said that individuals who are interested in
becoming shareholders will have
60 days to contribute to the project.
The minimum investment is
£1,000 for those from the UK
or Europe and US$5,000 for
Americans.
In return, they will help to
get rid of drilling in dentistry
and transform global dental
health.
“With their help and investment, our tooth rebuilding
treatment could be available
to patients within three years,”
predicted Reminova CEO Dr
Jeff Wright.
According to Reminova, its
technology prepares damaged tooth enamel in such a
way that the ions of minerals
required to remineralise the

tooth, such as calcium and phosphate, can be pushed to the deepest
parts of lesions faster. This remineralisation process is stimulated
by short electronic pulses emitted
by a specially developed instrument, which is estimated to cost
less than £10,000 once it enters the
market.
“With our treatment you can
top-up your natural teeth enamel
whenever you need, just as you’d
service your car when it needs a bit
of loving care,” Wright said.
Reminova claims to currently hold
or to have applied for 17 patents
for the technology, which was first
presented to the public in 2014.
A King’s College London (KCL) spinout, the company is based in Perth
in Scotland and managed by tooth
decay experts, including KCL Professor Professor Nigel Pitts and
dentist Dr Chris Longbottom.

[9] =>

DTUK0415_09_Ivoclar 10.09.15 15:16 Seite 9

Dental Tribune United Kingdom Edition | 4/2015

BUSINESS

09

Ivoclar updates dentists
about latest materials
and treatment protocols
By DTI
Leicester, UK: For years, the International Centre for Dental Education from Ivoclar Vivadent has
been offering dental education
and training for dentists and dental technicians in the UK. At its anniversary celebration in June, over
200 came to Leicester to celebrate
the Centre’s achievements and update themselves on the latest materials and treatment protocols,
such as the company’s IPS e.max
system.
Focusing on innovation in dental design, renown dental technician and Ivoclar Vivadent Global
Opinion Leader Oliver Brix from
Germany presented a series of
case reports involving the materials and ranging from single tooth
restorations to full mouth rehabilitations. State-of-the-art protocols and critical steps to ensure
long-term success were also presented by Dr Markus Lenhard
from Switzerland.
Leading UK experts such as
Chris McConnell, Rob Lynock, Alan
Casson and Carl Fenwick, further
provided live demonstrations to
illustrate the revolutions that are
taking place in composite dentistry with advanced products,
such as the light-curing lab composite SR Nexco Paste, IPS e.max
frameworks with the fully automated injection-mould-ing device
Ivobase and the Tetric EvoCeram
Bulk Fill system.
In addition to legal, ethical and
practical issues surrounding the
selection of patients for implants
and the placement and management of the peri-implant site presented by dental hygienist Donna
Shembri from Huddersfield. Oldham dental technician and Ivoclar
Vivadent Opinion Leader John
Wibberley addressed the aesthetic
and functional needs of the patient when creating restorations,
while he explored the principals
and materials used in the customising of denture teeth, gingival contouring and gingival staining.
Following this, dental technician Phillip Reddington from
Leeds further educated delegates
on ‘high-performance polymers’
which are considered as a replacement for materials such as metal
and zirconia in framework fabrication and are increasingly used to
manufacture hybrid composite/
ceramic restorations.
Since 2011, the ICDE has been
offering education for dentists in
its Leicester premises. Based close
to the M1, the facility provides

state-of-the-art dental surgery for
live demonstrations and a fully
equipped lecture theatre that can

hold up to 40 participants. A full
list of courses and seminars is
available at the centre’s website.
AD

[10] =>

DTUK0415_10_12_Alani 10.09.15 15:17 Seite 1

TRENDS & APPLICATIONS

Dental Tribune United Kingdom Edition | 4/2015

Graduation: A mineﬁeld
for the younger generation of dentists
By Aws Alani, UK

Common reasons for choosing dentistry as a vocation in the UK include
having a fulfilling career where, after five hard years invested at dental
school, one could be rewarded with a
high probability of employment and
the opportunity to marry scientific
knowledge with practical hand skills
to provide for the public, either on an
NHS or private basis or both. A-level
students have high standards to
achieve and maintain to gain admission to undergraduate programmes.
Towards the end of their training,
young dentists may feel like they are
about to enter a minefield on graduation.
In the last year of dental school,
those wishing to enter vocational
training are pitted against each
other, then ranked nationally and
allocated a training position according to their performance in
that selection process. Whatever
happened to being interviewed by
a future employer and performing
at that more personal, mutual assessment level? It appears that the
system is becoming increasingly
mechanistic, a conveyor belt if you
will, where a college student enters,
is educated in a cost-effective manner, assessed and allocated around
the country.
The issues involved in undergraduate training, as opposed to education, have been topical recently.1,2
Dentistry has both educational and
training aspects. Undergraduates
need to undergo appropriate volume-based improvement of their
diagnostic, planning and hand
skills, linked to appropriate knowledge. Pure education will never be
enough for a practical profession
where one is more likely to be
judged against a technical outcome yardstick than on purely
theoretical knowledge. Are dental
schools providing this requisite
training or are these absorbent

minds being failed by the environment that they now have to learn
the practical, technical aspects, as
well as some helpful clinical tricks
of the trade? The fault seems now to
lie more in the lack of appropriate
nurturing of these talented and
capable individuals, as opposed to
unfairly criticising their nature,

does not appear to be valued to
the same level as other professions.
We tend to undersell and understate ourselves compared with
other professions. Doctors tend to
be looked upon favourably—there
when patients need help most.
Lawyers are viewed in a different,
more formal way, especially when

not outright defensive, when treating patients for fear of litigation
or a complaint to our regulatory
body, however trivial that may be.
Can we expect them to develop
and hone skills in such an environment? This is highly unlikely
where self-preservation becomes
the understandable consideration.

“It appears that the system is
becoming increasingly mechanistic...”
abilities or motivations. I think less
of the “when I were a lad” and more
of the realisation of the difficulties
they face is required.

disputes arise. In contrast to its perception in many other places in the
world, dentistry is portrayed as pain
inducing and expensive in the UK.

NHS dentistry:
A brave new world?

Somewhat ironically, NHS medical services are free at the point of
delivery and NHS dental treatment
is not. Cue every patient comparing
us to our medical colleagues where
there is no bill for a hysterectomy
or a hip replacement, but they have
to pay £200 for a spoon denture.
As such, the perception by the
public and the media may always
be more negative than positive, and
the government may play on this
to squeeze the pips of goodwill out
of dentists until nothing is left.

Once they have attained a position in the system in which they
then work, this should surely be
conducive to providing the right
treatment to the right patient at
the right time, right? Wrong. Even
if skills were attained at the undergraduate level, the current NHS
system based on units of dental activity (UDA) does not reward those
most technically demanding, most
rewarding procedures that can improve quality of life, such as saving
a molar tooth with endodontics.
These time-consuming delicate
skills with expensive single-use instruments are rewarded financially
at the same level as an extraction.
Therein lies the paradox, and consequently the problem. Dentistry

PurSUEing a career
The NHS system is not the only
daunting aspect of this brave new
world that young dentists are
entering. Dental litigation in the
UK is rife and ever increasing and,
as expected, indemnity premiums
are increasing. Young dentists may
well be nervous and risk averse, if

As such, “defensive dentistry” can
override instinctive motivation to
treat deserving and unfortunate
patients and thereby discharge our
wider duty to society.
This increase in indemnity premiums is unlikely to have been
instigated by a swathe of amalgam carvings without secondary
fissures by dental foundation
trainees. An increase in procedures
such as implants, short-term orthodontics and elective cosmetic
dentistry is more likely to have had
an effect on premiums for all.
As a growing number of settlements become increasingly sizeable,
those possibly avoidable mishaps
by the more senior, supposedly
experienced, among us make the
environment more difficult for
our junior colleagues.
There is so much overt dental disease and a great need for this to be
treated using predictable methods,
and it baffles me that despite this
many young dentists see opportu-

nities to supplement their income
and skill set with high-end, high-risk
procedures more likely to lead to
litigation well before the basics of
proper, proven dentistry have been
learnt, attained and honed. Unfortunately, the skills they may feel or
be led to feel they want to achieve are
not routinely what they probably
need most or possibly what potential employers really want and likely
what the public requires. Recently,
a colleague in practice called me
about the CV of a young graduate
with only four years of experience.
He had gained “qualifications” in
facial aesthetics and cosmetic dentistry, had completed a course in
super-quick orthodontics and was
studying for an MSc in metal screws.
My friend commented, “If I take him
on, who’s going to do the dentistry,
the therapist?”.
Again, the NHS UDA system may
be blamed for not rewarding the
management of plaque-associated
disease to the level it merits, and
because of that perception such individuals may hunt for more supposedly rewarding opportunities.
Further specialist training is seemingly London centric and expensive.
It looks increasingly unlikely that a
UK graduate with five years of debt in
tuition fees will be able to afford to
train and develop comprehensively
if he or she desires this without
falling deeper into debt. As such,
these postgraduate specialist courses
are popular among overseas students, whose large fees are welcomed
by academic units. Unfortunately,
the overall experience and skill set
within these shores is likely to decrease as a result of much of this postgraduate effort with a net increase for
countries abroad where they will
then bring that expertise.
Positive aspects of globalised
dental education include the im-

[11] =>

Extraction_Academy_280x400_2015.pdf 1

10.09.15 14:28

[12] =>

DTUK0415_10_12_Alani 10.09.15 15:17 Seite 2

TRENDS & APPLICATIONS

12
provement of oral health in those
countries less developed than our
own. Despite this, a balance should
be struck. Rewarding those hardworking, committed and talented
of home candidates with scholarships for further training is common overseas.

Spare a thought…

Dental Tribune United Kingdom Edition | 4/2015

“It looks increasingly unlikely that a UK graduate
with ﬁve years of debt in tuition fees will be able
to afford to train and develop comprehensively...”

A young graduate recently told
me about his experiences of applyAD

ing for jobs. Three people, two of
whom were friends, had applied
for a position in the North East. The
interviewing principal came into
the waiting room and said that he
was not interviewing, as they all
had very similar qualifications
and credentials. All he wanted to
know was who of the three would
take the lowest sterling amount
for a UDA.

PRINT
L
DIGITA N
TIO
EDUCA
EVENTS

He promptly gave them three
envelopes and asked them to write
down the magic number. One
applicant wisely got up and left.
Two of the friends remained and
seemingly agreed to write down
the same amount. Unfortunately,
the friendship came to a catastrophic end when one applicant
broke the pact and wrote a lower
amount. He got the job and the
principal pocketed the difference.
The conscientious and capable,
yet unsuccessful, candidate eventually relocated to Australia, the
reservoir to which some of our UK
talent drains.
When I heard this, my jaw
dropped and my heart sank. This
story smacks of a profession being
squeezed from all sides, resulting
in such acts of desperation. Imagine if you will dentistry in the UK
as a sand-castle and we dentists
each a grain of sand. When building
a sand-castle, gently cupping the
sand in a supportive way, as opposed to squeezing it tightly, is a
more efficient way of dealing with
it. Squeezing it too tightly results in
grains escaping between the fingers, and by the time one reaches
the castle site, there is nothing left
in one’s hands, but a few grains.
It appears that the hands that are
designed to facilitate and accommodate our efforts to treat patients
are gripping too forcefully, resulting in frustration and anger.
Our young colleagues desperately
want to build a career in this difficult and hazardous environment.
Spare a thought for them and help
if you can.
Editorial note: A list of references is
available from the publisher.

The DTI publishing group is composed of the world’s leading
dental trade publishers that reach more than 650,000 dentists
in more than 90 countries.

Aws Alani is
a Consultant in
Restorative Dentistry at Kings
College Hospital
in London, UK,
and a lead clinician for the
management of
congenital abnormalities. He can be contacted at
awsalani@hotmail.com.

[13] =>

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[14] =>

DTUK0415_14_16_Wolff 10.09.15 15:18 Seite 1

TRENDS & APPLICATIONS

Dental Tribune United Kingdom Edition | 4/2015

“Patients tend to go to court
more often nowadays”
An interview with Dr Andy Wolff, Israel
tially, an injured nerve can regain
function over time. However, if it is an
exposed nerve, such as the lingual
nerve, the damage is generally irreversible, although there are some
microsurgery procedures that may
improve the situation. Interventions
like this, however, carry extremely
high risks themselves and might even
aggravate the situation.

damage—cases like this show that
mistakes really can happen to anybody.

With the consequence that patients
partially lose sensation in the mouth
or face?
Yes. Another consequential damage, of which I only recently learnt,
is loss of sense of smell. Patients
whose sinus has been injured often
lose their ability to smell. Sometimes,
they may not even realise it initially,
because the sinus runs on both sides
of the face and the unaffected side
often functions normally. Imagine
losing your sense of smell completely
owing to a defective bilateral sinus
lift procedure—that would be a fairly
serious impairment of a person’s
quality of life.

So expertise does not preclude mistakes, but there are undoubtedly also
cases that result from negligence and
hubris.
I certainly see many cases in which
dentists have carried out a treatment
for which they were not qualified.
I remember an incident in which a
general practitioner injured nerves
on both sides of the mouth during an
implant treatment. That is truly unbelievable. I have seen many cases over
the years, but nothing quite like that.

Have malpractice incidents become
more common over the last decades?
I would say so. At least, litigation
has increased. Of course, there have
always been cases of malpractice, but
patients tend to go to court more often nowadays. Perhaps you could call
it an “Americanisation” phenomenon:
almost every problem is taken to court,
with the result that dentists are paying increasingly higher insurance
fees because the treatment risks are
so high today.

Dr Andy Wolff talking to Group Editor Daniel Zimmermann. © Kristin Hübner/DTI

Be it a careless error or a case of
misjudgement, even the most experienced practitioner can make a mistake. In fact, statistics indicate that it is
likely that every general dentist will be
involved in a malpractice suit at some
point in his or her career. Israeli-based
dentist Dr Andy Wolff has worked as a
medical expert in dental malpractice
litigation for many years and has
seen almost everything, ranging from
slight negligence to severe overtreatment. Dental Tribune had the opportunity to speak with him recently about
the steady increase in litigation in the
field and simple measures that can
help prevent many malpractice incidents in the first place.
Dental Tribune:Dr Wolff,you have been
a medical expert in dental malpractice
litigation for many years now. Why is
it so important to increase awareness
of this topic?
Dr Andy Wolff: So much literature
out there tells dentists how to do
things—whether it is placing implants or improving efficacy with
the newest technology—but there
are no books on how not to do things
or, more precisely, what can happen
when something has gone wrong.
This aspect is no less important, both
for the patient affected and for the
clinician, who might be facing legal
consequences.

instances of damaged nerves caused
while placing an implant, during
tooth extractions or through an injection. It is common and it happens
quickly. Typically, it is an inadvertent
mistake, because the clinician was either in hurry or impatient. However,
the consequences for the patient are
mostly very dramatic and often beyond repair.
Aside from nerve damage, is there an
area where mistakes are more likely?
If I had to choose one, I would say
it is implants. I recently had a very
disconcerting case where an oral surgeon did all the preliminary exami-

Displacement of dental implant into the maxillary sinus of a 70-year-old male patient. © Dr Andy Wolff

Many may think that it is not relevant to them, but every smart physician knows that things occasionally
go wrong and no one is immune. By
documenting dental malpractice incidents and by talking and writing
about these, I aim to raise awareness
and therefore help prevent future
incidents.

nation work meticulously, the CT
scan, the radiographs, everything. For
that reason, he knew for certain that
he was working with a bone structure
of 11 mm, yet he used an implant that
was 13 mm long in the treatment.
Maybe he was just mistaken or the
assistant handed him the wrong implant and he did not recheck it, but the
result was that he hit a nerve.

In your experience, what types of malpractice are most common?
There are definitely many cases in
the neurological field. As a medical
expert, I am confronted with many

In this particular case, the dentist
was a specialist, an experienced surgeon. Without raising the question
of guilt—although the surgeon was
without a doubt responsible for the

In another case, a dentist extracted
a third molar without the requisite
training. He should have referred the
patient to a specialist, but he chose
to do it himself—possibly because it
earned him another US$200 to 300
(£130 to 190)—with the result that the
patient now has to live with chronic
pain for the rest of her life.
Can injured nerves regain normal function eventually?
Mostly, damage is irreversible.
There are exceptions, of course, either
if the damage was not too severe or if
the nerve was inside a canal. Poten-

How common is legal action in dentistry and what is the compensation
amount paid compared with other
medical disciplines?
It is perhaps comparable to plastic
surgery. There are many complaints
filed for cases in which the result was
not what the patient expected it to
be. Compensation payments range
from US$10,000 to 100,000, which
is much lower than those in other
medical disciplines.
Do more cases of overtreatment or
cases of error on behalf of the dentist
end up in court?

These cases have an almost equal
occurrence. Of course, overtreatment
leaves the dentist in a bad position.
It raises the question of why he or she
treated the patient unnecessarily in
the first place and did so poorly in the
second; it leaves him or her doubly
guilty. If a mistake occurred after a
reasonable treatment plan had been
formulated, it is comparatively less
bad. Sometimes, even if a patient dies
while undergoing therapy, this does
not need to involve a distinct fault of
the clinician.
An American dentist was recently
charged because his patient died after
he extracted 20 teeth in one procedure.
I have performed such extensive
treatment in the past; it depends on
the need for the treatment and how
it is done. Probably, that case in the
US was the result of a combination of
many things. For instance, did the
dentist act in accordance with stateof-the-art practice? If not, he is at
fault. If he did, one has to remember
that dentists cannot rise above today’s level of knowledge and technology. Let us say an impaired patient
files charges for something that happened to him 20 years ago that would
have been preventable with the latest
medical treatment. He can, of course,
make a claim, but the dentist could
not be sued for it if he or she treated
the patient according to the best
knowledge available at that time.
That is a very important aspect
when writing expert reports on dental malpractice: did the dentist act
to the best of his or her ability and
according to the current knowledge
or with gross negligence? That is what
makes the difference.
What can medical professionals do
to protect themselves against legal
disputes arising from high-risk procedures they intend to perform?
Patients should not only be warned
of the possible consequences of a
certain procedure, but also be advised
of the alternatives—and one of those
alternatives is not proceeding with
treatment at all. In my opinion, the
patient should always understand
both options: the risks of a particular
treatment and what could happen if
nothing is done. Only then should the
patient be asked to sign a declaration
of consent.
Unfortunately, the reality is often
quite different. Patients are often
asked to sign declarations of consent
on their way into surgery or while
already on the dental chair. Even if
they had questions then, there would
be no time to answer them properly.
Although it should be of major concern for every dentist to thoroughly
inform the patient of the risks, as well
as alternative treatment methods,
before he or she is asked to sign a
consent form, I am constantly confronted with the opposite.
So, you are saying that consultation
should be of similar importance to
treatment?
Absolutely. In my opinion, building mutual trust between doctor
and patient is key for avoiding malpractice and consequential charges. If
patients feel that their condition is

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DTUK0415_14_16_Wolff 10.09.15 15:18 Seite 2

TRENDS & APPLICATIONS

16
being properly treated, and that
money is not the dentist’s first concern, this alone can prevent litigation
in many cases. Of course, if a nerve is
damaged, there needs to be a settlement of some kind, but if a bridge
fails, for example, instead of filing
charges the patient will return for
further treatment if there is a solid,
trust-based relationship.
Time, communication, trust—what
else is important when it comes to
preventing malpractice?

One more basic rule every dentist
should follow is adhering to evidencebased dentistry. This means not performing a certain treatment just because in the dentist’s experience it is
considered to be right. External scientific evidence should be implemented.
Also, every single finding should be
taken into account in determining how
to treat the individual patient: diagnosis, radiographs, periodontal analyses,
age, health status, literature and so on.
Neglecting these related aspects can
very likely lead to misconduct.

Dental Tribune United Kingdom Edition | 4/2015

Bilateral mental and labial paraesthesia in a 62-year-old female patient due to bilateral mandibular canal perforation. © Dr Andy Wolff

Do you see basic problems in dentistry
that need to change?
Nowadays, we face the problem
of “cheap” dentistry. Owing to the
amount of competition with the
large number of dentists in the
market, there are many cases of
overtreatment. Cheap dentistry needs
to be fast, yet I have documented
cases in which patients have returned for retreatment of a simple
problem up to 70 times in two years.
If you add up the time those patients
invest only to have a poor outcome, it
is striking. However, it is not possible
for there to be elite dental practices
solely. For legal purposes, dental
treatment does not need to be exquisite, but it has to be reasonable.

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Maybe it is a problem of today that
patients have increasing expectations
regarding the service or technologies
their dentist should be using.
That is certainly part of the same
problem. Advertising that promises
people a new Hollywood smile in
two hours forms the basis of patients’
beliefs or expectations regarding
treatment. Dentists should not be
tempted to involve themselves in
this kind of misguided pressure.
Honest communication is key when
aiming to avoid disappointing patients.
Measures to prevent malpractice
should begin as early as possible, but
where should prevention start?
Personally, I think legal regulation
should be extended, such as specific
laws or by-laws concerning the
amount of experience and training,
for example, required in order to perform certain procedures. Basically, it
is just what common sense calls for
and everybody will agree with if they
think about it: should one be allowed
to place an implant after attending
a speakers’ corner talk or looking over
a colleague’s shoulder? No, yet this is
often what happens.
A second measure could focus on
undergraduate education. Dental
schools should devote more time to
prevention of lawsuits. This aspect
is neglected in the curriculum, although it is an essential part of
dentistry. General awareness of the
subject needs to be raised and this
alone would help prevent mistakes.
As I said earlier, mistakes are not
always avoidable, but they should
at least not arise out of negligence,
hubris or greed. Apart from that,
there will always be cases of medical
malpractice. Dentists are humans
too; only he who does nothing makes
no mistakes at all.
Thank you very much for the interview.

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COSMETIC TRIBUNE
The World’s Cosmetic Newspaper · United Kingdom Edition
www.dental-tribune.co.uk

Published in London

Vol. 9, No. 4

MiCD: Do no harm cosmetic dentistry
By Dr Sushil Koirala, Nepal
The demand for cosmetic dentistry is
a growing trend globally. Increased
media coverage, the availability of free
online information 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 being forced to incorporate various
aesthetic and cosmetic dental treatment
modalities into their daily practices to
meet the growing demand of patients.

2

1

in daily clinical practice. Adopting
this holistic medical science practice
philosophy is not an easy task, as it
requires a change in the mindset of
professionals.

is no longer the exclusive domain of
the rich and famous.1 The population
of beauty- and oral health-conscious
people is increasing every year and
data from various sources shows that
the coming generations of children,
especially from the middle- to higherincome population, will have fewer decayed teeth and will need less complex
restorative dental care as they age.
These changing patterns of dental care
needs will bring about a major shift in
the nature of dental services from traditional restorative care to cosmetic
and preventive services.

3

cosmetic dentistry and its promotion.
It is widely seen that the treatment
modalities of contemporary cosmetic
dentistry are tending towards moreinvasive procedures with an overutilisation of full crowns, bridges, dentine veneers, and invasive periodontal
aestheticsurgery,whileneglectinglongterm oral health, actual aesthetic needs
and the characteristics of the patient.2
These aggressive treatment modalities are indirectly degrading social
trust in dentistry, owing to the trend of
fulfilling the cosmetic demands of
patients without ethical consideration
and sufficient scientific background
and promoting the “the more you replace, the more you earn” or “more is
more” mindset in dentistry.2

edge, clinical skills, honesty and humanity is difficult to find in today’s
business-oriented dental education.
I believe that knowledge should be
free and skill training must be useful
and easily affordable to our young
practising clinicians around the world.
Compromised university dental education and expensive private skill
training with biased mentoring have
been promoting health-compromising treatment protocols and costly
diagnostic, preventive and treatment
technologies. This highly businessoriented trend will promote a change
in the mindset of practising clinicians
to adopt more-aggressive and invasive
dental treatment modalities, leading
to the practice of unhealthy dentistry
in the long term.

Cosmetic dentistry is a sciencebased art guided by the desire of the
patient. Many young clinicians who
plan to incorporate it into their practice are confused about what they and
their patients actually wish to achieve.
It is to be noted that the treatment
modalities of any health care service
should be aimed at the establishment
of health and the conservation of the
human body with its natural function
and aesthetics. However, it is worrying
to note that the treatment philosophy
and technique adopted by many cosmetic dentists around the world tend
towards macro-invasive protocols,
and millions of healthy teeth are aggressively prepared each year for the
sake of creating beautiful smiles.

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
globally since 2009 as the MiCD global
mission. It is to be noted that both
parts are based on fundamental science (truth and available evidence),
clinical experience and the common
sense required in holistic dentistry.

The practice philosophy adopted
by the clinic and the professional team
members generally guides the overall
output of the practice. Minimally invasive cosmetic dentistry (MiCD), a
do no harm practice philosophy, has
four fundamental components: level
of care, quality of operator (dentist),
protocol adopted and technology
selected, which must all be respected

The prevalence and severity of dental decay have been declining over the
last decades in many developed countries and this trend is shifting towards
developing countries as well. With increased media coverage, the availability of free online information, public
awareness has fuelled the demand
for cosmetic dentistry globally. Now,
a glowing, healthy and vibrant smile

The increased market demand for
smile aesthetics among patients is
forcing general practitioners of today
to incorporate the art and science of
cosmetic dentistry into their practice.
Cosmetic dentistry is not yet recognised as a separate clinical specialty
like orthodontics, periodontics or paediatric dentistry. Cosmetic dentistry is
synonymous with multidisciplinary
dentistry, as its success and failure are
related to the patient’s psychology,
health, function and aesthetics. Ethical, high-standard cosmetic dentistry
skill training of clinicians is essential
for the increased global market of

4a

4b

5a

5b

5c

6a

6b

7a

7b

8a

8b

9a

9b

10a

10b

Cosmetic dentistry,
a global trend

Changing the professional mindset
of the practising clinician is not an easy
task; it is just like quitting smoking
for a heavy smoker. In order to practise healthy dentistry, one must be
groomed, starting from dental school
education, with moral values, a high
ethical standard, a positive attitude
and a patient-centred practice philosophy. A student reflects the mindset
of his or her teachers, and a teacher or
mentor with comprehensive knowl-

Aesthetic versus
cosmetic dentistry
The words “aesthetics” and “cosmetic” are viewed as synonyms by
many cosmetic dentists. However, it
is necessary to understand the core
difference in meaning. The Oxford
dictionary2 defines “aesthetics” as “the
branch of philosophy which deals

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DTUK0415_17-18_Koirala 10.09.15 15:19 Seite 2

COSMETIC NEWS

18

11a

11b

13b

11c

14a

with questions of beauty and artistic
taste” and “cosmetic” as “improving
only the appearances of something”.

more than an aesthetic requirement,
and must be considered a cosmetic
demand or requirement.

In dentistry, “aesthetics” explains
the fundamental taste of a person
concerning beauty, whereas “cosmetic”
deals with the superficial or external
enhancement of beauty. Therefore,
aesthetic dentistry falls under needbased dental service, and is generally
guided by the sex, race and age (SRA
factors) of the patient. However, cosmetic dentistry, which is influenced
by perception, personality and desires
(PPD factors), can be categorised as
want- or demand-based dental service. For example, a patient’s request to
replace old amalgam restorations
with tooth-coloured restorative materials can be considered an aesthetic
requirement or demand. The request
of an old woman for pearly white
teeth and the ideal smile design is far

In my clinical practice, I divide aesthetic and cosmetic clinical cases into
three different categories:

Treatment options

Treatment procedures

Biological cost

Non-invasive treatment:
when hard and soft tissue is
not prepared during smile
enhancement procedures

•Smile exercise
•Remineralisation of white spots
•Oral appliances and bruxism guard
•Dentures requiring no tissue preparation
•Gingival mask

None

Micro-invasive treatment:
when hard and soft tissue is
prepared at a micro-level during
smile enhancement procedures

•Cosmetic chemical treatment, such as
bleaching and micro-abrasion
•Cosmetic restorations with chemical tooth
preparation, such as direct bonding, ultra-thin
veneers, adhesive pontics and overlays

Very low

Minimally invasive treatment:
when hard and soft tissue is
prepared at a superficial
or minimal level during
smile enhancement procedures

•Cosmetic contouring (teeth and/or gingivae)
•Cosmetic restorations with minimal tooth
preparation, such as thin veneers, modified
inlays and onlays, partial crowns,
partial dentures, and inlay bridges
•Non-extraction conventional and
MiCD orthodontic treatment
•Mini dental implants (small diameter)
•Gingival depigmentation

Low

•Tooth preparation for crowns, bridge abutments
and deep veneers
•Orthodontic treatment with tooth extraction
•Dental implants
•Aesthetic surgical procedures, such as
periodontal, orthognathic and facial surgeries

High

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

14d

15b

15a

1. Preventive, or support based: treatment prevents or intercepts the
diseases, defects, habits and other
factors that may adversely affect the
existing or the future smile aesthetics of the patient.
2. Naturo-mimetic, or need based:
treatment is carried out to restore
or mimic the natural aesthetics,
bearing the SRA factors of the patient in mind, and the treatment
generally enhances the health and
function of the oral tissue.
3. Cosmetic, or desire based: treatment
is performed to enhance or supplement the aesthetic components of

13a

14c

14b

14f

Table II: MiCD core principles.

12b

12a

14e

Invasive treatment:
when hard and soft tissue is
prepared at a deeper level during
enhancement procedures

Cosmetic Tribune United Kingdom Edition | 4/2015

the smile; hence, the treatment outcome of cosmetic treatment may
not be in harmony with the patient’s
SRA factors as in nature-mimetic
dentistry, and cosmetic treatment
may not necessarily be beneficial to
the health and function of the oral
tissue.

Practice philosophy
in dentistry:
The mindset
The majority of dental schools
around the world focus on teaching
knowledge and skills in dental medicine that are based on contemporary
dental science and art. Dental school
education does not give due consideration to healthy dental practice philosophy owing to various factors, such
as the right to chose one’s practice
philosophy and the domination of
business rather than service-oriented
dental practice in the global market.
However, quality and healthy clinical
practice is always a dream of a good clinician, and establishing such practice
requires an unbiased vision, learning
and serving attitudes, and dedication
from the dentist. We must understand
that science and art in dentistry have
no meaning if practised by an unethical operator, who does not respect
the overall health of the patient. Any
scientific advancement in technology
has positive and negative sides; hence,
if not applied properly, it may adversely affect the profession and may
become a threat.
I believe that a clinic or treatment
centre must establish its practice philosophy according to its objectives.
What a clinician wants and the kind of
services he or she wants to deliver to
his or her patients guides the clinic.
Practically, the practice philosophy
in dentistry can be classified into two
different categories, depending on the
mindset of the operator.
Patient-centred
Clinicians with this kind of mindset
generally have a do no harm dental
practice (Fig. 1). Professional honesty
and humanity are the fundamental
principles of such a practice. Operators with this mindset enjoy sharing
their clinical knowledge and skills

15c

with their professional friends and
junior colleagues to promote patientcentred clinical practice in society.
This group of clinicians firmly believes
in the word-of-mouth approach to
practice marketing and always thinks
of the patient’s long-term health, function and aesthetics. Clinicians practising do no harm dentistry are generally
cheerful, happy and healthy in their
professional life.
Financially focused
Clinicians with this kind of mindset
practise a financially focused dentistry and adopt various kinds of direct
marketing approaches to sell their
dentistry like a commodity in the market rather than a health care service.
Practitioners in this group generally
achieve a secure financial position
quickly; however, it is frequently seen
that they develop chronic stress, burnout syndrome, depression, frustration
and professional guilt, leading to
compromised health and happiness
in their professional life.
Dentistry and professional stress
Dentistry has long been considered
a stressful occupation. Dentists perceive dentistry as being more stressful
than other occupations.3 Dentists
have to deal with many significant
stressors in their personal and professional lives.4 There is some evidence
to suggest that dentists suffer a high
level of occupation-related stress.5–9
A study has found that 83 per cent
of dentists perceived dentistry as
“very stressful”10 and nearly 60 per
cent perceived dentistry as more
stressful than other professions.11 Stress
can elicit varying physiological and
psychological responses in a person.
Professional burn-out is one of the
possible consequences of ongoing
professional stress. The effect of burnout, although work-related, often will
have a negative impact on people’s personal relationships and well-being.12–13
Hence, dentists need to take care of
their staff’s health and focus on professional happiness in daily practice.
A clinician has full right to adopt
the practice philosophy that he or she
prefers. However, it is always advisable
to apply oneself to understanding,
analysing and comparing this philos-

ophy with others. I am very fortunate
to have been brought up with the
Vedic philosophy of the law of nature
and the first, do no harm consciousness-based philosophy in my life
at home, at school and in my society.
The spiritual guidance and mentoring I received at an early age at home
and school have helped me to become
a professional with a firm philosophy
of do no harm; hence, I started practising consciousness-based dentistry
early in my career. During my 21 years
of private practice, I have always experienced happiness and joy with high
patient satisfaction, which has given
me complete confidence and faith in
my practice philosophy and the MiCD
treatment protocol that I apply in my
practice. Since late 2009, I have been
promoting my practice philosophy
and clinical protocol in South Asia,
and started the MiCD Global Academy
in 2012 with the help of like-minded
friends, who also practise a similar
kind of holistic dentistry around the
world. The MiCD Global Academy has
a mission to share clinical knowledge
and fundamental clinical skills free
of charge with all clinicians who desire to practise do no harm cosmetic
dentistry for better patient care and
to enhance their happiness in their
professional life.

Three-way test:
Questions for your
conscience
Cosmetic dentists can make errors
in practice in two ways, first owing to
a lack of the required professional
knowledge and skills, and second owing to a lack of professional honesty
and humanity. The first one can be
eliminated with good education and
proper training, but the second one
demands a total shift in mindset, with
a high level of consciousness in professional ethics, attitudes and respect
towards the patient’s long-term health,
function and natural beauty.
I apply a simple yet very powerful
test to keep myself stress- and guiltfree and within the boundaries of
professional ethics, honesty and humanity when proposing a dental
treatment plan to my patient. Clinicians can apply the three-way test

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DTUK0415_17-18_Koirala 10.09.15 15:19 Seite 3

Cosmetic Tribune United Kingdom Edition | 4/2015

mentioned below just by taking a
deep breath and closing their eyes
for few seconds and analysing their
answers (the true response that comes
to mind) with professional honesty
and humanity. If your conscience responds positively to all the questions,
then it is advisable for you to propose the treatment plan and take up
the case, but if you give negative responses to the questions, then you
should rethink your proposed treatment plan to safeguard your and your
patient’s long-term health, function
and aesthetics using a more sensible
and less destructive treatment approach.
The three-way test consists of three
basic questions:
• Would I use this treatment for a
member of my own family in this
situation?
• Am I competent enough to take up
the case?
• Will the patient be happy with the
biological, financial and time costs
of the proposed treatment?
I have been using this simple test
since my early days of practice and
enjoying every moment of my clinical
practice without any mental stress
and post-treatment professional
guilt. Moreover, I have found that the
end-result of my case has always
brought happiness to me and to my
entire supporting team with high
patient satisfaction. During all my
MiCD international lectures, training,
workshops and seminars, I always encourage my trainees and audience to
enhance the quality of their operator
factors (knowledge, skills, honesty
and humanity) because it is the pillar
of successful MiCD. It is my personal
belief that, if a clinician adopts a habit
of testing his or her treatment plan
with the three-way test before proposing it to the patient, it can certainly
help him or her to promote overall
happiness in his or her practice with
high patient satisfaction.

Extension:
Invasive dentistry
If we look carefully at the history of
restorative dentistry, the word“extension” (or “invasive”) has always been
a point of focus among clinicians.14
The concept of “extension for prevention and retention” was pronounced
by Dr G.V. Black 100 years ago and it
was appropriate in relation to the
restorative materials available at that
time. However, with the development
of porcelain-fused-to-metal technology in the late 1950s, the concept of
“extension for functional aesthetics”
was advocated, which is still very popular in clinical practice. In the early
1980s, the concept of the “Hollywood
smile” was introduced, which established the concept of “extension for
cosmetics” in dentistry.
In 2002, the FDI World Dental
Federation endorsed the approach
of minimal intervention dentistry,
which has basically focused on the
conservative management of carious
lesions, applying the concept of
“minimal extension for decay removal”. History clearly shows that,
since Dr G.V. Black era to the present

day, we have been applying the concept of “extension in dentistry” in the
name of prevention, retention, function, aesthetic need and cosmetic desire, and caries removal. It is a clinical
fact that this concept will remain the
focus because each clinical situation is
different, as its treatment modalities
are guided by multifactorial issues
such as patient factors (mind, body,
behaviour and surroundings), operator factors (knowledge, skills, honesty and humanity), protocol factors
(the truth, evidence, experience and
common sense), technology factors
(health, reliability, affordability and
simplicity). The use of science and
technology requires consciousness in
operators and awareness in patients;
hence, the operator must use his or
her professional knowledge and skills
with honesty and humanity to select
the least invasive procedure, protocol
and technology in treatment, so that
extension in dentistry is always minimal, safe and healthy.
The invasiveness of procedures selected in cosmetic dentistry depends
on the level of smile defect, type of
smile design, proposed treatment
types and treatment complexity.
MiCD uses the most conservative
smile enhancement procedure possible. The level of invasiveness in cosmetic dentistry can be classified into
four types, namely non-invasive, micro-invasive, minimally invasive and
invasive, and the treatment options,
various treatment procedures and
their biological cost for each are presented in Table I. There is only one
principle in selecting treatment modalities in MiCD: always select the
least invasive procedure as the choice
of the treatment.2 Treatment procedures mentioned under non-invasive,
micro-invasive and mini-invasive are
used selectively in MiCD.

MiCD treatment
protocol and clinical
technique
Minimally invasive dentistry was
developed over a decade ago by
restorative experts and founded on
sound evidence-based principles.15–24
In dentistry, it has focused mainly
on prevention, remineralisation and
minimal dental intervention in caries
management and not given sufficient
attention to other oral health problems. For this reason, I developed the
MiCD concept and its treatment protocol in 2009, which integrates the
evidence-based minimally invasive
philosophy into aesthetic dentistry in
the hope that it will help practitioners
achieve optimum results in terms of
health, function and aesthetics with
minimum treatment intervention
and optimum patient satisfaction.
The MiCD concept and treatment
protocol are explained in an article
titled “Minimally invasive cosmetic
dentistry—Concept and treatment
protocol”;25 hence, in the current article,
I only discuss the MiCD core principles
(Tab. II), MiCD treatment protocol
and clinical technique briefly (Fig. 2).
MiCD clinical technique:
Rejuvenation, restoration,
rehabilitation and repair
The MiCD clinical technique
focuses on the aesthetic pyramid

COSMETIC NEWS

Aesthetic components

Smile design parameters

Macro-aesthetics: deals with the overall structure
of the face and its relation to the smile. In order
to establish the macro-aesthetic components
of any smile, the visual macro-aesthetic
distance should be more than 1.5 m.

• Facial midline
• Facial thirds
• Interpupillary line
• Nasolabial angle
• Rickett’s E-plane

Mini-aesthetics: deals with the aesthetic correlation
of the lips, teeth and gingivae at rest and in smile position.
The aesthetic correlation can be established properly
when viewed at a closer distance than the visual
macro-aesthetic distance. The visual mini-aesthetic
distance is similar to the across-the-table distance,
which is normally within 60 cm to 1.5 m.

In M-position:
• Commissure height
• Philtrum height
• Visibility of the maxillary incisors

Micro-aesthetics: deals with the fine structure of dental
and gingival aesthetics (Fig. 8). Micro-aesthetics can
be established at a visual micro-aesthetic distance
of less than 60 cm or within normal make-up distance.

• Maxillary central incisors (tooth size ratio)
• Principle of golden ratio
• Axial inclination
• Incisal embrasures
• Contact point progression
• Connector progression
• Shade progression
• Surface micro-texture

In E-position:
• Smile arc (line)
• Dental midline
• Smile symmetry
• Buccal corridor
• Display zone and tooth visibility
• Smile index
• Lip line

Table III: Aesthetic components and smile design parameters.

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

MiCD summary ten

Table IV: The MiCD summary ten.

of the Smile Design Wheel1 (Fig. 3).
Aesthetic components in dentistry
are divided in to three broad groups:
1. macro-aesthetics,
2. mini-aesthetics; and
3. micro-aesthetics.
Each aesthetic group deals with different smile aesthetic components
(Tab. III) and each component must be
harmonised at the end of treatment.
According to the smile defect and patient’s desire, there are four different
techniques in MiCD to enhance smile
aesthetics:
1. Rejuvenation: to rejuvenate in
MiCD is to enhance smile aesthetics
with minor modifications in tooth
position, colour and form, also
known as the MiCD ABC principles,
namely align, brighten and contour
(Figs. 4–9):
• Align: minor discrepancies between the facial and dental midlines are acceptable in many instances.26 However, a canted midline would be more obvious27 and
therefore less acceptable in cosmetic dentistry. Similarly, the
disharmony in natural progression of axial inclination or the
degree of tipping of anterior teeth
affects the aesthetic outcome of
a smile. The correction to the
midline and axial inclination progression, and necessary changes to
anterior tooth position are carried
out using cosmetic orthodontic
procedures with fixed or removable aligners. Once the anterior
teeth are in an aesthetically acceptable position, the aesthetic concerns of the patient generally shift
towards the colour enhancement
of the dentition. It is to be noted

aesthetics. Restoration is performed
using micro- to mini-invasive treatment options, such as direct restorations, veneers, inlays, onlays or
adhesive pontics, depending upon
the extent and severity of the smile
defect (Figs. 10a & b & 11a–c).
3. Rehabilitation: rehabilitation is the
process of complete reconstruction
of the smile to enhance psychology,
health, function and aesthetics
using micro- or minimally invasive
treatment options to minimise the
possible biological cost. Direct and
indirect composite resin and feldspathic porcelain are the materials
of choice for rehabilitation in MiCD
(Figs. 12–14).
4. Repair: the role of repair in restorative dentistry is very important.
The restoration cycle or each rerestoration process generally increases the size of the smile defect
by 15 to 20 per cent per re-restoration.
Hence, MiCD protocol recommends
performing repair wherever aesthetically appropriate and possible
using suitable adhesive restorative
materials so that the health of the
oral tissue will not be compromised,
while maintaining function and
aesthetics (Figs. 15a–c).

that a well-aligned tooth generally
requires no or less tooth preparation during tooth contour (shape
and size) modification. This helps
the clinician to achieve aesthetic
smiles with micro- or minimally
invasive procedures with a very low
biological cost.
• Brighten:tooth bleaching or colour
modification in MiCD is carried out
once teeth are in acceptable alignment but before the tooth form is
modified. The level of tooth colour
modification depends on the quality of the existing colour of the
dentition and the patient’s desire.
Home and office bleaching are
popular methods for modifying
tooth colour. However, in some
cases, procedures such as remineralisation, micro-abrasion, walking
bleach and thin enamel veneers
are used.
• Contour: a contour is an outline of
the shape or form of something.28
In dentistry, cosmetic contouring
entails reshaping teeth or gingivae
to an aesthetic form. Cosmetic
contouring can be performed in
two ways, additive and subtractive.
Additive cosmetic contouring entails changing the tooth form using
tooth-coloured restorative materials, such as a resin composite
(direct and indirect restorations)
or ceramic (veneers), and changing
the gingival shape using graft materials. Subtractive cosmetic contouring entails removing dental
tissue by grinding or texturing,
and gingival tissue by selective surgical procedures—which are nonreversible in nature and so proper
care must be taken.
2. Restoration: restoration is a process
of replacing missing dental tissue
to enhance health, function and

After completion of any MiCD clinical case, the patient’s overall satisfaction and the clinical success must be
evaluated. In order to evaluate clinical
cases comprehensively and practically, in the MiCD protocol, a clinician
is advised to always summarise his or
her cases under the ten areas listed in
Table IV, called the MiCD summary ten.

Conclusion
In order to practise do no harm cosmetic dentistry, a clinician requires
the desire, passion, dedication and
will-power to become an honest professional with humanity because
honesty and humanity are the pillars
of do no harm cosmetic dentistry,
since the mind controls all other
practice factors. The clinician must
understand that honesty and humanity are not scientific like knowledge
and skills, which can be learned,
copied and applied immediately in
the practice. Honesty and humanity
are inner qualities of a person and are
deeply related to the level of a person’s
consciousness, which are generally
expressed as habits and attitudes.
Therefore, we need to learn these qualities at home and school, and from the
profession and society.
Self-evaluation and the realisation
of the level of inner happiness that
you obtain through your daily professional work are vital to understanding
and beginning to practise do no harm
cosmetic dentistry in your practice.
Editorial note: A complete list of references
is available from the publisher.

Dr Sushil Koirala
is the Chairman
of and chief instructor at the
Vedic Institute
of Smile Aesthetics. He can
be contacted at
drsushilkoirala@
gmail.com.

[20] =>

DTUK0415_20_22-23_McLaren 10.09.15 15:47 Seite 20

TRENDS & APPLICATIONS

Cosmetic Tribune United Kingdom Edition | 4/2015

Smile analysis and photoshop
smile design technique
Prof. Edward A. McLaren & Lee Culp, USA

Fig. 1: Three altered views of the same patient enable analysis of what can be accomplished to enhance facial and smile
aesthetics.—Fig. 2: Sagittal views best
demonstrate which specialists should be
involved in treatment, whether orthodontists or maxillofacial surgeons, to best
aesthetically alter the facial aesthetics.—
Fig. 3: Drawing a line along the glabella,
subnasale, and pogonion enables a quick 4
5
evaluation of aesthetics without the need
for radiographs 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 1 mm of tooth display at rest (left), minus 3 mm of gingival display, and 4 mm of space between the incisal edge and the lower lip (right).

Introduction:
Smile analysis and
aesthetic design
Dental facial aesthetics can be
defined in three ways.
Traditionally, dental and facial
aesthetics have been defined in
terms of macro- and micro-elements. Macro-aesthetics encompasses the interrelationships between the face, lips, gingiva, and
teeth and the perception that these
relationships are pleasing. Microaesthetics involves the aesthetics
of an individual tooth and the perception that the colour and form
are pleasing.

Historically, accepted smile design concepts and smile parameters have helped to design aesthetic
treatments. These specific measurements of form, colour, and
tooth/aesthetic elements aid in
transferring smile design information between the dentist, ceramist,
and patient. Aesthetics in dentistry
can encompass a broad area—
known as the aesthetic zone.1
Rufenacht delineated smile
analysis into facial aesthetics,
dentofacial aesthetics, and dental aesthetics, encompassing the
macro- and micro-elements described in the first definition
above.2 Further classification identifies five levels of aesthetics: facial,

orofacial, oral, dentogingival, and
dental (Tab. I).1, 3

Initiating smile
analysis: Evaluating
facial and orofacial
aesthetics
The smile analysis/design process
begins at the macro level, examining
the patient’s face first, progressing
to an evaluation of the individual
teeth, and finally moving to material selection considerations. Multiple photographic views (e.g., facial
and sagittal) facilitate this analysis.
At the macro level, facial elements are evaluated for form and

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.

balance, with an emphasis on how
they may be affected by dental
treatment.3, 4 During the macroanalysis, the balance of the facial
thirds is examined (Fig. 1). If something appears unbalanced in any
one of those zones, the face and/or
smile will appear unaesthetic.

complexity and uniqueness of a
given case, orthodontics could be
considered when restorative treatment alone would not produce the
desired results (Fig. 2), such as when
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 occlusion to open the
bite and enhance aesthetics when
a patient presents with relatively
even facial thirds (Fig. 3).

Such evaluations help determine
the extent and type of treatment
necessary to affect the aesthetic
changes desired. Depending on the
6

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 symmetrical on 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 4–5 mm.—Figs. 8–10: Acceptable width-to-length ratios 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 1–2 mm shorter than the central incisors,
and canines 0.5–1 mm 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 lateral incisors.—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 with proper 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 to select 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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[22] =>

DTUK0415_20_22-23_McLaren 10.09.15 15:47 Seite 22

TRENDS & APPLICATIONS

Cosmetic Tribune United Kingdom Edition | 4/2015

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 by dividing 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: Measure the 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 tooth grid 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.

Evaluating
oral aesthetics
The dentolabial gingival relationship, which is considered oral
aesthetics, has traditionally been the
starting point for treatment planning. This process begins by determining the ideal maxillary incisal
edge placement (Fig. 4). This is accomplished by understanding the
incisal edge position relative to several different landmarks. The following questions can be used to determine the ideal incisal edge position:
• Where in the face should the maxillary incisal edges be placed?
• What is the proper tooth display,
both statically and dynamically?
• What is the proper intra- and intertooth relationship (e.g., length and
size of teeth, arch form)?
• Can the ideal position be achieved
with restorative dentistry alone, or
is orthodontics needed?
In order to facilitate smile evaluation based on these landmarks, the
rule of 4.2.2—which refers to the
amount of maxillary central display
when the lips are at rest, the amount
of gingival tissue revealed, and the
proximity of the incisal line to the
lower lip—is helpful (Fig. 5). At a time
when patients perceive fuller and
brighter smiles as most aesthetic,
4 mm of maxillary central incisor
display while the lips are at rest may
be ideal.2, 5 In an aesthetic smile, seeing no more than 2 mm of gingiva
when the patient is fully smiling is
ideal.6 Finally, the incisal line should

come very close to and almost touch
the lower lip, being no more than
2 mm away.2 These guidelines are
somewhat subjective and should be
used as a starting point for determining proper incisal edge position.

Dentogingival
aesthetics
Gingival margin placement and
the scalloped shape, in particular,
are well discussed in the literature.
As gingival heights are measured,
heights relative to the central incisor,
lateral incisor, and canine in an
up/down/up relationship are considered aesthetic (Fig. 6). However,
this may create a false perception
that the lateral gingival line is incisal
to the central incisor. Rather, in most
aesthetic tooth relationships, the
gingival line of the four incisors is
approximately the same line (Fig. 6),
with the lateral incisor perhaps being
slightly incisal.7 The gingival line
should be relatively parallel to the
horizon for the central incisors and
the lateral incisors and symmetric
on each side of the midline.2,8 The gingival contours (i.e., gingival scallop)
should follow a radiating arch similar to the incisal line. The gingival
scallop shapes the teeth and should
be between 4 mm and 5 mm (Fig. 7).9

Several rules can be applied when
considering modifying the midline
to create an aesthetic smile design:
• The midline only should be moved
to establish an aesthetic intra- and
inter-tooth relationship, with the
two central incisors being most important.
• The midline only should be moved
restoratively up to the root of the
adjacent tooth. If the midline is
within 4 mm of the centre of the
face, it will be aesthetically pleasing.
• The midline should be vertical
when the head is in the postural rest
position.

Evaluating dental
aesthetics
Part of evaluating dental aesthetics
for smile design is choosing tooth
shapes for patients based on their
facial characteristics (e.g., long and
dolichocephalic, or squarish and
brachycephalic). When patients present with a longer face, a more rectangular tooth within the aesthetic range
is appropriate. For someone with
a square face, a tooth with an 80 %
width-to-length ratio would be more
appropriate. The width-to-length ratio most often discussed in the literature is between 75 % and 80 %, but
aesthetic smiles could demonstrate
ratios between 70 % and 75 % or between 80 % and 85 % (Figs. 8–10).1

age length of an unworn maxillary
central to the cementoenamel junction is slightly over 11 mm.10 The aesthetic zone for central incisor length,
according to the authors, is between
10.5 mm and 12 mm, with 11 mm being a good starting point. Lateral incisors are between 1 mm and a maximum of 2 mm shorter than the central incisors, with the canines slightly
shorter than the central incisors by
between 0.5 mm and 1 mm (Fig. 11).

for a fee, it is possible to use Photoshop CS5 software (Adobe Systems)
to create and demonstrate for patients the proposed smile design
treatments. It starts by creating
tooth grids—predesigned tooth
templates in different width-tolength ratios (e.g., 75 % central, 80 %
central) that can be incorporated into
a custom smile design based on patient characteristics. You can create
as many different tooth grids as you
like with different tooth proportions
in the aesthetic zone. Once completed, you will not have to do this
step again, since you will save the
created tooth grids and use them to
create a new desired outline form
for the desired teeth.

The inter-tooth relationship, or
arch form, involves the golden proportion and position of tooth width.
Although it is a good beginning, it
does not reflect natural tooth proportions. Natural portions demonstrate
a lateral incisor between 60 % and
70 % of the width of the central incisor, and this is larger than the golden
proportion.11 However, a rule guiding
proportions is that the canine and all
teeth distal should be perceived to
occupy less visual space (Fig. 12). Another rule to help maintain proportions throughout the arch is 1-2-3-4-5;
the lateral incisor is two-thirds of the
central incisor and the canine is fourfifths of the lateral incisor, with some
latitude within those spaces (Fig. 13).
Finally, contact areas can be moved
restoratively up to the root of the adjacent tooth. Beyond that, orthodontics is required (Fig. 14).

Follow these recommended steps:
• To begin creating a tooth grid, use a
cheek-retracted image of an attractive smile as a basis (e.g., one with
a 75 % width-to-length ratio). Open
the image in Photoshop and create
a new clear transparent layer on top
of the teeth (Fig. 15). This transparent layer will enable the image to be
outlined without the work being
embedded into the image.
• Name the layer appropriately and,
when prompted to identify 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, move to the
tool palette, and select either the
polygonal lasso tool or the magnetic lasso tool. In the authors’
opinion, the polygonal works best.

Related to normal gingival form is
midline placement. Although usually the first issue addressed in smile
design, it is not as significant as tooth
form, gingival form, tooth shape, or
smile line.

The length of teeth also affects aesthetics. Maxillary central incisors average between 10 mm and 11 mm in
length. According to Magne, the aver-

Although there are digital smile
design services available to dentists

Creating a digitalsmile
designed in Photoshop

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 selection modify 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 liquify tool.—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.

[23] =>

DTUK0415_20_22-23_McLaren 10.09.15 15:47 Seite 23

Cosmetic Tribune United Kingdom Edition | 4/2015

Once activated, zoom in (Fig. 16)
and trace the teeth with the lasso
tool.
• To create a pencil outline of the
tooth, with the transparent layer
active, click on the edit menu in the
menu bar; in the edit drop-down
menu, select “stroke”; choose black
for colour, and select a two-pixel
stroke pencil line (Fig. 17), which will
create a perfect tracing of your
selection. Click “OK” to stroke the
selection. Select (trace with the lasso
selection tool) one tooth at a time
and then stroke it (Fig. 18). Select and
stroke (trace) the teeth up to the
second premolar (the first molar is
acceptable; (Fig. 19).
• The image should be sized now
for easy future use in a smile design.
In the authors’ experience, it is best
to adjust the size of the image to
a height of 720 pixels (Fig. 20) by
opening up the image size menu
and selecting 720 pixels for the
height. The width will adjust proportionately.
• At this time, the tooth grid tracing
can be saved, without the image
of the teeth, by double-clicking
on the layer of the tooth image.
A dialog box reading“new layer”will
appear; click “OK”. This process
unlocks the layer of the teeth so it
can be removed. Drag the layer of
the teeth to the trash, leaving only
the layer with the tracing of the
teeth (Fig. 21). In the file menu, click
“save as” and choose “.png” or “.psd”
(Photoshop) as the file type. This
will preserve the transparency. You
do not want to save it as a JPEG,
since this would create a white background around the tracing. Name
the file appropriately (e.g., 75 % W/L
central).
• By tracing several patients’ teeth
that have tooth size and proportion
in the aesthetic zone and saving
them, you can create a library of
tooth grids to custom design new
teeth for your patients who require
smile designs.

The Photoshop smile
design technique
The Photoshop Smile Design
(PSD) technique can be done on any
image, and images can be combined
to show the full face or the lower third
with lips on or lips off. This article
demonstrates how to perform the
technique on the cheek-retracted
view.
The first step in the PSD technique
is to create a digital conversion of
the actual tooth length and width,
and then digitally determine the
proposed new length and proportion of the teeth.
Determining digital tooth size
To determine digital tooth size,
follow these steps:
• Create a conversion factor by dividing the proposed length (developed
from the smile analysis) by the
existing length of the tooth.
• The patient’s tooth can be measured in the mouth or on the cast
(Fig. 22). If the length measures
8.5 mm but needs to be at 11 mm
for an aesthetic smile, divide 11
by 8.5. The conversion factor equals
1.29, a 29 % digital increase lengthwise.

• Open the full-arch cheek-retracted
view in Photoshop, and zoom in
on the central incisor.
• Select the eyedropper palette.
A new menu will appear. Select the
ruler tool (Fig. 23).
• Click and drag the ruler tool from
the top to the bottom of the tooth
to generate a vertical number, in
this case 170 pixels (Fig. 24). Multiply the number of pixels by the
conversion factor. In this case,
170 x 1.29 = 219 pixels; 219 pixels
is digitally equivalent to 11 mm
(Fig. 25). Determine the digital tooth
width using the same formula.
• Create a new layer, leave it transparent, and mark the measurement
with the pencil tool (Fig. 26).
Applying a new proposed tooth form
Next, follow these steps:
• After performing the smile analysis
and digital measurements, choose
a custom tooth grid appropriate
for the patient. Select a tooth grid
based on the width-to-length ratio
of the planned teeth (e.g., 80/70/90
or 80/65/80). Open the image of
the chosen tooth grid in Photoshop
and drag the grid on to the image of
teeth to be smile designed (Fig. 27).
• If the shape or length is deemed
inappropriate, press the command
button (control button for PCs) and
“z” to delete and select a suitable
choice.
• Depending on the original image
size, the tooth grid may be proportionally too big or too small.
To enlarge or shrink the tooth grid
created (with the layer activated),
press command (or control) and “t”
to bring up the free transform function. While holding the shift key
(holding the shift key allows you to
transform the object proportionally), click and drag a corner left or
right to expand or contract the
custom tooth grid.
• Adjust the size of the grid so that the
outlines of the central incisors have
the new proposed length. Move the
grid as necessary using the move
tool so that the incisal edge of the
tooth grid lines up with the new
proposed length (Fig. 28).
• Areas of the grid can be individually altered using the liquify tool
(Fig. 29).
Digitally creating new aesthetic teeth
Next, follow these suggested
steps:
• With the new tooth grid layer and
the magic wand tool both activated,
click on each tooth to select all of
the teeth in the grid (Fig. 30).
• Expand the selection by two pixels
in the expand menu; click “select >
modify > expand”(Fig. 31). Note that
the selection better approximates
the grid. You can expand the selection or contract as necessary using
the same menu.
• Activate the layer of the teeth
(cheek-retracted view) by clicking on it (Fig. 32).
• Next, activate the liquify filter
(you will see a red mask around
the shapes of the proposed teeth).
The mask creates a digital limit
that the teeth cannot be altered
beyond. This is similar to creating
a mask with tape for painting a
shape (Fig. 33).
• Use the forward warp tool by clicking on an area of the existing tooth

TRENDS & APPLICATIONS

and dragging to mold/shape the
tooth into the shape of the new
proposed outline form (Fig. 34).
Repeat this for each tooth. If you
make a mistake or do not like something, click command (or control)
and “z” to go back to the previous edit
(Fig. 35).
Adjusting tooth brightness
The following steps are recommended next:
• Select the whitening tool (dodge
tool) to brighten the teeth. In the
dodge tool palate, click on “midtones” and set the exposure to approximately 20 %. Click on the areas
of the tooth you want brightened
(Figs. 36 & 37).
• Alternatively, with the teeth
selected, you can use the brightness
adjustment in the brightness/contrast menu; click “image > adjustments > brightness/ contrast”.
Performing the changes on only
one side of the mouth allows the patient to compare the new smile design to his/her original teeth before
agreeing to treatment.

23
Create a copy
To save the information you have
created for presentation to the 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”.

Editorial note: A complete list of references 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.

A file of the current state of the image will be created in the designated
area. You can now continue working
on the image and save again at any
point you want.

Conclusion
Knowledge of smile design, coupled with new and innovative dental technologies, allows dentists to
diagnose, plan, create, and deliver
aesthetically pleasing new smiles.
Simultaneously, digital dentistry is
enabling dentists to provide what
patients demand: quick, comfortable, and predictable dental restorations that satisfy their aesthetic
needs.

Prof. Edward A.
McLaren is the director of the University
of California, Los
Angeles Center for
Esthetic Dentistry.
He can be contacted at emclaren@
dentistry.ucla.edu.

Lee Culp, CDT, is an
adjunct faculty member at the University of North Carolina at Chapel Hill
School of Dentistry.
He can be contacted at lee_culp@
microdental.com

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[cover] => DT UK No. 4, 2015

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Table of contents

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