DT U.S.

NCOHF grants support community-based children’s care / Hello - San Antonio! / Where did all the periodontists go? / Offer pediatric patients a ‘NuSmile’ / Fast and safe protecting and matrixing with FenderWedge and FenderMate / COSMETIC TRIBUNE 5/2010 (part1) / COSMETIC TRIBUNE 5/2010 (part2)

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DENTAL TRIBUNE
The World’s Dental Newspaper · U.S. Edition

May 2010

www.dental-tribune.com

ENDO TRIBUNE
The World’s Endodontic Newspaper · U.S. Edition

Where are the periodontists?

Read about the mind-set change in perio and
decide for yourself if it’s good or bad. u page 4A

AAE hosts meeting

New techniques and products revealed at San
Diego event.
u page 1B

Vol. 5, No. 12

CHosmetiC
RiBUNe
YGIENE TtRIBUNE
the
Dentistry
Newspaper
· U.s.
edition
TheWorld’s
World’sCosmetic
Dental Hygiene
Newspaper
· U.S.
Edition

The Smile Design Wheel

Learn the four steps of this wheel, which will simplify an often complex design process. upage 1C

NCOHF grants support communitybased children’s care
By Fred Michmershuizen, Online Editor

The money donated to National Children’s
Oral Health Foundation: America’s Toothfairy
is being put to good use. NCOHF recently
announced it has awarded grants totaling
$109,050 to eight not-for-profit community,
university and hospital-based dental programs
nationwide.
The grants are as follows:
• Catholic Healthcare West, Chandler, Ariz.,
$15,000
• Community Oral Health Services, Salinas,
Calif., $15,000
• Sonrisas Community Dental Center, Half

Moon Bay, Calif. $9,050
• The Children’s Dental Center, Inglewood, Calif., $15,000
• The Gary Center, La Habra, Calif.,
$10,000
• Indiana University School of Dentistry,
Indianapolis, $15,000
• Community Dentistry on Wheels, Largo,
Md., $15,000
• A Fluoride Connection Non Profit Corp.,
Madison, Wis., $15,000
According to the NCOHF, the grant recipients are members of the growing affiliate
network delivering comprehensive
g DT page 2A , ‘NCOHF’
preventive, restorative and education-

(Photo/NCOHF)

Hello, San Antonio! Economic hardship
takes toll on teeth
The Henry B.
Gonzalez Convention Center in San
Antonio will host the
Texas Dental Association’s meeting May
6–9. Read about
what there is to do
in the city when you
have some spare
time.

Is it true that people postpone or
forgo dental treatment in difficult
economic times? According to one
recent survey of dental practitioners,
the answer is, unfortunately, yes.
The Chicago Dental Society conducted a poll of 250 members to
learn more about their opinions on
currents trends, dental topics and
more. According to the survey, the

g See page 3A

effects of the recession on the dental
industry have worsened over the
last year.
More than 90 percent of dentists
surveyed said their clients are putting off cosmetic procedures, the
Chicago Dental Society reported. In
addition, more than 75 percent of
g DT page 2A , ‘Economic’
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(Photo/Brandon Seidel, Dreamstime.com)

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New York, NY 10001

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[2] =>

2A News

Dental Tribune | May 2010

DENTAL TRIBUNE

‘More should be done to improve
children’s oral health,’ AGD says

Publisher & Chairman
Torsten Oemus
t.oemus@dental-tribune.com

By Fred Michmershuizen, Online Editor

Vice President Global Sales
Peter Witteczek
p.witteczek@dental-tribune.com

According to the Academy of
General Dentistry, more needs to
be done to improve children’s oral
health as oral diseases negatively
impact learning, interfere with eating and contribute to poor selfesteem.
AGD President David F. Halpern, DMD, FAGD, testified in the
nation’s capital recently during
the first meeting of the Institute
of Medicine (IOM) Committee on
Oral Health Initiative. During his
testimony, Halpern emphasized
access to care and oral health literacy.
“Public schools have played a
critical role in keeping our children
healthy,” Halpern said. “Schools
routinely hold programs to ensure

f DT page 1A, ‘NCOHF’
all oral-health programs to children
from vulnerable populations.
Through continued support from
financial and product contributions,
as well as technical resources, the
affiliate network has reached more
than 1 million children since 2006,
NCOHF said.
ADS

that our children can hear properly, see properly and are free from
other diseases. However, dental
diseases, the most prevalent of all,
do not receive the same attention.”
Halpern asked the Department of
Health and Human Services (HHS)
to consider mandating oral health
programs in all public schools.
Additionally, Halpern expressed
his support for initiatives that
ensure that minority and rural populations receive quality oral health
care services from dentists. Such
initiatives, he said, could include
loan repayment programs to dentists working in community health
and underserved settings, the restoration of Title VII, and patient
transportation and non-dental
social services programs.
Halpern also spoke about the

importance of shifting from a treatment-based concept of medicine
to one based on prevention. He
stated that this transformation can
be achieved by assisting patients,
physicians and communities to
become oral health literate.
“Yes, the HHS must continue
its water fluoridation programs as
a fallback to maintain a minimal
level of oral health in communities, but this is not nearly sufficient — utilization through greater
oral health literacy is mandatory,”
Halpern said.
Halpern also expressed his disappointment over the lack of a
practicing private-practice dentist
on the committee and encouraged the committee to reconsider
appointing a general dentist from
the private-practice community. DT

“It is only through the continued generosity of NCOHF individual,
organizational and corporate partners that America’s Toothfairy grant
awards are possible,” said Fern Ingber, NCOHF president and CEO, in
expressing gratitude to supporters.
“We are honored to serve as a
comprehensive resource provider
for our affiliate network of nonprofit

health-care facilities, and we are
grateful that so many donors share
in the NCOHF mission to eliminate
children’s unnecessary suffering
from pediatric dental disease.”
A representative of A Fluoride
Connection Non Profit Corp., one
of the grant recipients, expressed
gratitude to NCOHF for the financial
support.
“We work in an area that has
many rural poor farm families.
Many don’t qualify for the stateoffered dental health plan, and as
a result our organization receives
very low reimbursement from the
state program,” said Kathleen Traut,
executive director of A Fluoride
Connection.
“We won’t turn any child away
if they are uninsured or otherwise
aren’t on the program, we simply get
paid less. Funding from America’s
Toothfairy has eased our financial
worries in providing vital services
for the little ones who won’t otherwise have any dental experiences
at all. It is gratifying to share such
a passion for children’s oral health
with America’s Toothfairy.” DT

The World’s Dental Newspaper · US Edition

Chief Operating Officer
Eric Seid
e.seid@dental-tribune.com
Group Editor & Designer
Robin Goodman
r.goodman@dental-tribune.com
Editor in Chief Dental Tribune
Dr. David L. Hoexter
d.hoexter@dental-tribune.com
Managing Editor/Designer
Implant Tribune & Endo Tribune
Sierra Rendon
s.rendon@dental-tribune.com
Managing Editor/Designer
Ortho Tribune & Show Dailies
Kristine Colker
k.colker@dental-tribune.com
Online Editor
Fred Michmershuizen
f.michmershuizen@dental-tribune.com
Product & Account Manager
Mark Eisen
m.eisen@dental-tribune.com
Marketing Manager
Anna Wlodarczyk
a.wlodarczyk@dental-tribune.com
Sales & Marketing Assistant
Lorrie Young
l.young@dental-tribune.com
C.E. Manager
Julia E. Wehkamp
j.wehkamp@dental-tribune.com

Dental Tribune America, LLC
213 West 35th Street, Suite 801
New York, NY 10001
Tel.: (212) 244-7181
Fax: (212) 244-7185
Published by Dental Tribune America
© 2010 Dental Tribune America, LLC
All rights reserved.
Dental Tribune strives to maintain the
utmost accuracy in its news and clinical reports. If you find a factual error or
content that requires clarification, please
contact Group Editor Robin Goodman at
r.goodman@dental-tribune.com.
Dental Tribune cannot assume responsibility for the validity of product claims
or for typographical errors. The publisher also does not assume responsibility
for product names or statements made
by advertisers. Opinions expressed by
authors are their own and may not reflect
those of Dental Tribune America.

Editorial Board
f DT page 1A, ‘Economic’
dentists said their patients are putting off needed dental work and
visits for preventative dental care
are also on the decline according to
more than half of dentists.
The survey also revealed that
nearly 75 percent of dentists surveyed said their patients are reporting increased stress in their lives,
and 65 percent of dentists are seeing
an increase in jaw clenching and
teeth grinding among their patients,
signs that stress may be taking its
toll on the mouth. DT
By Fred Michmershuizen, Online Editor

Dr. Joel Berg
Dr. L. Stephen Buchanan
Dr. Arnaldo Castellucci
Dr. Gorden Christensen
Dr. Rella Christensen
Dr. William Dickerson
Hugh Doherty
Dr. James Doundoulakis
Dr. David Garber
Dr. Fay Goldstep
Dr. Howard Glazer
Dr. Harold Heymann
Dr. Karl Leinfelder
Dr. Roger Levin
Dr. Carl E. Misch
Dr. Dan Nathanson
Dr. Chester Redhead
Dr. Irwin Smigel
Dr. Jon Suzuki
Dr. Dennis Tartakow
Dr. Dan Ward

[3] =>

Dental Tribune | May 2010

Texas Dental Meeting

3A

Hello, San Antonio!
By Robin Goodman, Group Editor

San Antonio is Texas’ second mostpopulated city and is best known for
the Alamo and the River Walk — a
three-mile stretch of waterside paths
laden with shops, restaurants and
nightclubs.
For those attending the upcoming
Texas Dental Association meeting,
here are some free things to do in the
city, but you can also head out to visit
some nearby towns. (There’s even one
that will let you be a cowboy for a day.
Giddyap!)

The Missions & the Alamo
San Antonio’s beginnings are found
in the five Spanish colonial missions
that were built along the San Antonio
River. These missions and the Alamo
offer free admission. If you are feeling
energetic, grab a bike (or your hiking
boots) and cruise the 12-mile Mission
Trail that links them all.

The River Walk
Complete with shade-filled parks, the
sound of splashing water and lots of
people watching, the River Walk is
worth a trip. Browse the wares and
take your pick of one of the many
restaurants and dessert options along
the way.

La Villita
Along the River Walk is la villita,
which means “the little village.”
Today this historical site is an art
village with galleries, shops and private residences.

Live music
The Main Plaza, found near the River
Walk and San Fernando Cathedral,
features free music concerts on the
weekends. Marvel at the wise, old
oak trees and the tinkling of water in
nearby fountains.

Glass blowing
Gini Garcia is a renowned glass
blower who you might be able to
catch a glimpse of in action in Southtown at Garcia Art Glass.

Mexican artists
Head to Market Square to view the
cornucopia of works presented by
local working artists. This happens
to be the largest Mexican market in
the nation too.

Japanese Tea Garden
Located next to Brackenridge Park,
you’ll find Koi ponds strewn around
stone paths that wander through the
gardens. (The San Antonio Zoo is
nearby too.)

Gruene Market Days
Revel in arts and crafts galore just 20
miles outside of San Antonio in the
town of Guene. Painting, sculpture
and everything in between are part
of the monthly juried art show called

Gruene Market Days. Hit downtown
for music and German cuisine, and
shuffle over to the Guene Dance Hall
for country and Tejano music.

Cowboy for a day
Just 40 miles outside of San Antonio is Bandera. Bring your cowboy
hat to enjoy horseback riding or a
longer trail ride through the Texas
Hill Country. There are rodeo shows
every night at Lightning Ranch or
Twin Elm Guest Ranch. DT
(Source: www.visitsanantonio.com)

ADS

[4] =>

Practice Matters

Dental Tribune | May 2010

Where did all the periodontists go?
By Louis Malcmacher, DDS, MAGD
ADS

Through my weekly travels to

different cities across America, I
speak to many dental specialists
and their groups on the hottest
topics in dentistry, practice management and total facial esthetics.
There are definite treads that
are changing in all specialties
across the board, whether it is
short-term orthodontics versus
long-term orthodontics, adhesive
resin endodontics versus traditional gutta-percha endodontics
or the conversation as to whether
or not general dentists should be
providing some of these specialty
services.
I would have to say that the big-

gest change of any single dental
specialty that I have seen has been
in the periodontal field. There has
been a real mind-set change that
deeply affects the profession. I am
not commenting here on whether
this change is good or bad — I will
leave that up the to the reader to
decide.
It is certainly something to consider as general dentists who refer
patients to periodontists on what
your treatment will be for the long
run.
I have always believed that general dentists are the quarterbacks
of any patient treatment case and
we certainly rely on the skills and
input of dental specialists, but the
ultimate responsibility should be
on the general dentist.
Here is what I am being told by
many periodontists whom I have
spoken to over the last couple of
years: they would rather remove
teeth and place implants than
actually treat patients through traditional periodontal surgery and
try having them maintain their
dentition.
The reason for this is really
quite simple and every dentist
knows this inherently. Patients
refuse to take good care of their
teeth even after they have gone
through the time, cost, commitment and pain of traditional periodontal surgery. This is certainly
not earth-shattering news to any
of you.
For years in our own practice,
we have had patients who did
not want periodontal surgery and
would rather maintain the state
of their oral health with threeto four-month recall prophylaxis
visits. We would often predict that
their teeth would fall out within
two to three years.
Surprisingly, many of these
patients have done reasonably
well 20 years later, with the occasional loss of a tooth here or there.
This thought was blasphemy to
periodontists for years and years,
but certainly it seems that conservative non-surgical periodontal recall visits and treatment has
helped many patients maintain
their dentition in a reasonable
state so that they can function and
smile with their original teeth for
years.
As general dentists we have
known that even with the best
periodontal surgery treatment,
patients would often fall into their
old habits and eventually their
dentition would fail anyway. Not
all patients, but many of them.
We have learned that we have
to treat people as people and
sometimes you just cannot change
them no matter what you do.
It seems to me that periodontists have now caught up with
this concept and that is where
this mind-set has really changed

[5] =>

Dental Tribune | May 2010

Practice Matters
periodontal services into the minimally invasive realm as a solution
for patients who do want to keep
their teeth without heavily invasive periodontal surgery.
Laser periodontal treatment will
continue to develop and become
even more effective in the future.
Procedures such as implants

5A

and minimally invasive laser periodontal therapy will continue to
improve and change the way we
practice in this new decade.
Is this good or bad?
You are the dental clinician, so
this is for you, the periodontist and
the patient to decide. DT

About the author

(Photo/Webking, Dreamstime.com)
periodontics today. Patients like
the concept of implants, which
are still vastly underused in North
America.
Many patients would rather not
have to take care of their teeth
and have these unsightly, mobile
teeth extracted and replaced with
implants, which would restore
their function and their esthetics.
With a 94 percent implant success rate, it is hard to argue when
that success rate is so high compared to the poor long-term suc-

cess rate of traditional periodontal
surgery.
This is primarily because we
have to depend upon the patients
to keep up their regimen for the
long-term success of their natural
dentition.
New procedures — such as the
wavelength optimized periodontal therapy (WPT) procedure with
the Powerlase AT Laser by Lares
Research, and LANAP procedures
done with the Periolase laser by
Millenium Dental — have brought

Dr. Louis Malcmacher is a
practicing general dentist in Bay
Village, Ohio, and an internationally recognized lecturer and author
known for his comprehensive and
entertaining style.
An evaluator for Clinicians
Reports, Malcmacher has served
as a spokesman for the AGD and
is president of the American Academy of Facial Esthetics.
You may contact him at (440)
892-1810 or e-mail dryowza@mail.
com.
You can also see his lecture
schedule at www.commonsense
dentistry.com where you will find
information about his Botox and
dermal filler live patient hands-on
training, practice-building audio
CDs and free monthly e-newsletter.

AD

#103

[6] =>

6A
AD

Industry News

Dental Tribune | May 2010

Offer pediatric
patients a ‘NuSmile’

Esthetic crowns provide a durable restoration for decayed primary teeth
By Sierra Rendon, Managing Editor

NuSmile offers practitioners easy placement of esthetic stainless-steel crowns for
children, said CEO/President
Diane Johnson Krueger.
“Stainless-steel crowns have
always been the restoration of
choice for ease and durability for children whose teeth
are affected by early childhood
caries (ECC), but parents and
doctors have never been happy
with the esthetics of these restorations,” she said.
NuSmile was first introduced in 1991, and though
other companies have similar
products, Krueger said NuSmile is set apart by its quality
and durability.
“There are a few other
companies that have similar
products, but NuSmile has
performed with consistently
higher results in laboratory
studies that measure things
such as fracture and fatigue
resistance, color stability and
wear,” she said.
“Also, in two separate surveys of pediatric dentists, more
dentists preferred NuSmile
crowns than any other esthetic
pediatric crowns offered.”
Dentists can quickly learn
the NuSmile technique for
properly fitting crowns.
“The technique for placing
Nu-Smile crowns differs a bit
from the technique for placing standard stainless-steel

Fight
oral
cancer!
AD

Jason Johnson, chief operating officer of NuSmile Primary Crowns,
shows off the company’s products in the exhibit hall at the recent
Midwinter Meeting in Chicago. (Photo/Sierra Rendon)

crowns,” Krueger said. “We
have a great instructional DVD
with actual patient cases that
demonstrates exactly how to
prepare the tooth and seat
a NuSmile crown. NuSmile
crowns are offered for both
anterior and posterior deciduous teeth.
“There are currently two
shades offered; they are sold
in kits and individually with no
minimum order,” she said.
What’s the main thing to
remember when considering
NuSmile crowns?
“Easy placement, not technique-sensitive like a strip

crown. Full coverage protection of remaining tooth structure, just like a stainless-steel
crown,” Krueger said.
“Good esthetics for many
years; these crowns are
extremely durable … more so
than strip crowns or any other
esthetic-coated crowns available.
“Our company is dedicated
to beautiful, healthy smiles for
all children. NuSmile anterior
and posterior crowns are anatomically correct, stainlesssteel crowns with the most
natural-looking, tooth-colored
facing available.” DT

Did you know that dentists
are one of the most trusted
professionals to give advice?
Thus, no other medical professionals are in a better position to show patients that they
are committed to detecting
and treating oral cancer.
Prove to your patients just

how committed you are to
fighting this disease by signing up to be listed at www.
oralcancerselfexam.com.
This website was developed for consumers in
order to show them how
to do self-examinations for
oral cancer.
You can explain the procedure in brief and
then let them
know about the
website,
www.
oralcancerself
exam.com,
that
can provide them
with all the details
they need.
If dental professionals do not
take the lead in
the fight against
oral cancer, who
will? DT

[7] =>

[8] =>

Industry News

Dental Tribune | May 2010

Fast and safe protecting and matrixing
with FenderWedge and FenderMate
During Class II preparation
there is a major risk for damaging the adjacent tooth. Research
shows adjacent teeth are damaged
in up to 70 percent of all cases.
Until now, protection methods
have the disadvantage that the
shield loosens when the approximal contact point is cut away,
increasing the risk of accidental
aspiration of the shield.
The need for improved pro-

tection methods led Directa to
design and develop FenderWedge,
a plastic wedge with an attached
vertical stainless-steel band that
protects the adjacent teeth and,
at the same time, separates the
teeth for an optimal restoration of
the contact point. FenderWedge is
securely held in place throughout
the entire preparation.
FenderWedge is inserted into
the approximal space as easily as

FenderWedge

FenderMate

ADS

(Photo/Directa)
any other wedge. As the wedge
creates interdental separation, the
vertical steel band automatically
establishes correct positioning for
a good contact point.
The comfort of knowing that
0.08 mm of metal protection will
help avoid needless damage to
healthy teeth is simply priceless.
FenderWedge is available in
four different sizes from extra
small (1.0 mm) to large (2.3 mm).
They accommodate all interdental
spaces.
In Directa’s quest to design and
develop high-quality useful products, the logical next step after the
use of FenderWedge is the introduction of FenderMate, an innovative wedge and section matrix
combined. FenderMate offers a
two-in-one-step procedure like
nothing else in the market.
After pre-separation of the
interdental space with FenderWedge, FenderWedge is removed
and replaced by FenderMate.
After
insertion, FenderMate
adapts around the tooth and holds
shape without the use of a reten-

tive ring.
FenderMate’s flexible wing separates the teeth and firmly seals
the cervical margin. A good contact point is created by the unique
pre-shaped indentation in the
matrix. No burnishing is necessary.
FenderMate is available in two
wedge widths, regular and narrow, and for left or right application. The new innovative design
accommodates most approximal
spaces.
The combined use of FenderWedge and FenderMate sets a new
standard in dentistry with a tissuefriendly approach for the preparation and filling of Class II cavities.
FenderWedge protects the adjacent tooth and separates the teeth,
thus creating a perfect contact
point, while FenderMate aids fast
and efficient restorations with a
one-piece wedge and matrix application.
Information about Directa products and distributors may be found
at www.directadental.com or by
calling (203) 788-4224. DT

Invest in your practice with HSFS
Henry Schein Financial
Services (HSFS) business
solutions portfolio offers
a wide range of financing
options that make it possible for you to invest in your
practice for greater efficiency, increased productivity and enhanced patient
services.
HSFS helps health care
practitioners operate financially successful practices
by offering complete leasing and financing programs.
HSFS can help obtain
financing for equipment

and technology purchases,
practice acquisitions and
practice start-ups.
HSFS also offers valueadded services including
credit card acceptance,
demographic site analysis
reports, patient collections,
patient financing and the
Henry Schein Credit Card
with 2% cash back or 11/2
points per dollar spent.
For additional information,
please
call
(800) 443-2756 or send
an
e-mail
to
hsfs@
henryschein.com.

[9] =>

[10] =>

[11] =>

Cosmetic TRIBUNE
The World’s Cosmetic Dentistry Newspaper · U.S. Edition

May 2010

www.dental-tribune.com

Vol. 3, No. 5

Smile Design Wheel
A practical approach to smile design
By Sushil Koirala, Nepal

Modern trends in cosmetic dentistry and media coverage of smile
makeovers have increased public
awareness of dental esthetics. People now know that smile esthetics
plays a key role in their sense of
well-being, social acceptance, success at work, in relationships and
self-confidence.
The esthetic expectations and
demands of dental patients have
increased substantially. Now, a
glowing, healthy and vibrant smile
is no longer available only to millionaires and movie stars.
Therefore, many dentists are
incorporating various smile design
protocols in their daily practices
to meet the increasing esthetic
demands of their patients.

Smile esthetics
A smile is a facial expression that
is closely related to the emotions

Fig. 1

and psychological state of a person. A smile is exhibited when a
person expresses happiness, pleasure or amusement.1 It is the most
important of facial expressions and
is essential in expressing friendliness, agreement and appreciation.2
A smile requires the coordination
of facial, gingival and dental components that are stimulated voluntarily
or involuntarily by various emotions.
It is evident that each smile is different and particular to each individual.3 On the other hand, an impaired
smile has been associated with higher incidences of depression.4
Esthetics deals with objective and
subjective beauty.5 Objective beauty
is based on the appreciable properties possessed by the object itself.
However, subjective beauty is relative to the perception and emotion
of the observing person. Perception,
however, in smile esthetics is based
g CT page 3C

Dentists share their thoughts on veneers
What do you charge for porcelain veneers?

By Fred Michmershuizen, Online Editor

The average price dentists charge
their patients for porcelain veneers
is about $1,100 per tooth, according to a survey conducted by The
Wealthy Dentist, a website offering
continuing education and marketing resources to dental professionals.
In the survey, dentists were also
asked to share their thoughts about
offering veneers.
Responses included the following:
• “I wish I could do them cheaper, but good lab work and planning takes time and money,”
said a Michigan dentist who
responded to the survey.
• “The fee is not enough for the
time it takes,” said another dentist, from Mississippi. “It is a lot
more complicated than a dental
crown.”
• “Depending upon the number
of teeth to be done, I will discount my per-tooth fee,” said an

Oklahoma dentist who responded to the survey.
• “Veneers are almost always
placed as multiple units of
eight to 10 veneers, making a
small discount per unit reasonable and still profitable,” said a
North Carolina dentist.
The survey noted that porcelain
veneers cost about the same as
Lumineers, a brand of teeth veneers
that have become a popular part of
cosmetic dentistry. Yet some dentists charge significantly more for
Lumineers veneers, while others
charge significantly less.
Prosthodontists in the survey
reported charging several hundred
dollars more per tooth veneer than
general dentists.
“We never say ‘crown’ in our
prosthodontic practice. Our patients
come back and say they ‘just love
their new veneers.’ Think about it,
crowns are really full veneers,” said
a Tennessee prosthodontist.
“Veneers are the best tool available for doing an extreme den-

tal makeover,” said Jim Du Molin,
founder of The Wealthy Dentist.
“With veneers, patients can change
the size, shape and color of their

teeth, giving them the smile of their
dreams.”
The Wealthy Dentist is located at
www.thewealthydentist.com. CT
AD

[12] =>

[13] =>

Clinical

Cosmetic Tribune | May 2010

COSMETIC TRIBUNE
The World’s Dental Newspaper · US Edition

Publisher & Chairman
Torsten Oemus
t.oemus@dental-tribune.com
Vice President Global Sales
Peter Witteczek
p.witteczek@dental-tribune.com
Chief Operating Officer
Eric Seid
e.seid@dental-tribune.com
Group Editor & Designer
Robin Goodman
r.goodman@dental-tribune.com

Fig. 2

Fig. 3

f CT page 1C

and their clinical protocols.

on personal beliefs, cultural influences, esthetic trends and fashion,
and input from the media.
Hence, smile esthetics is a multifactorial issue, which needs to be
adequately addressed for any esthetic treatment. The objective beauty
of a smile can be established with
the application of various principles
of smile design, and the creation of
subjective beauty may enhance cosmetic value.5,6

The Smile Design Wheel

Smile design
Smile design has been defined in
various ways in the literature; I
would like to summarise it as follows: “Smile design is a systematic
process governed by the psychology,
health, function and rules of natural esthetics to bring about some
changes in soft- and hard-oral tissue within anatomical, physiological and psychological limitations,
thereby creating a positive influence
on the overall esthetics of a person’s
face and personality as a whole”.7
We all appreciate a beautiful
smile when we see it, but it is difficult to explain exactly what makes
a smile beautiful.
It is evident that a pleasing smile
depends on the following features:
the quality of the dental and gingival
components, their conformity to the
rules of structural beauty, the relationship between teeth and lips, and
their harmonious integration with
the facial components.8
Overall facial beauty and smile
esthetics are normally judged by
psychological aspects — perception,
personality, desire — the state of
health, the mathematical ratio of
the facial, dento-facial and dentogingival components. The psychological aspects are highly subjective
and fluctuate constantly because of
identity, peer and media pressure.
Hence, the only objective method
of esthetic analysis is mathematical.
Indeed, mathematics has been
considered the only frame of reference for comprehending nature.8
Therefore, the cosmetic dentist
needs to be familiar with various
mathematical and geometric concepts for achieving smile esthetics

Editor in Chief Cosmetic Tribune
Dr. Lorin Berland
d.berland@dental-tribune.com

For any smile design procedure, the
clinician needs to consider the elements of the smile design pyramids
— psychology, health, function and
esthetics (PHFA), listed here according to order of importance.7
It is necessary to determine
the patient’s psychological status,
establish a healthy oral environment, restore function and then give
attention to enhancing the esthetic
aspect. All four pyramids should
be accorded equal importance to
achieve a desirable clinical result.
By integrating these PHFA pyramids, I developed the Smile Design
Wheel (Fig. 1), in which each pyramid is subdivided into three related
zones. The Smile Design Wheel was
devised as a simple guide to the
most important components of smile
design, their clinical significance
and sequence to be maintained during the smile design procedure.
I believe that the Smile Design
Wheel will help clinicians to easily
comprehend the “complex” smile
design procedures of esthetic dentistry. In the next section, I will
briefly explain the Smile Design
Wheel protocols with PHFH pyramids assessment and their basic
objectives.

Step No. 1: Understand the
pyramid of psychology
According to Prof. Robert A. Baron,
psychology is best defined as the
science of behaviour and cognitive
processes. Behaviour deals with any
action or reaction of a living organism that can be observed or measured.
Cognitive processes deal with
every aspect of our mental life: our
thoughts, memories, mental images,
reasoning, decision-making, and so
on, in short, with all aspects of the
human mind.
In smile design, we normally try
to understand the second part of
psychology, i.e., the human mind
or rather the minds of our patients.
There are three fundamental zones
we consider in detail for the psychological pyramid assessment: perception, personality and desire.

Managing Editor/Designer
Implant & Endo Tribune
Sierra Rendon
s.rendon@dental-tribune.com

Perception
Perception is the process through
which a person can select, organise and interpret input from their
sensory receptors. A person cannot imagine beauty and esthetics
without some input in advance. The
media is the most common source
of information at present regarding
beauty and esthetics.
A patient usually conceives his or
her own perception of smile esthetics based on his or her own personal
beliefs, cultural influences, esthetic
trends within society and information from the media.
Dentists need to communicate
with their patients to determine
such information during the initial
consultation, which helps in understanding the patient’s perception of
the treatment result.
The use of questionnaires, visual
aids, such as previous clinical cases
or smiles of various celebrities, can
aid immensely in this process.

Personality
According to the human psychology, personality is an individual’s
unique and relatively stable pattern
of behaviour, thoughts and emotions. It is to be noted that each
patient’s problem or concern should
be comprehensively evaluated with
respect to his or her personality
type. According to Roger P. Levin,9
there are four personality types.
Driven: This type of person
focuses on results, makes decisions
quickly and dislikes small talk. They
are highly organised, like details in
condensed form, are businesslike
and assertive.
Expressive: This type of person
wants to feel good, is highly emotional, makes decisions quickly, dislikes details or paperwork, and likes
to have a good time.
Amiable: People with this personality type are attracted by people
with similar interests, fear consequences, are slow in decision-making, react poorly to pressure, are
emotional and slow to change.
Analytical: This type of person
requires endless details and inforg CT page 4C

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Published by Dental Tribune America
© 2010 Dental Tribune America, LLC
All rights reserved.
Cosmetic Tribune strives to maintain
utmost accuracy in its news and clinical reports. If you find a factual error or
content that requires clarification, please
contact Group Editor Robin Goodman at
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Cosmetic Tribune cannot assume responsibility for the validity of product claims
or for typographical errors. The publisher also does not assume responsibility
for product names or statements made
by advertisers. Opinions expressed by
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Let us know by e-mailing feedback@
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hearing from you!

[14] =>

4C Clinical

Cosmetic Tribune | May 2010
Macro-esthetics

Fig. 4

Macro-esthetics deals with the
overall structure of the face and
its relation to the smile (Fig. 6).
To appreciate the macro-esthetic
components of any smile, the visual
macro-esthetics distance should be
more than 5 feet.
However, in clinical practice the
assessment of the macro-esthetic
components is done using various
facial photographs with geometric
and mathematical appraisals, using
reference points and their interrelation.
Various facial reference points
and guidelines are used for esthetic assessment for orthognathic and
facial cosmetic surgery; however, in
smile design the following macroesthetic guidelines are considered
fundamental: facial midline; facial
thirds; interpupillary line; naso-labial angle; and Rickett’s E-plane.

Fig. 5

Mini-esthetics

Fig. 7
restorative procedure on a patient.

Step No. 3: Restore the pyramid of
function

Fig. 6
f CT page 3C

mation, has an inquiring mind, is
highly exacting and emotional. This
type is the most difficult to convince
and takes the longest to reach a
decision.

Desire
Desire is a subjective component.
Increased public awareness of smile
esthetics through the media has
lead to a rapid increase in patients’
desires and levels of expectation.
Patients are now willing to pay for
the enhancement of their smile
esthetics.
Therefore, the ethical responsibilities of cosmetic dentists in identifying the need- or want-based desires
of patients have also increased. The
desires and levels of expectation in
many patients are higher than what
is clinically achievable, and it is the
clinician’s duty to explain and guide
patients towards a realistic esthetic
goal.
The psychological assessment
of any person is very subjective;
however, aspects like perception,
personality, expectation or desire
are important for the smile design
procedure.
Patient satisfaction is closely
related to these aspects. Hence,

understanding the pyramid of psychology is an integral aspect in smile
design.

Step No. 2: Establish the pyramid
of health
The pyramid of health is divided
into three zones: general health,
specific health and dento-gingival
health. The health pyramid assessment and its management play a
vital role in most cases, as patients
may have certain limitations owing
to their health, such as uncontrolled
diabetes, soft-tissue pathology, poor
bone structure, poor oral hygiene,
tooth decay, periodontal disease etc.,
which should be addressed prior to
functional and esthetic treatment.
The health pyramid assessment
process includes patient history
(medical, dental, nutritional), examinations (extra-oral, intra-oral) and
investigations (radiographs, pulp
vitality test, study models analysis).
Various types of questionnaires
and clinical examination and investigation protocols can be used to
obtain the necessary information
relating to the patient’s health.
The clinician can use this information to prepare a personalised
treatment protocol. All three components of the pyramid of health
should be established within normal
limits before starting any esthetic

Function is related to force and
movement. Hence, for the pyramid
of function assessment, the existing occlusion, comfort and phonetics are properly examined with the
evaluation of para-functional habits,
level of comfort during chewing and
deglutition, and temporomandibular
joint movement.
The clarity of normal speech and
pronunciation are also examined.
The occlusion, comfort and phonetics components of the functional
pyramid should be restored and
maintained at an acceptable level
before starting the treatment of any
esthetic component.

Step No. 4: Enhance the pyramid
of esthetics
The pyramid of esthetics is the last
but most sensitive pyramid of the
Smile Design Wheel, as esthetics
has both subjective and objective
aspects. The assessment of the subjective aspects — perception, personality, desire — is carried out
during the pyramid of psychology
assessment.
It is to be noted that the assessment
of the objective aspects depends on
the distance (focal length) used to
visualise the esthetic component.
Hence, the esthetics pyramid can
broadly be divided into three major
zones: macro, mini and micro.

Mini-esthetics deals with the esthetic correlation of the lips, teeth and
gums at rest and in smile position
(Fig. 7). The esthetic correlation
can be appreciated properly when
viewed at a closer distance than the
visual macro-esthetics distance.
The visual mini-esthetics distance is similar to the across-thetable distance, which is normally
within 2 to 5 feet. There are various
guidelines in esthetics based on the
relationship and ratio between lips,
teeth and gingival tissue. These can
be analysed during mini-esthetic
assessment using frontal, vertical
and transverse characteristics of the
smile. Clinical photographs are the
basic tools for mini-esthetic analysis. The smile can be analysed at rest
(M-position) or smile (E-position).
In the M-position, the following
references are measured and analysed: commissure height; philtrum
height; and visibility of the maxillary
incisors.
In E-position the following references should be analysed: smile arc
(line); dental midline; smile symmetry; buccal corridor; display zone
and teeth visibility; smile index; and
lip line.

Micro-esthetics
Micro-esthetics deals with the fine
structure of dental and gingival
esthetics (Fig. 8). Mini-esthetics can
be appreciated at a visual microesthetic distance of less than 2 feet
or within normal make-up distance.
For the clinical assessment of
micro-esthetic components of the
teeth and gingival tissue, appropriate illumination and magnification tools are required for intraoral examination. Necessary clinical
intra-oral photographs should be
taken for documentation and future
reference.
For micro-esthetics, the detail of
the individual tooth structure and
its relation to the surrounding gingiva and the adjacent teeth should
be analysed. The following are the
major points to be considered: upper
centrals (tooth size ratio); principle

[15] =>

Clinical

Cosmetic Tribune | May 2010

5C

About the author
Dr. Sushil Koirala is the founding president of the Vedic Institute of
Smile Aesthetics (VISA) and maintains
a private practice focusing primarily
on MI cosmetic dentistry (MICD).
He can be contacted at skoirala@
wlink.com.np.

Fig. 8

AD

of golden ratio; axial inclination;
incisal embrasures; contact point
progression; connector progression; shade progression; and surface
micro-texture.
In smile design, the esthetic conditions related to gingival health and
appearance are an essential component. The gingival shape, position,
embrasure and contour in relation
to the teeth are interdependent. The
following are major aspects that
should be addressed during smile
design to achieve gingival or pink
esthetics: gingival shape; gingival
contour; gingival embrasure; gingival zenith; and gingival height (position or level).
To achieve higher patient satisfaction and long-lasting treatment
results, the following should be the
sequence in any smile design procedure: proper comprehension of
psychological aspects, the establishment of health and the restoration
of function within its normal limit,
and the subsequent enhancement of
esthetic components.

Conclusion
Today, various protocols of smile
design are available in cosmetic
dentistry. However, most clinicians
wish to use the simplest protocol
with the most predictable results.
It is to be noted that smile design
should always be a multifactorial
decision-making process that allows
the clinician to treat patients with an
individualised and interdisciplinary
approach.
The Smile Design Wheel presented in this article clearly indicates the
most important components (PHFA
pyramids) of smile design, their
clinical significance and sequence
to be maintained during the smile
design procedure.
I believe that the Smile Design
Wheel is a simple and practical protocol in smile design that can help
the clinician to easily comprehend
the ‘complex’ smile design procedures of esthetic dentistry. CT
Editorial note: A complete list of
references is available from the publisher.

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