COSMETIC TRIBUNE

The Worlds Cosmetic Newspaper Asia Pacific Edition

PUBLISHED IN HONG KONG

www.dental-tribune.asia

NO. 5 VOL. 13

MiCD: Do no harm
cosmetic dentistryPart 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.
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.

Cosmetic dentistry,
a global trend
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 patients 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

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 todays
business-oriented dental education. I believe that knowledge

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.

4a

4b

5a

5b

5c

6a

6b

7a

7b

8a

8b

9a

9b

10a

10b

! CT page 18

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18 Trends & Applications

11a

11b

13b

14e

CT page 17

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 patients 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

11c

12b

12a

14a

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

knowledge and skills in dental medicine that are based on contemporary dental science and art. Dental
school education does not give due
consideration to healthy dental
practice philosophy owing to various factors, such as the right to chose
ones 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.

Treatment options

Treatment procedures

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

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

Biological cost
None

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 (PHFAsequences 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.

14d

15b

15a

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 patients SRA factors as in
nature-mimetic dentistry, and
cosmetic treatment may not necessarily be beneficial to the health
and function of the oral tissue.

13a

14c

14b

14f

Asia Pacific Edition No. 5/2015

15c

I believe that a clinic or treatment centre must establish its

practice philosophy according to its
objectives. What a clinician wants
and the kind of services he or she
wants to deliver to his or her patients
guides the clinic. Practically, the
practice philosophy in dentistry can
be classified into two different categories, depending on the mindset of
the operator.
Patient-centred
Clinicians with this kind of
mindset generally have a do no
harm dental practice (Fig. 1). Professional honesty and humanity are
the fundamental principles of such a
practice. Operators with this mindset enjoy sharing their clinical
knowledge and skills 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 patients 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.59
A study has found that 83 per cent
of dentists perceived dentistry as

very stressful10 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 peoples personal relationships
and well-being.1213 Hence, dentists
need to take care of their staffs
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-

COSMETIC TRIBUNE
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 patients 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 patients 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.

Trends & Applications 19

Asia Pacific Edition No. 5/2015

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.1524
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
dentistryConcept 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).

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
Ricketts 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

Excellent

Good

Satisfactory

Needs improvement

10. Clinical success

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 patients 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. 49):
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 patients 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
procedureswhich 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 & 11ac).
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. 1214).
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. 15ac).
MiCD summary ten
After completion of any MiCD
clinical case, the patients 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 persons 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.

COSMETIC TRIBUNE

20 Trends & Applications

Asia Pacific Edition No. 5/2015

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 patients 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 areaknown
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 patients
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 casesbut 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

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11

12

13

14

15

16

17

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 45mm.Figs. 810: 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 12mm shorter than the
central incisors, and canines 0.51mm shorter than the central incisors for an aesthetic smile display.Fig. 12: The canines and other teeth distally located are visually perceived as occupying less space in
an aesthetically pleasing smile.Fig. 13: A general rule for achieving proportionate smile design is that lateral incisors should measure two-thirds of the central incisors and canines four-fifths of the lateral
incisors.Fig. 14: If feasible, the contact areas can be restoratively moved up to the root of the adjacent tooth.Fig. 15: Photoshop provides an effective and inexpensive way to design a digital smile with
proper patient input. To start creating custom tooth grids, open an image of an attractive smile in Photoshop and create a separate transparent layer.Fig. 16: The polygonal lasso tool is an effective way to
select the teeth.Fig. 17: Click edit > stroke, then use a two-pixel stroke line (with colour set to black) to trace your selection. Make sure the transparent layer is the active working layer.

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COSMETIC TRIBUNE

22 Trends & Applications

Asia Pacific Edition No. 5/2015

18

19

20

21

22

23

24

25

26

27

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 4.2.2which
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
lipis 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.
Several rules can be applied
when considering modifying the
midline to create an aesthetic
smile design:

The midline only should be

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

Evaluating dental aesthetics

Part of evaluating dental aesthetics for smile design is choosing tooth shapes for patients
based on their facial characteristics (e.g., long and dolichocephalic, or squarish and
brachycephalic). When patients
present with a longer face, a
more rectangular tooth within
the aesthetic range is appropriate. For someone with a
square face, a tooth with an 80 %
width-to-length ratio would be
more appropriate. The width-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. 810).1
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

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).

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-

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.

28

29

30

31

32

33

34

35

36

37

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.

COSMETIC TRIBUNE
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 patients 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.

Trends & Applications 23

Asia Pacific Edition No. 5/2015

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

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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