DT Asia Pacific No. 5, 2015

Asia News / World News / Why dentistry needs branding / Google Mobile Armageddon and what it means / The importance of pretreatment dental assessments in cancer treatment / Where periodontology has advanced / Implant-prosthetic restorations / Cosmetic Tribune Asia Pacific Edition

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DENTAL TRIBUNE

DENTAL TRIBUNE Asia Pacific Edition No. 5/2015

18 News & Opinions

The World’s Dental Newspaper · Asia Pacific Edition

PUBLISHED IN HONG KONG

www.dental-tribune.asia

Cancer
The importance of
pretreatment assessments
Page

NO. 5 VOL. 13

Periodontology
A critique of current
trends in the field

Page

Special Tribune
News & trends from
cosmetic dentistry

Page

Economic downturn affects adoption More teeth,
longer life
of CAD/CAM in Asia-Pacific region
A number of studies have
shown a link between tooth loss
and mortality. Now, an analysis of
almost 600 elderly participants
from Japan has provided new
evidence that retaining good oral
health and having more teeth at
an older age could be an indicator
of longevity. The study showed
that the risk of mortality was
associated with the number of
remaining teeth.

DTI

VANCOUVER, Canada: The latest report by international market
research and consulting group
iData Research shows that the
Asia-Pacific market for dental
prostheses and CAD/CAM devices
is currently valued at over US$10
billion. According to the report,
the penetration rate of CAD/CAM
prostheses has been limited, however, by difficult economic circumstances in Japan, South Korea,
Australia and China, among other
countries.
In particular, the report showed
that the economic recession
slowed unit sales growth and that
dental laboratories faced budget
constraints.
“We are seeing less investment
in CAD/CAM systems in many
Asia-Pacific countries due to
preference for porcelain-fusedto-metal, as opposed to all-ceramic
restorations. Dental laboratories
increasingly prefer standalone
scanner systems as a more affordable option than higher-priced
milling systems,” explained iData

In order to assess the possible
role of the number of teeth as
a predictor of mortality in the
elderly, researchers at the Niigata
University examined the oral cavities of 569 healthy 70-year-olds.

A dental technician using Sirona’s inLab system. (Photo courtesy of Sirona)

CEO Dr. Kamran Zamanian.
“Standalone scanners will be a
large driver for growth in this market, as many companies in the AsiaPacific region seek to expand their
networks of scanners to support
their full in-lab CAD/CAM system.”
Other growth factors will be
pricing pressure owing to more

manufacturers entering the market and demographic factors owing
to an aging population worldwide,
with the resulting demand for
dental prostheses.
According to the report, dental
company Sirona holds a majority share in the Asia-Pacific
CAD/CAM systems market, fol-

lowed by competitors E4D Technologies, 3M ESPE, 3Shape, Nobel
Biocare, KaVo, Wieland and
Roland.
The full report, titled “AsiaPacific Markets for Dental Prosthetics and CAD/CAM Devices,”
can be accessed on iData’s website. DT

During a follow-up period of
five years, 25 (4.4 per cent) participants died. The researchers
observed that individuals with
20 teeth or more had a significantly lower mortality rate (2.5 per
cent) compared with those with
19 teeth or fewer (6.1 per cent).
Overall, the data indicated that
there was a 4 per cent point increase in the five-year survival
rate per additional tooth retained
at the age of 70, the researchers
reported. DT
AD

Eat your
curry

Photo shows clearing work in Kathmandu. The capital of Nepal was among the
regions hit by the country’s worst earthquake in over 80 years. ASIA NEWS, Page 2

Market player
reorganises

Gum helps with
earworms

KaVo Kerr Group has announced that it will be reorganising three of its five professional
consumables brands. After the
internal restructuring Kerr, Kerr
TotalCare and Axis|SybronEndo
will be operated under four
core identities: Kerr Restoratives,
Kerr Endodontics, Kerr Rotary
and Kerr TotalCare. DT

A study from the UK has found
that people who chewed gum after
hearing catchy songs thought less
often about the song than in two
control conditions in which they did
not chew gum or tapped with each
of the fingers of their dominant
hand in turn. Chewing gum also reduced the frequency with which they
“heard” the song by one-third. DT

New research has demonstrated that curcumin, one of
the primary components of
turmeric and curry powders,
has a quelling effect on the
activity of the human papillomavirus (HPV), which has
been increasingly associated
with the development of oral
cancer over the past several
decades.
The scientists found that
the natural antioxidant curcumin slows the expression of
HPV, suggesting that it could
help control the extent of HPVrelated oral cancers.
Oral squamous cell carcinoma is the sixth most common
cancer worldwide. The World
Health Organization states that
the incidence of oral cancer
ranges from one to ten cases
per 100,000 people in most
countries. DT

Distinguished by innovation
Healthy teeth produce a radiant smile. We strive to achieve this goal on a daily basis. It inspires
us to search for innovative, economic and esthetic solutions for direct filling procedures and
the fabrication of indirect, fixed or removable restorations, so that you have quality products
at your disposal to help people regain a beautiful smile.

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Ivoclar Vivadent AG
Bendererstr. 2 | FL-9494 Schaan | Liechtenstein | Tel.: +423 / 235 35 35 | Fax: +423 / 235 33 60

[2] => Standard_300dpi

DENTAL TRIBUNE Asia Pacific Edition No. 5/2015

Asia News

AP prominent “We are still pretty
in global dental much in shock”
schools list
An interview with Nepalese dentist Dr Sushil Koirala
DTI

LONDON, UK: According to the
QS World University Rankings
by Subject 2015, Swedish dental
schools are among the best in the
world. With the Karolinska Institutet leading the list of top dental
schools and the University of
Gothenburg following closely in
third place, the country claims
two of the world’s best three dentistry faculties.

lege London in the UK at number
seven and the University of Otago
in New Zealand at number eight.
The QS World University
Rankings are published annually
by Quacquarelli Symonds (QS),
a British company specialised
in education and study abroad.
Its list comprises an overall university ranking and a variety of
subject rankings. Dentistry is
one of the six new additions to the
individual subject
rankings, bringing the total number of academic
disciplines the report covers as of
2015 to 36.

The rankings
are based on major global surveys
of academics and
graduate employers, as well as research citations
data from the lit© Camilla Svensk, Karolinska Institutet Mediabank
erature database
Scopus. For the QS World UniverIn second position, the Unisity Rankings by Subject 2015,
versity of Hong Kong is located in
the midst of the Swedish leaders.
85,062 academics and 41,910 graduate employers from 60 counThe list of top ten dentistry
tries and 894 universities were
schools further includes the Uniasked to list up to ten domestic
versity of Michigan in the US at
and 30 international institutions
number four, KU Leuven in
they consider excellent in cateBelgium in fifth place, Tokyo
gories such as academic repuMedical and Dental University in
tation, citations per faculty and
Japan ranked sixth, King’s Colemployer reputation. DT

In one of the worst earthquakes
in over 80 years, more than
10,000 people are believed to
have died in the Federal Democratic Republic of Nepal. Living
in and practising dentistry in
the capital of Kathmandu, dentist Dr Sushil Koirala has been
directly affected by the disaster.
Dental Tribune Asia Pacific
had the opportunity to talk to
him briefly about the situation
in the country and how the
international community can
help it to overcome the humanitarian crisis.
Dental Tribune Asia Pacific:
The earthquake on 25 April had
a devastating effect on your
country’s infrastructure and
its people. What is the situation
currently in Kathmandu, and
how have you been affected
personally?
Dr Sushil Koirala: The situation in Kathmandu at present remains very difficult owing to the
extensive damage to many public buildings, government offices
and schools. Nearly 7,500 lives
have been lost and 14,500 people
have been injured. Those who
survived the earthquake are
traumatised.
While physically my family
and I are fine, we are still pretty
much in shock. My children are
very distressed because they
were alone at home during the

Monk looking at destruction caused by the 25 April earthquake in the
Nepalese capital Kathmandu. Damages are estimated at US$200 million.
(Photo Narendra Shrestha/EPA)

first episode of the earthquake.
Some of my staff from the hospitals and clinics lost their houses
unfortunately and have to stay
with relatives for the moment.
Have you heard from colleagues in other parts of the
country, and if so what is their
situation?
Most of my dental colleagues
are unharmed, but many of them
are facing problems with their

damaged clinics. Most of the
dental hospitals in Kathmandu
are still closed owing to the
damage and employees not being able to work because they
are busy rebuilding their lives.
Various agencies have estimated
that more than eight million
people across 39 of the country’s
75 districts have been affected
by the earthquake. The most
DT page 3

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DENTAL TRIBUNE Asia Pacific Edition No. 5/2015
DT page 2

severely affected
areas include the
Bhaktapur, Dhading,
Dolakha, Kathmandu, Kavre, Lalitpur,
Nuwakot, Ramechhap, Rasuwa, and
Sindhupalchowk
districts of Nepal’s
Central Region, as
well as the Gorkha
District of its Western Region.
Dr Sushil Koirala

phase for the earthquake victims is going
to be a great challenge
for our country. I personally feel that in order
to overcome this difficult time our country
needs support from
each individual and
professional in Nepal.
We have, therefore,
started a humanitarian
project, the Dental
Community for Humanity—Nepal Earthquake
Relief Project, under

Have you received any correspondence
from the dental community?
I am glad to have received
many e-mails with best wishes
and prayers from our dental
friends around the world. It is so
gratifying to know that many of
them have pledged their support
of the earthquake victims of
Nepal. Some dental manufacturers have shown keen interest to
help us in the rehabilitation of
children who have been affected.

World News

the umbrella of the Punyaarjan
Foundation, a charitable and nonprofit organisation dedicated to
supporting people most in need.
This project aims to support poor
children living in these remote
villages in particular. I humbly
appeal to the international dental
community to support this cause.
Please, with your donations and
support, we can bring back the
smiles of our poor children.
Thank you very much for
taking the time and all the best
for the future. DT

For more information on how to support the Dental Community for Humanity
project, please contact Dr Koirala at drsushilkoirala@gmail.com.
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Despite an immediate response from India and Western
countries, relief efforts seem to
be insufficient, according to reports. What is your impression?
International communities
have offered immediate support
and we really appreciate their
help. However, 39 of the most
affected villages are in remote
locations with mountainous
terrain. The relief work, therefore, is hampered and support
items cannot be delivered on
time. Many people in these small
villages are still waiting for basic
items, such as food and shelter.
Regardless of the efforts by
the Nepalese army, police and
Red Cross Society, as well as national and international organisations, which are working 24/7,
the manpower and supplies are
still felt to be inadequate.
In your opinion, how will
this disaster affect the infrastructure of your country in
the long run?
Nepal’s development budget
depends mainly on foreign aid.
Rebuilding all the infrastructure
affected by the earthquake will require an estimated US$200 billion.
The government plans to meet
this mainly through foreign and
international funding. However,
damaged infrastructure will
definitely affect the economic
growth of Nepal negatively.
When I will be able to start
practising again depends on
when all my staff are mentally
ready for work. Daily life in
Kathmandu is still very stressful,
as there are frequent aftershocks
and people are still terrified.
Under these conditions, I do not
expect people will come for general dental treatment, except in
the case of an emergency.
What do you consider the
most important to improve
your situation, and how can
the international dental community help?
More than 95 per cent of
houses and infrastructure have
been damaged in the affected
villages, so the rehabilitation

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DENTAL TRIBUNE Asia Pacific Edition No. 5/2015

Opinion

Why
dentistry
needs
branding
Amanda Maskery
UK

Owning a dental practice or
group has always presented
challenges, but the marketplace has never been more
crowded than it is now. With
an ever-increasing level of
choice for patients, it is more
important than ever for dental
businesses to stand out from
the crowd. While we of course
all know the value of providing
a first-rate customer service,
and that will always remain
the most important factor, how
many of us recognise the importance of creating and building
a brand?
Generally, in dentistry, branding has not been regarded in
the same way it is in the corporate world, where multi-national
businesses expand on the strength
of their brands. But now, with the
growth of dental corporates and
multi-practice groups, branding
is becoming an increasingly important factor. That is not to say
that branding is only the domain
of the big players. Creating a
brand which is unique and people
can identify, talk about, recommend to others and remember
is just as important for a single
practice, and in some situations
even more so, where there are
other local competitors for existing and potential clients to choose
from.

Effective branding is also important when looking to expand,
franchise or sell one’s business.
When dentists are adding another
site to their existing portfolio, doing
so under a brand will enable people
to know who is moving into their
area, and can help give confidence
that this is an established dental
business taking over their local site.
One example being a business in
North East England I act for, the
Burgess & Hyder Dental Group,
who now operate 11 clinics across
the region under their brand. They
are welcomed into each area as
their brand is widely known, as is
the quality associated with it.

Equally in franchising, the importance of a strong brand is crucial to enable a business to thrive in
other areas relies on an existing
strength of reputation. Through being part of that recognisable brand,
patients will know that each site
under that umbrella will offer the
same levels of service and quality.
Another of my clients, Damira
Dental, has recently rebranded
from Aspire Dental Care, and is
pursuing a franchising model under its new and fresh identity. The
business, which has 14 sites across
the South of England, has amassed
a strong reputation during its eight
years in operation, and the strength

of its service coupled with its branding will allow that to be replicated
across the UK.
The creation of a brand identity,
which can help support the expansion of a business, can also be
of great importance when it comes
to selling. It is much easier to market a business which is well known
and has invested time and effort in
standing out from the crowd. To a
potential buyer, they are important
factors in instilling the confidence
to take on a site in a new territory.
In this day and age of dentistry
being an increasingly competitive

business, distinguishing oneself
from the many other players has
never been more important, and is
something that must be given due
consideration. DT

Contact Info
Amanda Maskery is one of the
UK’s leading dental lawyers.
She is Chair of the Association of
Specialist Providers to Dentists
(ASPD) in the UK and a Partner
at Sintons law firm in Newcastle. She can be contacted at
amanda.maskery@sintons.co.uk.

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DTAP0515_05_News 28.05.15 15:52 Seite 1

DENTAL TRIBUNE Asia Pacific Edition No. 5/2015

World News

US to lower fluoride
in drinking water
after 50 years
DTI

WASHINGTON, USA: US health
authorities have updated their
guidelines for fluoride in drinking
water and now recommend an
optimal fluoride concentration of
0.7 mg/l. As Americans today have
greater access to fluoride in the
form of toothpaste and mouthrinse
and owing to the increasing incidence of fluorosis due to excess
fluoride, the Department of Health
and Human Services sought to
replace its previous recommendations that were issued in 1962.

and Sweden, do not fluoridate
their water supply. Other European countries, such as Ireland

and the UK, currently add fluoride to drinking water at levels
ranging from 0.2 to 1.2 mg/l. DT
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however, this will be reduced by
0.1–0.5 mg/l, and fluoride intake
from drinking water alone will
decline by approximately 25 per
cent. The total fluoride intake will
be reduced by about 14 per cent.
According to the department’s
report issued on 27 April, the
new optimal concentration of
0.7 mg/l was chosen to maintain
caries prevention benefits, but reduce the risk of dental fluorosis.
Although a number of studies
have found that community water
fluoridation has led to a significant decline in the prevalence and
severity of tooth decay, data from
the 1999–2004 National Health and
Nutrition Examination Survey
and the 1986–1987 National Survey
of Oral Health in US School Children indicate that over 20 per cent
of people aged 6–49 have some
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community water systems that
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6

DENTAL TRIBUNE Asia Pacific Edition No. 5/2015

World News

Swiss study finds sonic toothbrushes
vary greatly in efficacy
DTI

BERN, Switzerland: Sonic
toothbrushes are increasingly
used in daily dental care today,
as they promise to reduce
biofilm without any mechanical bristle contact owing to

hydrodynamic effects. However, not every model is equally
effective in cleaning teeth, a recent study by researchers at the
University of Basel has found.
In order to inhibit damage
to the gingiva and teeth, the

biofilm formed by oral bacteria
must be removed regularly.

spaces—without any mechanical bristle contact.

Sonic toothbrushes claim to
reduce the amount of biofilm—
even in areas that are difficult
to reach, such as the lateral
tooth area and interdental

This is possible because of
the high frequency movements
of sonic toothbrushes, which
are believed to cause hydrodynamic effects that remove

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adhesive bacteria. These effects
result from acoustic sound
waves, as well as the shearing
forces and the surface tension
forces of moving air bubbles in
liquid media.
However, the Swiss researchers found that the effectiveness of different models
of sonic toothbrushes varies
greatly. The toothbrushes analysed in their study reduced the
amount of biofilm by between
9–80 per cent.
In their in vitro study, the
researchers cultivated an artificial biofilm on titanium
plates. The biofilm contained
three different strains of bacteria and was developed by
dousing the titanium plates in
a mixture of saliva and serum.
Afterwards, the researchers
tested the impact of four different commercially available
sonic toothbrushes on the artificial biofilm. They varied the
distance between the toothbrush bristles and the biofilm surface (0.2 and 4.0 mm),
as well as the exposure time
(2.4 and 6.0 seconds). Using
fluorescence microscopy and
special software, the researchers then quantified the remaining biofilm.
They found distinct variations regarding the efficiency
of the sonic toothbrushes.
The two high-quality products
analysed were able to reduce
the amount of biofilm on the
titanium plates significantly,
whereas two low-cost models
had only little impact on the
artificial biofilm. According to
the researchers, the different
exposure times and bristle distances did not influence the
reduction of biofilm.
The study, which was cofinanced by the research fund
of the Swiss Dental Association,
confirms the results of various international studies and
proofs that sonic toothbrushes
can reduce biofilm without actual bristle contact—although
the cleaning efficacy depends
greatly on the respective toothbrush model used.
The research fund of the
Swiss Dental Association is
financed through the membership fees of the association’s member dentists. It
supports and fosters dental
research, especially in the
fields of prevention and dental
practice.
The study, titled “Efficacy
of various side-to-side toothbrushes for noncontact biofilm
removal”, was published in the
Clinical Oral Investigations
journal in April 2014 and
was recently reported in the
2/2015 issue of Dimensions,
the journal of the Swiss Dental
Hygienists. DT

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DENTAL TRIBUNE Asia Pacific Edition No. 5/2015

World News

“Holding ConsEuro in London
was a little bit of a risk”
An interview with Prof. Stephen Dunne, King’s College London Dental Institute
must have academic content
of excellence to attract researchers and teachers, as well
as clinical content suitable for
clinicians to provide evidencebased knowledge for the work
that they do. Therefore, for
every session that we have this
year here at ConsEuro 2015, we
have an evidence-based start,
followed by clinical applications and hands-on sessions
after lunch-time that help
practitioners get to grips with
equipment they heard about
and want to have a chance to
play with. That is very attractive
to clinicians and you can see a
great deal of interest there.

Prof. Stephen Dunne is also Professor and Chairman of the Department of Primary Dental Care at Kings College London—
Dental Institute.© Daniel Zimmermann
DTI

As one of many dental organisations to do so, the European
Federation of Conservative
Dentistry (EFCD) chose to
hold its international congress
in the UK this year. Dental
Tribune Asia Pacific sat down
with EFCD President and
King’s College London professor Stephen Dunne in London
to discuss the event and how
technology is increasingly
shaping the field of dentistry.
Dental Tribune Asia Pacific:
Prof. Dunne, the ConsEuro
conference in London seems
to have been excellently organised. Would you say that
the event has met your expectations?
Prof. Stephen Dunne: To be
honest, holding ConsEuro in
London was a little bit of a risk
because with all the other conferences to be going on this year
in the capital and other parts of
Britain there could be an overload. We actually spent months
discussing a window in which
we would attract the highest
number of delegates.
With 500 and growing so far,
the congress has clearly exceeded our expectations and,
while previous congresses in
Italy or Turkey might have had
a bigger turnout, the conference here has attracted delegates from 29 countries, including from Australia, the US and
the Middle East. It is probably
one of the most multinational
conferences we have ever had.
You were originally planning for 350–450 participants.

Can the outcome mainly be
attributed to the London factor?
While we chose one of the
best conference centres in the
world with the Queen Elizabeth
II Centre right in the heart of
London, it is fair to say that we
also chose one of the most expensive ones. This made us very
concerned when we planning
this three years ago because at
that time we were in an economic downturn. Trying to re-

between the EFCD and King’s
College London.
King’s recently made it
on to the list of the top ten
best dental schools globally.
How much do you think
the school’s reputation contributed to the congress outcome?
There are a number of
dental schools surveys and
rankings worldwide. Despite
different methodologies and

The programme for ConsEuro 2015 is very focused on
technology issues. Would you
confirm this to be the overall
theme of this conference?
From the beginning, we
planned this to be a very hightech conference. In society and
certainly in dentistry, medicine
or surgery, technology is becoming increasingly important. And while air turbines
and scalpels are still staples of
the trade, there is a huge
amount of technological equipment coming on to the market
for operative work, dental surgery, logistics and communication.
Our belief is that dentists
need to know about all of these
things, as well as to have an
understanding of the evidence

Almost every dental practice
across the world now employs
some form of technology, be
it electronic patient records,
stock-taking or equipment,
such as lasers, CAD/CAM and
digital imaging to show patients
areas of the tooth they could not
possibly see otherwise. Digital
imaging and photography are
also very important from a medical and legal point of view, as
this area is increasingly becoming a concern.
Where do you see the
trends with regard to dental
materials?
The materials that we use
now were not available to me
when I was in training and
in my early practice and the
stages or requirements for their
use are infinitely more sophisticated. Nowadays, you might
have ten stages to a bonding
procedure and every one of
those stages is critical. If you
fail in only one of them, your
restoration fails before it has
even started.
Historically, dentists have
been trained by representatives
of the companies who make the
materials and that means they
may not get the most honest or
scientifically valid perspective.
Although we very much support
manufacturers contributing to
education programmes, we
certainly like clinicians and
scientists to be involved in those
to provide the evidence base.

“...the conference here has attracted delegates
from 29 countries, including from Australia,
the US and the Middle East.”
quest sponsorship from companies was difficult back then.
They were all downsizing and
did not have any money to spare
for conferences.
Owing to the economic situation gradually improving over
time, we exceeded our expectations with regard to sponsorships. We actually sold out
the exhibition space several
months ago. That has been very
successful and helped us to
cover the costs. We came above
break-even on the first day, so
I am much more relaxed today
than I was yesterday morning.
And it looks as though we
might make a reasonable profit,
which would then be shared

different variables, King’s usually comes out very near the top,
which I am very pleased about.
The school attracts not only
good teachers and researchers,
but also equally good clinicians
from across the world.

base. Should they be using
these things and, if they are
using them, which particular
model? This was very much the
rational when we were planning the programme.

When I first joined the EFCD
about ten years ago, there was
very much an effort to compete
with the International Association for Dental Research, so it
was very focused on academics
and researchers from the universities.

We also ought to have a paperless conference. Our website and app have been very
effective and when I read statements yesterday on our Twitter
feed, participants commented
that this was the most technologically advanced conference
they have ever been too.

My view is that this was a
mistake, as we really need to
provide a conference that has
interest across the board, so it

Technology has clearly expanded the scope of this conference. Does this also apply
to clinical practice?

This is exactly what we are
doing here now.
What other lessons will
you take home from the conference?
Our conference proves that
you can take a high-tech approach and still hopefully be
profitable or at least break even.
Technology is definitely here to
stay; we just need to look at the
evidence base. We also need to
have training in the use of technology and need to look at clinicians and scientists to guide us
in the selection of the particular
devices that we should use.
Thank you very much for
the interview. DT

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DTAP0515_10_Haque 28.05.15 15:54 Seite 1

DENTAL TRIBUNE Asia Pacific Edition No. 5/2015

10 Business

Google Mobile Armageddon
and what it means
Naz Haque
UK

Google has just released an update that will prioritise mobilefriendly websites. It is indeed
widely known that online audiences are moving to smart

phone and tablet computers.
At Dental Focus, we have seen
massive shifts in the online audience over the last few years
to the point now where most
clients see a minimum of 55 per
cent of their organic audience
visits from mobile devices.

Websites and marketing campaigns achieve higher conversions when they are mobile optimised. The diagram below shows
a marketing campaign we are
running at the moment. In this,
we achieved 10,835 sessions over
30 days. The blue bar indicates

the total sessions and the orange
bar segments the mobile and
tablet audience. In all traffic
sources, mobile has the lion’s
share of the market. In this project, we invested heavily in Google
pay per click and 95 per cent of
conversions were via mobile.

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Professor Bilal Al-Nawas (Germany)
Professor Mark Bartold (Australia)
Dr. John Lin (Taiwan)
Dr. Derek Mahony (Australia)
Professor Chooi-gait Toh (Malaysia)
Dr. Patrick Tseng (Singapore)

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To qualify this trend further,
consider that desktop sales have
started to decline significantly since 2005. After 2013, the
growth in purchases of mobile
devices (mobiles, tablets and
phablets) has continued to outgrow desktop sales. Google focuses
on its users and anyone who wants
to have a presence on Google is
directed to follow its guidelines
to serve these users. In this instance, such users are dentists’
existing and prospective patients. Therefore, it is really important that your website deliver
to their online expectations or
Google will not present your
website to them.
For your website to be mobile
friendly, there are specific factors to which it must adhere.
The website must not make
use of any mobile-incompatible
animations created with software like Adobe Flash. This
appears as a black space in
a mobile screen and serves
no purpose. The text on your
website should be readable on
mobile devices without the user
needing to resize or zoom. Responsive websites will automatically adjust to serve readability
factors.
User experience has always
been a core area from Google’s
perspective, and mobile-friendly
websites have links separated
sufficiently to allow a user to make
a selection with ease. Google
provides a platform to check
whether websites are mobile
friendly. Just type in your website
address at www.google.com/
webmasters/tools/mobile-friendly.
There is no reason to panic if
your website is not ready yet;
however, expect to lose more
customers to businesses with
mobile-friendly websites, as they
will be favoured by Google. The
company has such a massive job
to do reading the entire Internet,
it is unlikely you will start suffering from 12.01 a.m., but you can
expect to see your rankings diminish over time, especially on a
mobile device search.
Your presence on Google is
directly affected by your competition, so if your practice is
in the middle of nowhere with
limited competition you will live
another day, but surely it is time
that you start to think how to best
serve your audience before it is
too late. DT

Author Info
Naz Haque, aka
the Scientist, is
Operations Manager at Dental
Focus, UK. He has
a background in
mobile and network computing,
and has experience supporting a
wide range of blue-chip brands,
from Apple to Xerox. As an expert in search engine optimisation, Naz is passionate about
helping clients develop strategies to enhance their brand and
increase the return on investment from their dental practice
websites. He can be contacted at
naz@dentalfocus.com.

[11] => Standard_300dpi

DENTAL TRIBUNE Asia Pacific Edition No. 5/2015

Trends & Applications 11

The importance of pretreatment dental
assessments in cancer treatment
Prof. Ansgar Cheng
Singapore

In Singapore, an average of
33 people are diagnosed with
cancer daily and one in three
die from some form of the
disease eventually. While
treatment for oral cancer, including tongue cancer, is associated with dentists (usually
oral surgeons and oncologists
working together), few realise that they also have an
important role to play in the
case of patients with other
forms of cancer. These can
include nose cancer (nasopharyngeal carcinoma), head
and neck cancer, and even
breast cancer.
In addition to the oncologist
and surgeon, the dentist should
be part of the patient’s core treatment team. A comprehensive
treatment team should consist
of a radiation and medical oncologist, a cancer surgeon, a
dental surgeon trained in the
clinical care of cancer patients,
as well as a maxillofacial prosthodontist.
The importance of obtaining
a pretreatment dental assessment and treatment cannot be
overemphasised. Many dental
problems are silent and they
may not cause any clinical
symptoms when a person is
healthy. When chemotherapy or
radiotherapy is indicated for
cancer patients, it is important
for them to seek a pretreatment
dental assessment to identify
and address any underlying
dental issues (e.g. gingival
problems or impacted teeth)
that need to be treated prior to
commencing cancer treatment.
This is because once radiation
treatment has started, oral and
periodontal surgery may be
contra-indicated. The immune
system will be significantly
compromised once the patient
starts the chemotherapy treatment.
Irradiation also places the
patient at high risk of treatmentrelated complications, such as
xerostomia (dry mouth syndrome), oral infections, oral
muscle fibrosis, and osteoradionecrosis. Currently, the use
of intravenous bisphosphonatebased chemotherapeutic agents
is becoming more common.
Bisphosphonate is effective in
chemotherapy and it essentially
slows down bone remodelling.
As a result, the bone healing capacity is compromised. A simple
dental extraction after the use
of bisphosphonate medication
may result in bone necrosis that
lasts for months, a condition that
is complicated and difficult to
treat.
The oral cavity contains a
myriad of bacteria at any given
time, even if a person is per-

Left: Multiple dental caries after high dosage radiation therapy. (Photo courtesy by Prof. Ansgar Cheng)—Right: Bone necrosis.

fectly healthy. Many of the normal oral flora cause no symptoms; however, bacteria and
fungi in the mouth may develop
into an infection when the immune system is not working
well or when white blood cell
counts are low.
Irradiated tissues can thin
and waste away, causing sores
in the mouth (ulcerative oral
mucositis) in the atrophic mucosa. Such complications can
result in a significant reduction
in the patient’s quality of life and
even death. It is alarming that up
to 54 % of the causative organisms in cancer patients’ deaths
are from the oral cavity.1 Therefore, it is imperative for cancer
patients to have a thorough dental check-up, a good cleaning
by the dentist and problematic
areas treated prior to cancer
treatment. The bacteria in the
mouth are likely to enter the
bloodstream, thus increasing
the risk of infection for those
with compromised immunity
due to cancer treatment.
In the healthy mouth, saliva
balances the pH value of the
mouth. Since irradiated salivary
glands produce very little or
no saliva, acids in the mouth
can take advantage and attack
the teeth post-treatment. This
greatly increases the risk of dental caries, which in healthy subjects may take years to reach the
pulp. When xerostomic, patients
commonly develop multiple
dental caries that may reach the
dental pulp in just a few months.
Undergoing a dental as sessment before, during and
after cancer treatment is a step
that can help save much costs,
pain and psychological trauma
for the patient. It is also helpful to medical specialists, as
they will be able to manage
their cancer patients more
smoothly.

Petreatment
dental assessment
It would be ideal to allow for
a week of recovery from any
required surgical dental pro-

cedures. Typically, the dentist
will go over the patient’s medical history and review the
radiographs of the patient. He or

she will also conduct a physical
examination of the dentition
and hard and soft tissue in the
patient’s jaw and mouth for any

abnormal swelling, lesion or
evidence of chronic or acute
DT page 12
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12 Trends & Applications
DT page 11

dental infection. The dentist
should discuss with the patient’s
core treatment team all the
treatment options and timelines
in conjunction with the schedule of upcoming major surgery
or cancer treatment. It is essential to be familiar with various
radiation, chemotherapy and
surgical treatment protocols.
Crucial pretreatment assessment will be performed in such
a way as to minimise downtime
and to keep as close to the origiAD

DENTAL TRIBUNE Asia Pacific Edition No. 5/2015

“Even though side-effects of cancer treatment
may not be life-threatening, they can greatly affect
the patient’s quality of life.”
nally scheduled medical treatment as far as possible.
The initial pretreatment assessment consultation should take
under one hour. If there are no

pre-existing dental conditions
that need to be addressed before
the major surgery or cancer
treatment, the follow-up may be
performed after medical treatment has been completed. In the

event that dental treatment is required before the major surgery
or cancer treatment, this should
be done in a timely manner and
with the patient’s best interests
and comfort in mind.

The pretreatment dental
procedures should ideally be
performed by a dental team with
experience in the management
of cancer patients. For instance,
routine dental procedures such
as extractions should be approached carefully in the case of
cancer patients, mainly because
the bone quality of cancer patients may be altered by previous chemotherapy or radiation,
as these treatments may significantly slow down or stunt
the growth of new bone cells.
The dentist should identify
teeth with a guarded or poor
prognosis and have those teeth
removed atraumatically prior
to the initiation of cancer treatment owing to the slower healing process in wound sites after
extraction. In some cases, the
bone around the infection area
may turn necrotic (also known
as osteoradionecrosis).
Patients should be able to
resume usual activities after
dental treatment without any
major interruption to their daily
routine.

Post-treatment oral care
After the cancer episode is
over, a patient’s general health
condition may be still weaker
than that of a healthy person.
Therefore, it is important for
the patient and any attending
dentist to have comprehensive
dental records about the patient’s medical history before
new dental procedures are considered. For example, the effects
of intravenous bisphosphonate
treatment and radiation therapy
commonly last for years, and
the risk of postoperative bone
necrosis should never be overlooked.
Continuous post-treatment
oral care is critical in the prevention or reduction of the incidence and severity of oral
complications. Even though
side-effects of cancer treatment
may not be life-threatening, they
can greatly affect the patient’s
quality of life. Hence, it is crucial
to help patients manage and obtain relief from side-effects such
as mucositis, xerostomia, dental
caries, osteoradionecrosis and
trismus. Since the immune system is suppressed, any type
of infection could be serious.
Diligent lifelong personal oral
health care and frequent dental
recall appointments are recommended. DT

Author Info
Prof. Ansgar Cheng
is a specialist
in prosthodontics
at Specialist Dental Group in Singapore. He can
be contacted at profcheng@
specialistdentalgroup.com.

[13] => Standard_300dpi

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[14] => Standard_300dpi

14 Trends & Applications

DENTAL TRIBUNE Asia Pacific Edition No. 5/2015

Where periodontology has advanced
A critique of current trends in the field
Prof. Mark Bartold
Australia

ogy of these diseases can be used
to better define them.

Over the past 20 years there
have been some exceptional
advances made in periodontology. Many of these have led to
changes in our thinking and
our approach to periodontal
therapy. In 1999, the American
Academy of Periodontology
(AAP) devised a “new” classification system for the periodontal diseases. From this some
50 different types of periodontal conditions were identified
which were considered worthy
of individual classification.
Clearly this was an unwieldly
system and in reality it was distilled down to three main types
of plaque-associated periodontal diseases: gingivitis, chronic
periodontitis and aggressive
periodontitis.

However, it is worth noting
that in the past 25 years there
have been at least 10 different
classification systems proposed,
none of which have been fully
adopted. Clearly there remain a
number of important challenges
in this field. Since chronic and aggressive periodontitis are heterogeneous groups of diseases,
for example, there will be unique
subcategories based on their
multifactorial nature basis of
microbial, host response and

While the appropriateness of
the terms “chronic” and aggressive” have been debated they
have served as a framework for
both clinicians and researchers
to define specific types of periodontitis with identifiable clinical parameters. It also provided a
framework for understanding
management protocols and outcomes. Nonetheless, over time
it has become evident that such
a classification system (chronic
and aggressive) may be too simplistic because of the heterogeneity of the periodontal diseases. Therefore, it may be
timely to revisit such a classification system and determine
whether current understanding
of the epidemiology and pathol-

thinking of how the subgingival
microbiota interacted not only
with itself but also the host.
Notwithstanding this, research
through the 1990’s and 2000’s began to question the role of the
biofilm and its component bacterial consortia in the overall
process of the development of
periodontitis. While it was very
clear that periodontitis cannot,
and will not, develop in the absence of bacteria, it was becoming increasingly obvious that
clinically there were some patients who, despite the presence
of considerable plaque deposits,

“It remains to be established whether
treatment of periodontitis has any
impact on systemic conditions...”
environmental components. At
present, apart from “plaqueassociated” designation, the current AAP classification is not
based on cause-related criteria.

Recognition that bacteria are
necessary but not sufficient
for periodontitis to develop
During the 1990’s a very important conceptual advance occurred in our understanding of
dental plaque and its interaction
within the subgingival environment. The recognition that
subgingival plaque existed as
a biofilm with its own microregualtory and communicative properties changed our

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did not develop periodontitis. On
the converse it was also evident
that there were individuals who
had very minor visible deposits
of plaque yet developed very
advanced and destructive periodontitis.
These observations led to a
major paradigm shift in periodontology in which it was
agreed that although plaque was
necessary for periodontitis to
develop, it was not sufficient for
it to develop. Indeed it became
evident that in addition to dental
plaque, environmental and host
response factors were critical for
the clinical manifestation of periodontitis. With this came a new
more informed management process for our patients which dictated that in addition to management of oral hygiene patients must
be assessed for other factors which
would lead to the development of
periodontitis and these must be
controlled in order for treatments
to be successful. Indeed, it is now
recognised that dental plaque
(and its constitutive elements)
accounts for only 20 per cent of
the risk for developing periodontitis and thus the other 80 per cent
of modifying and predisposing
factors must be taken into account when diagnosis and treating the periodontal diseases.

Development of the
sub discipline of
Periodontal Medicine

S AT
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2
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had become very compelling. Indeed the relevance of oral health
to overall health and general
well-being was recognised by the
US Surgeon General in a landmark publication titled “Oral
Health in America”. This document for the very first time articulated the importance of oral
health in an holistic approach to
medical care. Despite the title,
its content was relevant to the
whole global scene. From this
the concept of periodontal medicine gained further traction
and its central hypothesis stated
that periodontal infection and

The term “Periodontal Medicine” was first proposed by
Offenbacher in 1997 as “A broad
term that defines a rapidly
emerging branch of periodontology focusing on new data establishing a strong relationship
between periodontal health or
disease and systemic health or
disease”. It arose with the emerging evidence suggesting that a
number of systemic conditions
and periodontal disease were inter-related. By 2000 the evidence
that oral health and systemic
health should not be separated

inflammation presents a significant chronic inflammatory burden at the systemic level.
While there is considerable
work still to be done significant
progress has been achieved in
the past decade. Diabetes is now
well recognised to be a significant risk factor for development
of periodontitis and conversely
periodontitis is considered to be
a significant modifying or risk
factor for glycaemic control in
diabetics. Other conditions for
which there is good evidence to
support interrelationships with
periodontitis include cardiovascular disease, rheumatoid
arthritis, obesity and renal disease.
It remains to be established
whether treatment of periodontitis has any impact on systemic
conditions but there is emerging
evidence to indicate this may be
the case for diabetes, cardiovascular disease and rheumatoid
arthritis. Unfortunately, this has
become an opportunistic field
of research and to date some
58 conditions have been claimed
to fall within the periodontal disease/systemic disease axis, most
of which have little or no biological or clinical plausibility.

Understanding that
periodontal regeneration
is biologically possible
Regeneration of damaged periodontal tissues as a result of
periodontitis has been considered
the ultimate goal of periodontal
treatment. Over the decades
many procedures have been advocated, mostly associated with
root surface conditioning and
implantation of bone substitutes
into periodontal defects as a
means of obtaining periodontal
regeneration.
Unfortunately, these early
concepts were naïve owing to
a poor understanding of the
requirements for periodontal

regeneration, namely the encouragement of new cementum,
bone and periodontal ligament.
Filling a periodontal defect with a
substance which had no relevance to the next functional stage
of reconstruction is irrational.
Nonetheless, as a profession, we
had become obsessed with filling
holes in bone rather than studying the natural healing processes
required to regenerate the periodontal attachment apparatus.
Ignorance of the contribution of
the various tissue components in
periodontal wound healing explained the widespread misuse
of bone transplantation in the
treatment of intrabony pockets
which unfortunately still pervades some areas of periodontology.
It is now recognised that regenerative treatment of periodontal defects with an agent or
procedure, requires that each
functional stage of reconstruction be grounded in a biologically
directed process. With such
concepts in mind, the seminal
studies of Karring, Nyman and
coworkers from Gothenburg in
Sweden led to the development
of guided tissue regeneration
(GTR) as a treatment modality.
While this was a significant advance it became evident that
while periodontal regeneration
was biologically possible, it was
clinically very difficult to achieve
on a reliable basis owing to a vast
range of patient and operator
variables.
More recently we have seen
the development of biological
agents and preparations which,
when applied onto root surfaces,
can result in significant regeneration of damaged periodontal
tissues. The use of such agents
offers a simpler approach to periodontal regeneration with equivalent, and sometimes superior,
results compared to GTR procedures. However, as has been
noted for GTR, the clinical outcomes using biological agents
can be variable and further work
is needed to improve their clinical utility. Moreover, the use of
mesenchymal stem cells and genetic modulation of periodontal
cells have been explored for the
purposes of achieving periodontal regeneration. The future
looks promising but no doubt
there is a considerable amount of
work to be done before reliable
and predictable periodontal regeneration becomes a reality. DT

Author Info
Mark Bartold is
currently Professor of Periodontics and Director
of the Colgate
Australian Clinical Dental Research Centre at
the University of Adelaide in
Australia. He can be contacted at
mark.bartold@adelaide.edu.au.

[15] => Standard_300dpi

DENTAL TRIBUNE Asia Pacific Edition No. 5/2015

Trends & Applications 15

Implant-prosthetic restorations
The challenge of creating an aesthetically pleasing smile in an edentulous patient

Fig. 1: Aesthetic evaluation prior to treatment: the edentulous upper jaw had been provided with a conventional complete denture.—Figs. 2 & 3: After the healing and osseointegration process of the four implants,
an impression of the oral situation was taken. The impression posts were splinted together prior to impression taking.—Fig. 4: Implant model for the reconstruction of the overdenture.—Fig. 5: The models mounted on the
articulator clearly demonstrate the challenges involved in this clinical case.—Fig. 6: Try-in of the wax set-up and evaluation of the aesthetic parameters.—Fig. 7: Customised titanium abutments.—Fig. 8: Reconstruction
of the primary structure after scanning the model, abutments and set-up.
Cristian Petri
Romania

Rehabilitation of the edentulous
jaw can be achieved with various
treatment modalities. Removable
implant-supported overdentures
can provide a comfortable, aesthetic and functional option even
in cases in which only a limited
number of implants can be used.
Since the number of patients desiring an alternative to complete
dentures is on the rise, this treatment option is becoming a frequent choice.
Patients’ expectations regarding prosthetic tooth replacements
are similarly high compared with
fixed ceramic veneered restorations. With the emergence of new
materials and their combination
with CAD/CAM technology, outstanding clinical outcomes can be
achieved for this indication. An
adequate solution can be found for
almost every patient and budget.
Generally, overdentures offer
several advantages over conventional removable prostheses, including improved stability, functionality, comfort, confidence in the
ability to interact socially, straight
forward rehabilitation and easy
maintenance for the patient. Quite
simply, overdentures result in a significant improvement in the quality
of life of the patient.

and financial constraints, as well as
the clinical condition of the maxillary prosthetic field, into account,
we decided in favour of an implantsupported prosthetic treatment
modality. The plan was to insert four
maxillary implants to retain an overdenture prosthesis using the double-crown method. This procedure
is frequently followed in such cases
and has seen constant improvement
with the emergence of new technologies and materials.
Our protocol required primary
telescope crowns milled from zirconia at an incline of two degrees and
secondary copings obtained by electroforming. This approach combines
the advantages of zirconia (primary
telescopes) with those of hydraulic
retention (galvanic copings). After a
complication-free period of healing
and osseointegration, the four implants were uncovered and a preliminary impression was taken.
Also, a customised tray was created
from the resulting model.

In our case, a 58-year-old patient
presented at the practice with discomfort caused by her complete
maxillary denture. When looking at
her history, we found a prosthetic
restoration retained on six implants
in the lower jaw and a complete
maxillary denture that was aesthetically and functionally inadequate
(Fig. 1). An initial aesthetic evaluation established that the shape and
shade of the teeth were inappropriate. In addition, the midline was
misaligned and the curvature of the
maxillary anterior teeth was shaped
incorrectly.

In order to proceed to the next
stage of the treatment, we required
a functional impression that would
transfer the exact position of the
implants. For this purpose, the four
impression posts were splinted
together on a custom tray with
composite material (Figs. 2 & 3).
After creating the working models
(Fig. 4), we determined the patient’s
vertical dimension of occlusion, the
length of the future teeth, as well as
the gingival smile line, by means of
an occlusal plate (bite rim). In the
upper jaw, the occlusal rim was
shaped in such a way that 2 mm of
the edge was visible when the upper
lip was in rest position. The lower
edge of the rim was aligned parallel to the bipupillary plane and
smoothly followed the curve of the
lower lip when the patient smiled.
On the maxillary rim, the midline,
the smile line and the line of the canines were outlined. A facebow was
used for the transfer of the maxillary
position in relation to the base of the
skull.

The poor stability of the denture
was caused by insufficient prosthetic support and by the method
with which it had been produced.
Taking the patient’s requirements

Once all of the relevant ratios
had been obtained, the models were
mounted on the articulator (Fig. 5).
The difficulty of this case was that
we had to make allowance for the

existing mandibular restoration in
the design of the maxillary rehabilitation. The implant axes of the
mandibular prosthesis in particular
posed some problems. Shade selec-

tion was dictated by the mandibular
restoration and, consequently, our
room for decision-making was reduced to deciding on the shape of
the teeth. To this end, a photograph

of the patient as a young adult was
useful, as it was her wish that the
shape and size of her teeth as they
DT page 16
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[16] => Standard_300dpi

16 Trends & Applications

DENTAL TRIBUNE Asia Pacific Edition No. 5/2015

DT page 15

Figs. 9 & 10: Grinding and smoothing of the primary structure made from zirconia in a milling unit using CAD/CAM technology.—Fig. 11: Intra-oral bonding of the electroformed secondary structure with the tertiary
structure.—Figs. 12 & 13: Detailed view of the completed denture: customised prefabricated teeth and soft-tissue parts.—Fig. 14: The macro-texture and shade effect of the denture were individualised in a straight forward
manner to achieve a result that is true to life.—Fig. 15: The implant-retained overdenture in the patient’s mouth.

were when she was young should be
re-established in the prosthetic reconstruction. With the aim to attain
as perfect a prosthesis as possible
and to make the most of the available
space, we created a wax set-up using
prefabricated denture teeth (SR
Phonares II, Ivoclar Vivadent).

Primary structure
A try-in of the set-up was performed to check the phonetics, aesthetics and occlusion (Fig. 6) and
then a silicone key was created over
AD

the set-up. This acted as a guide in
the subsequent working steps. In
order to manufacture the primary
structure, the four titanium abutments were customised (Fig. 7), the
resulting abutments were scanned
together with the model and set-up
(double scan), and these datasets
were imported into the design software. The CAD program proceeded
to suggest the shape, height and angulation of the telescope crowns,
which we adjusted and optimised as
required (Fig. 8). The primary tele-

scopes were milled from zirconia
and sintered to their final density at
1,500 °C. After the accuracy of fit had
been checked, the zirconia crowns
were permanently bonded to the
titanium abutments (Multilink
Hybrid Abutment, Ivoclar Vivadent).
Finally, the zirconia telescopes were
adjusted using a laboratory turbine
and parallelograph. The walls of the
telescopes were given a 2-degree
incline and smoothed using appropriate diamond grinding tools and
sufficient water-cooling (Figs. 9 & 10).

Secondary structure
The primary crowns could now
be prepared for manufacturing the
secondary crowns by means of the
electroforming technique. For this
purpose, the zirconia surfaces were
covered in a thin coating of conductive silver using the airbrush
method. Upon completion of the
process, the galvanised gold crowns
were detached from the telescopes
and the conductive silver coating
was removed with a solution containing nitric acid. In the process, a
highly accurate secondary structure
was obtained.

Tertiary structure
All of the components were
repositioned on to the working
model. Before the tertiary structure
was fabricated, the electroformed
crowns were covered in a thin
layer of wax to create the space necessary for the cement that would
later be used. The tertiary structure
was invested, cast in a cobalt–
chromium alloy using induction
casting technology and then finished. The tertiary structure was
intra-orally cemented on to the
electro-formed telescopes (Multilink
Hybrid Abutment and Monobond,
Ivoclar Vivadent) in order to obtain
a tension-free restoration (Fig. 11).

Aesthetic design
The structure obtained was covered in an opaque light-curing laboratory composite (SR Nexco, Ivoclar
Vivadent) in pink and white prior
to finishing the prosthesis. Again,
the silicone key was used as a guide.
The SR Phonares II teeth were repositioned from the wax set-up to the
framework. The occlusal parameters were checked again and then
we proceeded to complete the
restoration. In order to reconstruct
the pink gingival portion, we used
the IvoBase Injector system (Ivoclar
Vivadent). First, the denture was
invested in two specially designed
flask halves using Type III and IV
plaster. After removing the wax
and isolating the plaster surfaces,
we prepared an IvoBase capsule and
placed it together with the flask into
the polymerisation chamber. The
IvoBase injection and polymerisation process is fully automated and
takes about 60 minutes. Users can
choose between two programme
options. Running the standard programme takes about 40 minutes.
If the RMR programme is additionally activated, the pressing time
increases, as a result of which the
monomer concentration is reduced
to less than 1 per cent. This aspect is
beneficial to patients because the
risk of allergies and irritation of the

mucous membrane is virtually
eliminated.
After the injection programme
was complete, the flask halves were
opened, and the denture divested
from the stone core and processed
with milling and polishing instruments. In order to create a tooth replacement that closely met the expectations of the patient, we decided
to customise the visible areas of
the denture by applying additional
material (SR Nexco). To this end, the
vestibular surfaces of the anterior
teeth and the corresponding pink
parts were sand-blasted. SR Connect (Ivoclar Vivadent) was applied
and the teeth and prosthetic gingiva
were characterised with SR Nexco.
The shape was adjusted in accordance with the requirements of the
patient. Final polishing was carried
out with biaxial brushes and pads.
The result proved very lifelike
(Figs. 12–15).

Conclusion
Many patients are reluctant to
be given removable dentures. If
dentures are optimised by adding
the stability of implants and the
effectiveness of telescopes, dental
professionals will be able to help patients overcome their reservations
and offer them a tooth replacement
that provides the level of comfort
they expect. Completely edentulous
patients have the same high aesthetic expectations as patients requiring fixed restorations. However, some of these requirements
are more difficult to satisfy in the
edentulous patient, because we
have to replace soft tissue in addition
to missing teeth. In order to achieve
this, we need to find a way to create
harmony between the pink and
white aspects of the denture.
Today’s patients tend to be wellinformed. They have ever higher
expectations of the aesthetic and
functional aspects of tooth replacements. Therefore, we need to be well
trained and know which materials
and technologies can aid our work
and increase our efficiency. This will
enable us to solve any clinical case,
regardless of its difficulty. DT

Author Info
Cristian Petri is
working as a
dental technician at Artchrys
Dental Laboratory in ClujNapoca, Romania. He can be
contacted at office@artchrys.ro.

[17] => Standard_300dpi

COSMETIC TRIBUNE
The World’s Cosmetic Newspaper · Asia Pacific Edition

PUBLISHED IN HONG KONG

www.dental-tribune.asia

NO. 5 VOL. 13

MiCD: Do no harm
cosmetic dentistry—Part I
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

Cosmetic dentistry,
a global trend

3

The practice philosophy adopted by the clinic and the profes-

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 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 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 middleto higher-income 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.

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 cosmetic dentistry and its promotion. It is widely seen that the
treatment modalities of contemporary cosmetic dentistry are tending
towards more-invasive procedures
with an over-utilisation of full
crowns, bridges, dentine veneers,
and invasive periodontal aesthetic
surgery, while neglecting long-term
oral health, actual aesthetic needs
and the characteristics of the patient.2 These aggressive treatment

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10b

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.

sional 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 re-spected 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.

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
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 knowledge,
clinical skills, honesty and humanity is difficult to find in today’s
business-oriented dental education. I believe that knowledge
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18 Trends & Applications

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 CT page 17

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 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.

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.

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.

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 with questions of beauty and artistic taste” and
“cosmetic” as “improving only the
appearances of something”.
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 need-based 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 more than an aesthetic requirement, and must be considered
a cosmetic demand or requirement.
In my clinical practice, I divide
aesthetic and cosmetic clinical
cases into three different categories:
1. Preventive, or support based:
treatment prevents or intercepts

Practice philosophy
in dentistry: The mindset
The majority of dental schools
around the world focus on teaching
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

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

• 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

Table II: MiCD core principles.

15c

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 with their
professional friends and junior colleagues to promote patient-centred
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, burn-out 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 burn-out, 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 philosophy 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 profes-

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COSMETIC TRIBUNE Asia Pacific Edition No. 5/2015
sional 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
guilt-free 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
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 porcelainfused-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).

Trends & Applications 19

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

Table IV: The MiCD summary ten.

MiCD clinical technique:
Rejuvenation, restoration,
rehabilitation and repair
The MiCD clinical technique
focuses on the aesthetic pyramid 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 en-

hancement of the dentition. It is
to be noted 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 aesthetics. Restoration is performed using microto 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 re-restoration 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).
MiCD summary ten
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. CT
Editorial note: A complete list of references
is available from the publisher.

Author Info
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.

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20 Trends & Applications

Smile analysis and photoshop
smile design technique
2

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 evaluation of
4
5
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 1mm of tooth display at rest (left), minus 3mm of gingival display, and 4 mm of space between the incisal edge and the lower lip (right).

Prof. Edward A. McLaren
& Lee Culp
USA

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 microelements. Macro-aesthetics encompasses the interrelationships between the face, lips,
gingiva, and teeth and the perception that these relationships
are pleasing. Micro-aesthetics
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 balance, with an emphasis
on how they may be affected by
dental treatment.3, 4 During the
macro-analysis, the balance of
the facial thirds is examined
(Fig. 1). If something appears
unbalanced in any one of those

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.

zones, the face and/or smile will
appear unaesthetic.
Such evaluations help determine the extent and type of treatment necessary to affect the
aesthetic changes desired. Depending on the 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).

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 accom CT page 22

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 4–5mm.—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 1–2mm shorter than the
central incisors, and canines 0.5–1mm shorter than the central incisors for an aesthetic smile display.—Fig. 12: The canines and other teeth distally located are visually perceived as occupying less space in
an aesthetically pleasing smile.—Fig. 13: A general rule for achieving proportionate smile design is that lateral incisors should measure two-thirds of the central incisors and canines four-fifths of the 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.

[21] => Standard_300dpi

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COSMETIC TRIBUNE Asia Pacific Edition No. 5/2015

22 Trends & Applications

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.
CT page 20

plished 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
inter-tooth 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
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 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-tolength 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

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).
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 four-fifths 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).

posed smile design treatments.
It starts by creating tooth grids—
predesigned tooth templates in
different width-to-length 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.
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-tolength 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. Once activated,
zoom in (Fig. 16) and trace the
teeth with the lasso tool.

Several rules can be applied
when considering modifying the
midline to create an aesthetic
smile design:

The length of teeth also affects aesthetics. Maxillary central incisors average between
10 mm and 11 mm in length.
According to Magne, the average
length of an unworn maxillary
central to the cementoenamel
junction is slightly over 11 mm.10
The aesthetic zone for central

Creating a digital smile
designed in Photoshop
Although there are digital
smile design services available
to dentists for a fee, it is possible
to use Photoshop CS5 software
(Adobe Systems) to create and
demonstrate for patients the pro-

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] => Standard_300dpi

COSMETIC TRIBUNE Asia Pacific Edition No. 5/2015
• 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 doubleclicking 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 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

Trends & Applications 23
teeth before agreeing to treatment.
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”.
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.

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.

Author Info
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.

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. CT

Author Info
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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