Elaine Halley, BDS

SM ILE A N A LY SIS

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This book is dedicated to the memory of my father, James
Raymond Maclean Philip.
Why I Wrote This Book and What Is It About
Dear Reader,
As a child, I had a bad experience at my dentist’s office, which up to that
point I had trusted. My orthodontist had given me a prescription to have two
second molars removed on my right side. My upper central incisors were
overlapping and I had a tendency to an anterior open bite. Removing two
second molars is an unusual treatment plan perhaps, but I was fourteen and
eager to get through the fixed brace stage and have my front teeth
straightened.
My dentist easily removed my upper tooth on my first visit. I was so
confident for the second removal that I went to the appointment by myself.
The dentist’s office was across the street from my high school. My parents
ran a busy shop so it suited them not to have to leave it to come with me,
especially since the first appointment had been so straightforward.
The ID block did not work, and although my tongue and lip were numb, my
tooth most certainly was not. The dentist did not believe me and continued to
try and extract my tooth with a dismissive, “You must be numb by now.” I
became hysterical and they had to call my mother. I was asked to wait in the
reception area until I calmed down—all the time being made to feel that I
was making it up and being a drama queen. I am not a drama queen. I am
quiet by nature and do not like to make a scene.
I will never forget the injustice of being told that I couldn’t possibly feel
something that I certainly did feel. Now that I am older and wiser, I can
reflect. The dentist was obviously working on a schedule. She was frustrated
that the anesthetic hadn’t had the desired effect. She was obviously upset that
I didn’t sit still and allow her to take out my tooth. She didn’t have empathy
for me.
When I became a dentist, I vowed that I would always believe a patient if
they told me that they could feel pain!
Years later, when I was considering owning my own practice, I already had a
deeply held value to treat patients with kindness and consideration. I wanted
to try and make dentistry as comfortable as possible and to always believe a
patient if they told me that they could still feel pain, whether I thought they
should be able to or not.
I spent many years after that youthful experience being fearful of dentistry, but
dental school helped me tremendously. I found that once I understood the
reason why, the fear disappeared.
This book is about connecting the dots—specifically the dots of empathy and
customer care, guided observation, diagnoses, and smile design, all of which
lead to effective treatment planning, and planning for predictable clinical
outcomes. My hope is that this book will encourage you as a dentist and give
you some of the tools to be able to pay attention at an early stage in the
patient journey, and to listen, think creatively and solve problems.
I am writing this book because I believe that there is a shifting tide in the way
we can practice dentistry, which is not to say that I am an expert on the
“only” way, or that it is my way or the highway. I have been working in a
dental practice for nearly 30 years and as a practice owner for over 25 years.
Naturally, I have had successes and I have had failures, both on the business
side and the patient care side. I have learned a thing or two and I would like
to share those lessons with you.
One of the biggest causes of stress in dentistry is the failure of treatment,
particularly if the failure is early and deemed to be our fault, or is something
we did or did not do. The old adage has been “My tooth was fine until you
touched it.” As dentistry becomes more and more litigious, I see many young
dentists fearful to attempt treatment, and often overthink and worry, with the
end result that patients sense the hesitation and decline treatment. This then
reinforces the dentist’s belief that patients don’t want complex complex
dentistry and that next time it would just be safer to do what the patient asks
and fix that one thing. What can be even more dangerous is the opposite
strategy, where dentists fail to see the complexity and possible pitfalls and
present a complex treatment plan as if it were easy, only to fail and face the
unhappy consequences of a patient who has been over-promised and the
dentistry has under-delivered.
Over the course of my career, I have realized that we are often led by the
patient and jump into single-tooth dentistry. This works most of the time in
many patients, but only up to a certain point. The problem is, we miss things.
“Ah, but the patient only wanted this one thing fixed.” Or “the patient came to
see me for tooth straightening, so we didn’t talk about the loss of enamel due
to acid erosion.” We did not risk assess, or risk manage the patient or their
oral condition, and we did not share that information with them.
Thanks to the Internet, patients have access to more information than ever
before and they may very well come to our practice or office asking for a
particular treatment. However, it is worth remembering that despite the
wisdom of Google, they do not have a dental degree. We do.
TAKE A BREATH
Many times, general dentists have to work against the clock and are under
huge pressure to come up with answers and solutions without the time or
space to think holistically. This is an oversimplification of the complexity of
the mouth and oral environment and denies patients the opportunity to
understand the consequences of decisions that are made without due
consideration. In anything but emergency and perhaps specialist referral
situations, there should be space to think. Thinking can be most effective with
a system to follow, including guided observation, guided thinking and guided
analysis.

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As general dentists, we are very often time poor. Thinking and planning takes
time. How and when can we fit this into our otherwise crazy schedules and
the pressure of home/life balance?
This book is about carving out the space and time to analyze, and a system to
do so efficiently. Together we will learn how to take a breath, pause and
analyze a smile (and the mouth, face, and person it belongs to) so that we can
be more deliberate and effective in our treatment planning and in presenting
the options to our patients.
The four main reasons why patients do not proceed with dentistry are:

1. FEAR OF PAIN

2. FEAR OF COST

3. LACK OF TIME

4. NO PERCEIVED NEED

The order of priority of the reasons can differ and it is important to note that
we are not talking about actual pain and cost, but simply the fear related to
these. No perceived need is all about education. We have not explained,
educated or motivated our patients enough, or their value system does not
prioritize health and/or appearance at this time in their life.
Communication skills are highly important. To be effective with our patients,
we need to learn how to connect the dots of customer care, guided
observation leading to diagnosis, and treatment planning with smile design
and functional design, and then how to use those excellent communication
skills to tell the story of the patient’s own mouth to the patient and be able to
codiagnose our way to increased case acceptance. Most important of all, we
need to bring the patient with us on the journey of education and
understanding.
This book is about giving us, as dental professionals, a fighting chance at
predictability. This reduces stress and informs our patients. This puts the
decision-making in the hands of our educated patients—who have choices to
make. We can guide them. We can give our opinion. We can be their partners
in oral healthcare.
In this book, I will give you suggestions on how to look at your patients. I
have suggestions about how to train your eyes and mind to see, and how to
record the data. I have suggestions about how to structure your work and
utilize a team approach. I have examples of how I have used these strategies
with different types of clinical situations. In addition, I have lessons to share
in understanding human behavior. We are in an age of knowledge sharing,
collective intelligence and even artificial intelligence. We can be so much
more than tooth fixers if we set our minds to it.
There is work to be done! At Cherrybank Dental Spa, my team and I are
always learning, listening to each other and to others, and growing and
refining. I believe that if you join me in this journey, we may never be done,
but we will be better than we were last year—that is the beauty and the
excitement of our profession.
Start with a smile. Listen. Put on your detective hat and figure it out.
Break it down into the component parts and figure out what the journey to
here has been. Then, figure out how to tell the story of that journey to the
patient so that they can understand. Have suggestions for how the story
can play out from here. Weave the tapestry of possibilities that clinical
dentistry can offer. Be honest. Be positive. Be kind.
The benefit? You have invested so much time and money in educating your
mind and your hands. You will be able to do more of the clinical dentistry
that you have been taught to do. You will be able to refer when you need to.
If you set your mind to combining your excellent clinical knowledge with
implementing the strategies described in this book, I promise you that you
will be more efficient and predictable in the dentistry that you can offer your
patients. This is a more profitable and less stressful way of being a dental
surgeon and helping your patients to smile.
I hope that this book gives you the confidence to smile more, worry less and
bring the gift of a beautiful smile to your patients.
With best wishes,
Elaine Halley
Perth, Scotland
TA BLE O F C O N TEN TS
WHY I WROTE THIS BOOK AND WHAT IS IT ABOUT

CHAPTER 1 Why Do We Smile?

CHAPTER 2 Who Is the Person Behind the Smile?

FIRST… LISTEN
WHO IS THE PERSON BEHIND THE SMILE?

CHAPTER 3 The Dental Experience

VULNERABILITY AND TRUST
PATIENT PERCEPTION IS REALITY
TIMELINES FOR THE PATIENT JOURNEY
CHANGE AND THE STAGE OF LEARNING
VALUES AND LEADERSHIP
HABITS
PERSONALITY STYLES
LEARNING STYLES

CHAPTER 4 Decision Point: Single Tooth or Comprehensive Approach

DENTIST: DR. SMITH
DENTIST: DR. JONES
EMOTIONAL INTELLIGENCE
SINGLE-TOOTH PROBLEMS
WHEN TO IMPLEMENT A DIFFERENT STRATEGY
APPOINTMENT STRATEGIES FOR TRANSITION TO GUIDED
TREATMENT PLANNING
DIGITAL CAPTURE
SCREENING VERSUS DIAGNOSIS
RED FLAGS

CHAPTER 5 Capture the Data

PRECLINICAL
PHOTOGRAPHY AND VIDEO
Technical versus emotional photography
Full-face smile photograph
Full-face retracted photograph
Profile at rest
Full-smile profile
Full face at rest (M-Position)
Tooth display at rest
FURTHER IMAGES
INTRA-ORAL IMAGES
The value of a video capture protocol
FREEDOM—THE IMPORTANCE OF VIDEO
DIGITAL INTRA-ORAL SCAN
CLINICAL EXAMINATION
RADIOGRAPHS/CBCT
EMERGING TECHNOLOGIES
COMMUNICATION SKILLS TO ENHANCE CASE ACCEPTANCE
HOW TO ORGANIZE THE CAPTURED DATA

CHAPTER 6 Guided Observation

TIME MANAGEMENT
SCREENSHOT OF MULTIPLE SCREENS OPEN IN GOOGLE CHROME
Keynote storyboard open for the patient
STEPS FOR ANALYSIS THROUGH GUIDED OBSERVATION

CHAPTER 7 Macro Observations

STEP 1: GLOBAL DIAGNOSIS
STEP 2: GENERAL RISK FACTORS
STEP 3: MACROESTHETIC CONSIDERATIONS

CHAPTER 8 Mid Observations

STEP 4: GLOBAL FUNCTION
STEP 5: ORTHODONTIC OVERVIEW
STEP 6: MISSING TEETH

CHAPTER 9 Micro Observations

STEP 7: TOOTH-BY-TOOTH ANALYSIS
Example of annotated screenshot from MyiTero inserted into storyboard
Predicting the prognosis
STEP 8: MICROESTHETIC EVALUATION
Other microesthetic observations
STEP 9: SUMMARY RISK ASSESSMENT
Example case with storyboard and Diagnosis and Observations from filled
out
Diagnosis and Observations

CHAPTER 10 Smile Design

SEEING BALANCE AND HARMONY
SYSTEMATIC SMILE DESIGN
NON-RESTORATIVE SMILE DESIGN

CHAPTER 11 Dental Imaging — the Power of a Visual Image

SO HOW DOES DENTAL IMAGING HELP US?
ARTIFICIAL INTELLIGENCE OPTIONS

CHAPTER 12 Trial Smile

CHAPTER 13 Outcome Simulation

CHAPTER 14 Risk Assessment

1. PATIENT’S ESTHETIC EXPECTATIONS AS A RISK
2. MEDICAL CONDITIONS AS A RISK
Listen to your intuition
3. PERIODONTAL STATUS AS A RISK
4. SMILE LINE AS A RISK
High Smile line—No Hiding Place
5. LIP MOBILITY AS A RISK
6. GINGIVAL LEVELS AND BIOTYPE AS A RISK
7. AND 8. SKELETAL PATTERN AND BUCCAL CORRIDORS AS A
RISK
Anteroposterior dimension
9. OCCLUSAL PLANES AS A RISK
Curves of Spee, Wilson, and Monson
10. TMJ/MUSCLES AS A RISK
11. OCCLUSION AS A RISK
12. GUIDANCE IN LATERAL EXCURSIONS AS A RISK
13. BITE FORCE AS A RISK
14. CHEWING PATTERN AS A RISK
15. TOOTH ALIGNMENT AS A RISK
Bolton analysis
16. MISSING TEETH AS A RISK
17. BIOMECHANICAL RISKS
18. CARIES RISK
19. TOOTH SURFACE LOSS AS A RISK
20. TOOTH COLOR RISK ASSESSMENT

CHAPTER 15 The Pause Before the Patient Presentation

STEP 1: THE CHALLENGE SUMMARY
Considering integrated treatment planning
STEP 2: ASK FOR OPINIONS
STEP 3: TREATMENT PLAN OPTIONS
STEP 4: PATIENT PRESENTATION TOOLS

CHAPTER 16 Case Presentation

CODIAGNOSIS
WHO OWNS THE PROBLEM?
STEPS FOR CASE PRESENTATION
STEP 1: THIS IS WHAT I SEE
STEP 2: THIS IS WHERE WE COULD GO
STEP 3: HERE ARE THE WAYS WE COULD GET THERE
STEP 4: HERE ARE MY CONCERNS/OUR LIMITING FACTORS
STEP 5: HERE ARE THE RISKS, INCLUDING DOING NOTHING
BUILDING TRUST
STEP 6: HERE ARE THE NEXT STEPS, THE FIRST THINGS
STEP 7: HERE ARE THE COSTS INVOLVED
Discussing finance
COACHING OUR PATIENTS THROUGH THE DECISION-MAKING
PROCESS

CHAPTER 17 Case Studies

CASE STUDY 1: PATIENT A
Preclinical information
CLINICAL EXAMINATION
STORYBOARD CREATION
EDITING A VIDEO IN KEYNOTE
GUIDED OBSERVATION
FILLING OUT THE DIAGNOSIS AND OBSERVATIONS FORM
SMILE DESIGN
RISK ASSESSMENT FORM
PRE-TREATMENT AND POST-TREATMENT PHOTOGRAPHS
REFLECTION
CASE STUDY 2: PATIENT B
Preclinical information
CLINICAL EXAMINATION
DIGITAL TOUR OF THE MOUTH
Guided Observation
SMILE DESIGN
Risk Assessment
REFLECTION
CASE STUDY 3: PATIENT C
Preclinical information
CLINICAL EXAMINATION
Guided Observation
SMILE DESIGN
Risk Assessment
CASE PRESENTATION
ETHICS
REFLECTION

APPENDIX Diagnosis and Observations

References
To the Reader
Acknowledgments
 www.dentalbooks.org
The Author
C HA PTER 1
W HY D O W E SM ILE?
“The mind that opens to a new idea, never returns to its
original size”.
ALBERT EINSTEIN
Dentistry has an amazing array of clinical tools and techniques at our
disposal. We can solve so many problems with our skills. However, as much
as we love all of that, we should remember this: people don’t want dentistry.
They have better things to do in life than sit in our chairs and spend money
with us. When asked what they do want, most people want to be healthy and
to be able to chew without pain. They also, even if they can’t articulate it,
want to be able to smile. Many people have a genuine fear of losing their
teeth and having to wear dentures. Others have anxiety over the tiniest detail
in their smile. In short, people are different, but the power of a smile is
universal.
When I finished my Master’s in Science (MSc) in Restorative and Esthetic
Dentistry, I was filled with facts, figures and clinical techniques about how
to “do” dentistry, but I found myself asking questions about what lies behind
esthetics. I have always believed that there is beauty in nature, and in
authenticity, and I have a natural wariness of dictating that beauty is
something that can be defined by mathematics or “sameness.” I began to
wonder why. Why should central incisors be exact replicas of each other?
Why is it pleasing to our eyes when symmetry exists? I understood that as
humans, we make judgments about each other based on appearance, and the
smile is part of that, but I wanted to know more.
My research took me into the worlds of psychology, art and esthetics, and
even social anthropology. The ideas that I found there fascinate me to this day
and are being reinforced by neurobiologists and studies of social behavior as
we learn more and more about what it means to be human. This may feel like
a long journey away from clinical dentistry, but I believe it is at the very core
of becoming a better communicator and a better smile designer.
I discovered the work of Karl Grammer, a professor of Evolutionary
Anthropology in Vienna, Austria. He published an article in 1994 in the
Journal of Comparative Psychology titled “Human (Homo sapiens) Facial
Attractiveness and Sexual Selection: The Role of Symmetry and
Averageness” (Grammer and Thornhill 1994) where he showed that facial
symmetry has an influence on facial attractiveness. He has extensively
studied and published on the biological basis for attractiveness.
Another study by Fink and Neave in the International Journal of Cosmetic
Science in 2005 builds on Karl Grammer’s work. In their article “The
Biology of Facial Beauty” (Fink and Neave 2005), a face of a woman from a
white ethnic background is gradually morphed into being of African descent
and then of Japanese descent and back to where it started. In Karl Grammer’s
original work, they showed faces of different ethnicities to people from
remote places across the globe and found that while there were cultural
differences in beauty standards, there were also similarities based on
biological rules, a universal guideline for attractiveness across all cultures.

Fink and Neave concluded: “It was once widely believed that standards of
beauty were arbitrarily variable. Recent research suggests, however, that
people’s views of facial attractiveness are remarkably consistent,
regardless of race, nationality or age. Facial characteristics are known
to influence human attractiveness judgments, and evolutionary
psychologists suggest that these characteristics all pertain to health,
leading to the conclusion that humans have evolved to view certain bodily
features as attractive because the features were displayed by healthy
others.”

In evolutionary terms, attractiveness and symmetry are linked to health.

Therefore, if we are looking for a mate, a tendency toward symmetry and
“averageness” is a biological signal of health and therefore a good prospect
as a mate. This makes sense when we think about a healthy smile and a
diseased smile. A healthy smile tends to be more beautiful than an unhealthy
one, even if it is not perfect in terms of mathematics. Often, if we return our
patients to health, then improved appearance is an added bonus even if it was
not the primary intention.
When considering faces, in evolutionary terms, symmetry is a good
indication of health. Asymmetry may indicate parasitic infection or disease
and not be a good choice as a mate. There are, it seems, biological reasons
behind our choices, which affect our sense of beauty or attractiveness.
Of course, it isn’t quite as simple as that. There is the definition of healthy to
be considered and indeed the perception of health may not be the same as
actual health. Whiter teeth, for example, must be a projection of youth and
health. I looked further into this and discovered some answers in an unusual
place—the writings of Harry Beckwitt, an author on service culture and
marketing. In his book Unthinking—The Surprising Forces Behind What We
Buy, he says “our love of beauty is deep in our bones” and “we see spotless
and think healthy and what appears healthy appears beautiful to us.”
Biology is part of the puzzle. We have a sense of what a healthy individual
looks like and a tendency to assign other healthy characteristics to
accompany that.
The art world came next in my investigations, and I know I have only
scratched the surface of what can be discovered by reading the depth of study
and theories about esthetics that have been undertaken since the ancient
Greeks and beyond. My son, Hamish, is currently studying fine art. Art did
not feature in my own learning and upbringing, and his interest and passion
for the subject has pulled me into a world which, of course, has many
corollaries with smile design and esthetic dentistry. We may have imagined
that smiles were not often featured in art of times past because of the poor
state of dental health. In fact, as dental health was so commonly poor, it was
not a consideration for attractiveness.
From The Serious and the Smirk—the Smile in Portraiture by Nicholas
Jeeves: “Nonetheless, both painters and sitters did have a number of
good reasons for being disinclined to encourage the smile. The primary
reason is as obvious as it is overlooked: it is hard to hold and maintain a
smile. In the few examples we have of broad smiles in formal
portraiture, the effect is often not particularly pleasing, and this is
something we can easily experience today. When a camera is produced
and we are asked to smile, we perform gamely. But should the process
take too long, it takes only a fraction of a moment for our smiles to turn
into uncomfortable grimaces. What was voluntary a moment ago
immediately becomes intolerable. A smile is like a blush—it is a
response, not an expression per se, and so it can neither be easily
maintained nor easily recorded.”
Indeed, smiles in early portraits were considered to be associated with
drunkenness and unseemliness, particularly among the ranks of the upper
classes. It was not until photography became mainstream that the fleeting
capture of expression could include the unself-conscious and authentic
expression of a full smile.
Even in the earliest days of photography, a photograph was considered to be
an important documentation of a moment in time. Mark Twain, a
contemporary of Abraham Lincoln’s, was firm on the matter in a letter to the
Sacramento Daily Union: “A photograph is a most important document, and
there is nothing more damning to go down to posterity than a silly, foolish
smile caught and fixed forever.”

Nicholas Jeeves also states: “Nowadays each of us is recorded across

hundreds, or thousands of images, and many of us are smiling broadly.
Collected, they represent us accurately in all our moods and modes, so
we no longer have to worry about being defined by one picture. Indeed,
unlike Abraham Lincoln, modern US presidents try to ensure that a
number of images are available that will capture the gamut of their
emotional range, from troubled solemnity to enthusiastic joy. The same
goes for the royal families, recorded in either carefree, knockabout
moments, or in stately focus. In the 21st century these figures must be all
things to all people, and all occasions.”

A walk through the National Portrait Museum in London is the perfect

illustration of this transition. In the Portrait of Diana, Princess of Wales 1981
by Lord Snowdon, the princess breaks with the royal family tradition and is
captured in photography with a beautiful smile.
It seems that since a smile is a dynamic expression, a reaction, we feel
uncomfortable when we capture a stage of it in a painting. We find it difficult
to read the early stages of a smile without seeing the continuity or context.
Many such slight smiles captured are seen as smirks and we wonder as to the
nature of their origin. The Mona Lisa, for example, is perhaps the most
studied and commented-on expression of all time.
Moving past the complex reasons for the lack of smile design in the history of
art world, I was still on the quest to answer the question: “Why do central
incisors look better if they are symmetrical?” Why is this the first rule we
learn in smile design composition? We all know that complete symmetry
looks unnatural and if we are serious about creating natural, beautiful smiles,
then harmony is the key, not complete symmetry.
From the art world, I found a paper on Schotter/gravel stones (Georg Nees
2005). Schotter or gravel stones is a computer-generated illustration
resembling blocks of stone. At the top of the image the blocks are regular and
as we move down the page they start to tumble and fall. Take a few moments
to look at the first image on the facing page.
In the study, they tracked the eye movements of individuals looking at the
image; the results revealed that the eyes of the individuals tended to linger
about one-third of the way down the image where there is a sense of
movement and fluidity but before the sense of pattern and order is lost
completely.
The researchers deduced that for our visual perception, complete symmetry
and order is boring, rigid and uninteresting. And equally, complete chaos is
unsettling. We have a tendency to look for patterns and meaning and to prefer
a semblance of order but with something interesting to view, some level of
dynamic expression.
My conclusions from this research are that symmetry indicates health, and as
we have a biological bias toward seeking out health, symmetry becomes an
influencing factor in our judgment of what is esthetically pleasing. However,
complete symmetry is boring. As humans, we also look for connection, and
we have an esthetic tendency to look for interest and patterns. Too much
deviation from symmetry creates visual tension, which is an idea I will link
to smile design later in the book. Too much chaos in a smile, then, is
unattractive and signals disease to our biological brains, which then
computes to a list of other negative assumptions and judgments.
Symmetry, therefore, becomes the keystone on which asymmetry can be built
and manipulated. I have heard it described this way in terms of smile design
—central incisors should be identical twins, canines should be siblings, and
lateral incisors can be cousins. In other words, for beautiful smiles, the
symmetry of the curve of the smile, the depth of buccal corridors and the
frame of the lips gives us our foundation. The lateral incisors can be the
dancers on the stage, which brings it to life.
The last piece of this puzzle, for me, is to take a step further
back and think, Why does it matter if I smile or don’t smile? If
we move past the evolutionary, biological need to find a mate and reproduce,
why does a smile remain an important part of how others perceive us in
social interaction?
This comes back once again to our evolution as social beings. We are hard
wired to belong to our social groups. Human beings, in evolutionary terms,
did not survive alone. We need community for safety, food, shelter, all of the
basic levels of Maslow’s hierarchy of needs (Maslow 1948). Those needs
(food, water, warmth and safety, followed by love and belonging) require us
to live in communities and to be part of a group. We are social beings.
The health aspect will apply here. If we are not perceived as healthy, we can
imagine that we would not be welcomed as part of the group. Think of the
most confident person you know, not confident in an arrogant, dominating
ego-filled manner, but in a warm, yet self-assured way. Let’s add in
charisma. People are sometimes described as having a magnetic personality.
If you think about someone you know who could be described as such, or
someone in the public eye who demonstrates those qualities, what about their
body language springs to mind?
I’m thinking about George Clooney as an example, with his confidence,
upright posture, excellent eye contact, open arm position and stance, and that
smile. Confident and charismatic people tend to smile. The smile may not be
perfect but looks healthy and goes with the overall persona. It does not
detract; it harmonizes. It puts us at ease, communicating authenticity.
You may have seen the images on social media where celebrities have had
their teeth digitally removed or damaged and the effect is Leonardo di Caprio
with no teeth or Halle Berry completely edentulous. However, while these
images make the point that teeth are required for the individual to look
attractive, this is not the complete story. In real life, when an
individual perceives that his or her smile is not going to be
seen in a positive light, there is a defense mechanism that
kicks in as a form of self-protection. An individual will teach
themselves not to smile fully and may even stop smiling with lips apart or
even self-consciously bring their hand up to cover their smile.
Thinking back to the muscles of facial expression that we learn about in
dental school, a smile is primarily actioned by the seventh cranial nerve or
the facial nerve innervating the zygomaticus major muscle. This muscle runs
from the zygomatic arch to the corners of the mouth and initiates a smile.
However, a French neurologist in the mid-nineteenth century identified two
types of smile—the addition of the orbicularis oculi around the eye is known
as the Duchenne Smile. This smile is perceived in dynamic smiling and is
also called a genuine expression of emotion. When the orbicularis oculi is
not involved, the smile can be perceived as disingenuous or even fake.
It follows that if an individual is feeling self-conscious about their smile,
they will train their zygomaticus major muscle not to fully engage and not to
lift the lips away from their teeth. By default, the orbicularis oris muscles
will not kick in, and consequently, the perception other human beings have is
that this is not a genuine smile. Other judgments may therefore be applied—,
such as this person is not happy, they don’t like me, or they are saying one
thing and their smile says something else.
As humans, we are neurobiologically wired to be storytellers. Just as we
look for pattern and order visually, our subconscious mind looks for patterns
and signals in body language. We have a tendency to jump to conclusions and
make up stories. The person may be guarding their smile because they are
feeling self-conscious and vulnerable for fear that we make judgments about
their health and social status, but as a result of not engaging the full, authentic
Duchenne smile, we instead make other judgments that are complete
assumptions and most likely false.
A study from the Universities of Sheffield and Guy’s, King’s and St.
Thomas’s in London (Newton, Prabhu et al. 2003) took images of people and
digitally altered only the smile. These images were shown to members of the
public who were asked to rate the individuals in terms of their happiness,
trustworthiness, likeability, tendency to criminal behavior, and so forth. As
we would expect, the images with the better teeth ranked higher in terms of
friendliness, and likelihood to earn more and have more friends, while the
images with bad teeth ranked higher on likely to be in debt, untrustworthy,
more likely to be sad, and so on. Although these results make sense when we
consider our predilection for health, it is quite stunning to think how far our
storytelling minds will go in making these snap judgments.
And these pictures were still Duchenne smiling—they were showing their
unpleasant teeth. If we have an unpleasant smile, it seems our intuition kicks
in and protects us from these judgments—we hide or change our smile—but
unfortunately the ungenuine smile then leads to another set of judgments,
assumptions and storytelling.
A smile is an expression of joy. As humans, joy is linked to a feeling of
safety, belonging and purpose.
This is why our profession is so important. Health first, of course, and
always, but beyond that we can influence the ability of our patients to smile
with freedom, without restraint, and thus be accepted and correctly perceived
by those around them for genuine freedom of expression.
I will discuss more about the dynamic versus static smile in later chapters,
but it is important to emphasize that a smile is a means of expression. It is not
a static position other than when captured in still photography. Expression is
a social tool, both verbal and nonverbal, that is essential for us as humans to
communicate, relate to each other and integrate into our communities.
Restriction of expression can lead to a lack of self-esteem as well as other
psychological issues.
Further Reading
David Brooks, The Social Animal, Short Books Ltd., 2012.
Harry Beckwith, Unthinking, Orion Business Books, 1999.
Robert Sapolsky, Behave—The Biology of Humans at Our Best and
Worst, Vintage, 2018.
C HA PTER 2
W HO IS THE PER SO N
BEHIN D THE SM ILE?
“When you talk, you are only repeating what you already
know.
But if you listen, you may learn something new. ”
DALAI LAMA

F IRS T… LIS TE N
Dentistry begins with listening, first to the words and then to what is behind
the words. Develop a genuine curiosity in you and your team as to who this
person (patient) is. Feel gratitude that they have sought you out for care, but
also have clear boundaries. When aiming for high levels of customer care,
there can be a misconception that we have to be all things to all people.
Ask questions, peel back the layers, find out what their key drivers and
motivators are. As Dale Carnegie, author of the book How to Win Friends
and Influence People, would say, “Be genuinely interested.”
WHO IS THE P E RS ON B E HIND THE
S MIL E ?
You might ask why do I need to know this? I am a dentist, not a life coach or
a psychiatrist. You would be quite correct. We have looked at the reasons
why a smile is important. Indeed, if we are involved in single-tooth,
emergency-based dentistry, then I would agree that the person behind the
smile is probably grateful that you are able to treat their pain and it does not
particularly affect your treatment whether you know very much about them. In
fact, as we shall see, when people are in pain, we must focus and stabilize
their mouths first. As humans, when we are in acute pain, we cannot make
any other meaningful conversations or decisions other than short-term,
survival ones. But, if you are aiming to provide comprehensive dentistry on
any level, then you need the people behind the smiles to find you, decide that
you are the dentist for them, to trust you, to pay you willingly, and of course
to refer all their friends!
There are certain key skills that we can practice and develop which will help
us to form these positive connections with our patients: building trust,
empathy and seeking first to understand. All three are intertwined. When a
new patient comes to see us, there have already been a series of decisions or
connections that have led them to trust us enough to make an appointment.
Building Trust There are other specific tools that we can use to build trust
quickly, and one of the most important of these is to develop listening skills.
There is a human desire that we all have to be seen, to be heard, and to know
that we matter as individuals. We should also be mindful that trust can be
eroded very quickly with someone who hasn’t experienced our care as yet.
Empathy is massively important in building trust. I remember when I first
started my practice, my amazing mother was my first (unpaid) receptionist.
She used to drive over an hour to my practice, sweep the doorstep, answer
the phone and make appointments. In between patients, she would come to
me clutching the side of her face as if she herself had toothache and tell me in
dramatic tones about the plight of every emergency patient we had. As I was
starting a new practice, we had a lot of those patients and were very glad to
be able to see and treat them. I had to explain to my mother that I couldn’t
take on the emotions of every patient who had a problem, and neither could
she. We would become worn out! She was being extremely sympathetic,
rather than empathetic. For me, this was adding negative energy into my
already busy day. This is not empathy.
The best explanation of the difference between empathy and sympathy that I
have seen comes from Brené Brown in her YouTube video:
https://youtu.be/1Evwgu369Jw. Brené Brown is a professor from the
University of Houston who has studied shame and vulnerability. She has
written numerous books, including the excellent Dare to Lead and Braving
the Wilderness, and she has an excellent TED talk and Netflix show.
Empathy is a step beyond sympathy, and more complex in nature. It is the
ability to fully understand, mirror, then share another person’s expressions,
needs and motivations. Before we can have any sense of empathy for our
patients, we need to know who they are. We need to ask questions, be
genuinely interested and curious, and listen with open minds. A dentist friend
of mine who is an extremely talented writer, Dr. Ian Kerr from Kent,
England, puts it like this:
We are experts on teeth, but our patients are experts on themselves:
respect this. Just because the patient makes a treatment choice that we
consider to be a poor one, does not make them wrong, just different to
us. We know a lot about what is happening in their mouths, but very little
about what is happening in their life. Our primary role as dentists is to
provide patients with the opportunity to be in control of the health of
their mouths. Their role in this needs to be explained to them but after
that, the rest is down to their choice.
We want our patients to make informed choices. We want our patients to
understand their current condition, to truly understand the risks and benefits
of going ahead with treatment or not, and we want to maintain the
relationship even if now is not the right time. By the same token, we want to
be able to figure out at the earliest opportunity who those patients with unreal
expectations are or who will not be a good fit for our practice.
One of the most important skills that we can develop as dentists is how to
listen. Many of us think that we are good listeners, but we spend most of our
time in conversation, waiting for our chance to say what we have to say,
rather than actually listening to the other person. It is easy to say that the
more time we spend listening to our patients and discovering what is going
on in their lives, the more likely we will be able to formulate the appropriate
treatment plan for them. This needs to be put into the context of a busy day in
a busy dental practice. I believe that we should know some information about
why patients have come to see us and what their values are, and not try to
offer solutions too quickly.
Let me take a step back into human principles again. There is a book, a
timeless book called The 7 Habits of Highly Effective People by Dr.
Stephen Covey. These habits were distilled out of hours of research and a
clear definition of what it means to be effective—note, not “successful,” but
effective.
I first listened to this book as an audiobook read by the author in the first year
that I opened my practice in 1995. It was a year in which I was struggling
with all the challenges of being a young business owner and trying to
establish myself as a credible clinician. I was often filled with trepidation,
anxiety and self-doubt, while learning how to deal with human resource
issues, employment law and bank managers. Dr. Covey shares timeless
information in this book and later in my career I have come to appreciate
how these principles can be applied to clinical dentistry just as effectively as
to human relationships and being an employer.
Note also the word habit. These are not rules to be adhered to or broken.
They are the habits of highly effective people, meaning the repeated,
consistent behaviors which are employed over time, not as a means to an end
but as a way of being.
The habits:

1. Be proactive

Begin with the end in mind

 2.

3. First things first

4. Seek first to understand and then to be understood

5. Think win-win

6. Synergy

7. Sharpen the saw

These habits can be applied to treatment planning—in particular habit 2,

Begin with the end in mind that absolutely speaks to the importance of
design. And habit 4 that says, Seek first to understand and then to be
understood. So often, we begin diagnosing and treating in a single-tooth
fashion without either visualizing or talking to the patient about their needs
and taking the time to understand both the patient as an individual and their
dental history.
Habit number 1, Be proactive, means making decisions and taking action
rather than reacting to events. In dental practice, we can decide which
questions we will ask our patients when we first meet them. If we are
practice owners, we can decide how we want our patient journey to flow.
The whole sphere of preventive medicine and dentistry harnesses the habit of
being proactive. If we take action to improve our oral hygiene, then we are
being proactive in preventing periodontitis. In addition, if we decide to learn
more about an aspect of clinical care, we are being proactive in furthering
our knowledge and also in being able to help our patients. There is a saying
that says, “You don’t know what you don’t know,” which I like to couple
with the sentiment that we are all doing our best, and as author and poet
Maya Angelou said, “When we know better, we do better.”
I have always been driven to keep learning by a desire to be able to offer my
patients the best care that modern dentistry has to offer. I feel a sense of
obligation that if a patient trusts me enough to make an appointment and ask
my advice, then I have a duty to make sure that I am up to date and well
versed in what’s available. I have always believed that I should know what
is available to solve their particular problem, even if I don’t provide that
care. Particularly in general dental practice, that is both the exciting variation
and the challenge. We literally never know what combination of issues a
patient will present with, and if we are to practice the habit of proactivity,
we will be sure that we have systems set up to allow us both to listen and
discover, and then to communicate effectively with our patients.
Habit number 4 is key. Seek first to understand—and then and only then to
make yourself understood.
When I am working with young dentists, all too often I see a desire to talk at
a patient with answers, rather than to involve the patient with choices about
their care. I think, perhaps, this comes from the education system. In dental
school, we are trained to present the answers to other dental professionals.
We are given sets of clinical data and asked to come up with a treatment
plan. Even in study clubs, this is often how we discuss cases. Here is all the
clinical information, here is the list of what the treatment plan should be, and
here is what we did.
There is a big piece missing from this: how do we explain the options to our
patient, and how or why did they agree to go ahead?
This is the hidden art of successful clinicians: how to gain trust and how
to communicate in an effective way so that the patient goes ahead with
treatment.

I heard it described best by Dr. Bill Robbins at a presentation he did for the
American Academy of Cosmetic Dentistry (AACD). Dr. Robbins is a dentist
from San Antonio, Texas, whom I have met through the Seattle Study Club.
He published a book with his colleague, Dr. Jeffrey Rouse, called Global
Diagnosis, which I refer to multiple times in this book as it has had such a
positive influence on how I have brought facial diagnosis into smile analysis.
At the AACD meeting in Toronto in 2016, Dr. Robbins said that in dentistry,
one of the greatest challenges we face is the sheer number of diagnoses we
can have. Medicine tends to specialize, or to hone in on a specific symptom
or set of symptoms leading to a single diagnosis. In dentistry, we have tooth-
by-tooth or regional diagnoses; we have biological, bio-mechanical,
functional and esthetic diagnoses; and we have global diagnoses; we have a
multitude of diagnoses, some of which we need to treat, some of which may
influence how we treat, and some of which we need to accept.
Again, it all needs to be presented back to the patient in a manner in which
they will understand. Another phrase from Dr. Covey is we need to find the
“simplicity at the far side of complexity” to be able to explain to our patients
what their options are. A confused consumer will do nothing. If we
find it difficult to diagnose a complex full mouth rehabilitation that has a
myriad of different options, then our patients will not understand or value
what we offer. We may be offering the best solution for the long term, but if
we cannot communicate it in a straightforward manner, then we may lose
either the patient or the opportunity to truly help them.

Every single patient that comes to a dental practice has their own set of
values and their own history of decisions about the health of their
mouths, which have led them to where they are now.

We learn how to take a social, dental and medical history of our patients, but
often these consist of a list of questions acting a bit like a script. Asking
direct questions will gain a certain amount of information, but the key to
unravelling the story of the patient is to develop the curiosity to determine an
idea of their values and personality style.
Values. We all have them. Brené Brown, in her book Dare to Lead, shares
an exercise for determining our values. This can be a very useful exercise to
develop as a team. Developing core values for your practice will help you to
orient yourself in rocky times. If you know what you believe in, you can use
this to check yourself if you feel you have gone off course or if you have a
difficult decision to make. In terms of patients, we want to attract patients
who value the type of dentistry that we do.
Early on in my practice, I determined that I wanted to have the feel of a hotel
rather than a clinical setting, an environment that was comfortable and where
nervous patients would forget that they were at the dentist’s. I had a patient at
one time who told me that I shouldn’t invest in a nice lounge area, that it
would be better if I was delivering care in a portacabin and keeping the costs
down. I realized at that stage we had a difference of values. There are, of
course, dentists who would like to provide the most affordable care in a
temporary facility, but I knew that was not me. I was able to stand firmly by
my value set and explain to this patient that if the least expensive was what
she was looking for, then we probably were not going to be the best fit, as my
values put quality and comfort ahead of least cost. Interestingly, she is still a
patient of mine 20 years later. Sometimes people just like to complain.
Your values may not be the same as mine. Your team’s will not be exactly the
same either. But it is important to know and name the values you hold for
your office and to discuss these openly with your team. It is very helpful from
time to time to identify values as a team so that everyone feels a shared
ownership and holds themselves accountable. Those whose values do not fit
will quickly feel uncomfortable and move on to new pastures.
Our Cherrybank Dental Spa values

• Embrace and drive the change

• Do our best

• A happy team of individuals

From a patient’s perspective, the key values we want to uncover are how
high health is in their value set. Is keeping their teeth the most important thing
or is appearance a key driver? Sometimes appearance outvotes keeping teeth.
Some people have a fear of losing teeth. Some people have a fear of the
number of appointments it will take to achieve dental health. Some people
travel and require predictability above all else. Some people would rather
keep teeth with an uncertain prognosis for as long as possible. People are
different. It is our role to identify what is important to them and to inform and
advise them of the risks and benefits of their choices, but ultimately to
respect that their informed decision is theirs to make.
Further Reading
Dale Carnegie, How to Win Friends and Influence People, Vermillion,
2006.
Brené Brown, Dare to Lead, Vermillion, 2018.
Stephen Covey, The 7 Habits of Highly Effective People, Simon and
Schuster, 2020.
C HA PTER 3
THE D EN TA L
EX PER IEN C E
“Excellence is the result of caring more than others think is
wise, risking more than others think is safe, dreaming more
than others think is practical and expecting more than others
think is possible.”
ANONYMOUS
There’s a system and a flow to a patient experience or journey. Ultimately,
the ideal patient experience is designed like a tapestry—the system is the
underlying pattern, but woven within it are the threads that are unique to the
individual patient.
The result is a tailor-made experience where the patient feels seen and heard.
In order to implement the strategies of smile analysis, we need to consider
context. Just as patients need our help to put their dental reality and possible
treatment options into context, we are most effective when we create an
environment where our patients feel cared for and which reflects the style of
clinical dentistry that we are offering. That context can be considered the
patient’s dental experience and begins with their very first awareness and
impressions of us.
VUL NE RAB IL ITY AND TRUS T
Dentistry, by necessity, is an invasion of personal space, which means that
our patients have to put themselves in a very vulnerable position in our
dental chairs even for the most routine examination. This feeling of
vulnerability is compounded if an individual is nervous because of a
negative past experience or simply because this is a new environment. As
humans, we like certainty, so everything that we can do around the patient
experience to remove the uncertainty and to help people feel at home will
ultimately lead to a quicker build-up of trust.
Trust can be considered like a bank account. Those we trust the most have
usually made deposits over the years.
Patients who have been coming to see us for years, whom we have taken
good care of, will have a positive account. If something goes wrong, like if
they are kept waiting or if an item from the dental laboratory is not delivered
on time, they will usually be understanding as we have built up trust over
time. However, a new patient, particularly if we have also taken withdrawals
from the account by having to move an appointment, may well feel otherwise.
They may begin to question their decision to choose us for their dental care if
we are perceived to be disorganized.
How to build trust

• Patient testimonials—There is nothing like validation from existing

patients to build trust. These can be in video form on social media or in
written form.

• Show before and after images of similar cases that you have treated.

• Team members trained to validate the dentists with verbal skills, such
as “You’ve come to the right place.”

• Be completely transparent about fees and repeat that the patient will
know exactly what the costs are likely to be before committing to any
treatment.
 Repeat the message that the patient is in control.
•

• Listen actively—Reflect back what you understood the person has said,
including the feeling behind the words, without agreement,
disagreement or judgment, but simply to clarify that you have heard and
understood correctly. This skill is very powerful in allowing people to
feel that you have heard them. For example, “It sounds like you are
feeling very upset and angry because you feel that the previous
treatment was not explained correctly. Have I gotten that right?”

• Under-promise and over-deliver.

The book The Speed of Trust, by Stephen M. R. Covey identifies the

strategies that we can use to build trust quickly. This is particularly relevant
if you have opened a new practice or have recently taken a new job. Many
dentists find themselves in the position of taking over a list of patients from a
retiring colleague and taking the time to build trust effectively with those
patients will be key to success.
PATIE NT P E RCE P TION IS RE AL ITY
I learned early on in my career that patient perception is reality. If a patient
attends for an appointment and witnesses a cluttered, disorganized
environment, then they will assume that this level of disorganization extends
to our clinical care. This is why first impressions are so important,
particularly for the new patient. It is also the reason why first impressions of
your physical environment and how new patients are greeted on arrival are
worthy of thought and attention.
Thinking about our patients’ experience with us as a journey can help us to
break down the steps, considering every interaction, so that we first can
analyze and name the stages so that we first can analyze and name the stages,
and second, we can identify who does what and how we transition between
each stage. The stages of a patient journey are like a journey through a
tapestry with a beginning, middle and end, and hopefully a playback loop
where they become forever patients! As the patient moves along the journey,
we need to weave across a whole raft of skills that layer and build on one
another. There are an almost infinite number of variables when a patient
comes to see us as a dental patient, and as we have mentioned, our values
will define what is important to us and the style of practice that we wish to
have.
If, like me, you love the impact that improving a smile can have, and you are
open to treatment planning the whole mouth, a comprehensive style, then the
treatment plans you will be offering your patient will likely include asking
them to spend a significant amount of money and time with you. Does your
facility support this in the patient’s first impression of you?
The patient’s perception is reality. If they walk into your office and
sense chaos, clutter and disrepair, will they have a concern that maybe your
dentistry is carried out in the same way? It is a very useful exercise as a team
to walk outside your office and then come back in, looking at familiar
surroundings with fresh eyes, making a note of everything that you notice,
including when you sit in the dental chair. You can also ask a family member
or friend to do the same.
Think about the ambience that you are trying to create and remember that it is
difficult for patients to judge your dentistry. The environment in which you
work and receive them in is all they have to judge initially. A stock delivery
may have arrived and your team has it half unpacked, you may have had a
crazy day, you’ve been meaning to paint those chipped walls for months —
all of this will give off the impression of chaos and disorder, and when
dentistry is elective as in smile design, the patient has a choice.

A brilliant book to read if you are considering your patient journey is

Building the Happiness-Centred Business by Paddi Lund. Paddi Lund is an
Australian dentist who realized that he was miserable at work. It culminated
in him throwing an instrument across the room and having a nervous
breakdown. He realized that he could not continue like this, and so he
completely revolutionized the way he practiced dentistry. He took down his
external sign and decided to work only with patients he liked and with whom
he had mutual respect. His practice became by invitation only and he went
from strength to strength. The book became a best seller in the business
world as it was recognized that there was a different way to “be” at work.
Paddi also coined the term “critical nonessentials.” This is his name for all
the little things that you can do to make a patient feel more comfortable. In
isolation, these things may be small and seem unimportant, but when built
upon in layers and with consistency, they transform a “routine” or “ordinary”
dental experience into an extraordinary one. Any time you can do something
unexpected and “wow” a patient, you are also giving them a positive story to
tell about your office, which leads to word-of-mouth marketing.
Smell is the closest linked sense to memory. For phobic
patients, a clinical smell may take them right back to the
emotional state of childhood if they had a bad experience.
What does your facility smell like? Paddi Lund, the Australian dentist in
Building the Happiness-Centred Business takes this to the next level by
baking sugar-free muffins on the premises to serve with a tea ceremony for
visiting guests (he would not use the term patients!) At Cherrybank Dental
Spa, we bake bread in a bread maker to infuse the practice with a comforting
smell!
There’s a system and a flow to a patient journey, but ultimately, the ideal
patient experience is designed like a tapestry—the system is the underlying
pattern, but woven within are the threads that are unique to the patient.
TIME L INE S F OR THE PATIE NT
JOURNE Y
A timeline is a pictorial representation of a flow of events. The flow moves
in chronological order from left to right. Creating a timeline can bring clarity
to the sequence of events that need to happen in order for progression to be
made from a defined start point to a defined end point. Timelines can be
useful for brainstorming where bottlenecks may occur or where mistakes can
be made. They can also help team members to understand the urgency of the
tasks they perform, as they can see that the next task cannot be accomplished
until their part is completed. It also helps to share appreciation with the
whole team of all the steps that are involved. Sometimes team members may
be completely unaware of the work that goes into developing a storyboard
for example. A timeline can help them to understand and therefore make sure
that their tasks are completed in a timely manner.
Timelines can be very helpful when working with a dental team to break the
patient experience into small steps, considering every detail and the various
roles that team members play within that. Every practice will have a unique
patient journey that reflects the values and style of the owner and is
supported by every team member. Change can be difficult to implement in
practice, which is why it is worth considering your patient journey with your
entire team and listening to everyone’s suggestions as to how it can be
improved.
At Cherrybank Dental Spa, we use timelines to collate the results of
brainstorming all the steps that happen in a particular area of the practice. We
can then break the sections into the team members involved with each step
and develop task forces to work on each of them. We have separate timelines
for hygiene patients recall patients and patients on treatment journeys where
we incorporate the comfort zone menu. The comfort zone menu is a list of
optional comforts, such as a warm blanket or noise reduction headphones,
that the patient can choose for all but the shortest appointments.
Each box on the timeline can be further broken down into tasks.
For example, at the morning meeting, which is a short 10–15 minute gathering
at the beginning of every day, we identify any new patients who are due in
that day and we read from the appointment diary the initial information that
has been collected by the front desk team. In this way, we know if the
patient’s main concern is smile design or whether they have another reason
for attending. We call this “passing the baton” as in a relay race—making
sure that information is passed from each individual who is involved in
patient care so that the patient always feels listened to and that we know who
they are. This only works by having thought through the systems for the
transfer of that information.
The following diagram is our example of a patient journey timeline. It
begins with an enquiry and ends with the patient consenting for
treatment.

The boxes in purple represent the emotional touchpoints for education and
motivation. I will describe these in more detail in later chapters, but they are
key parts of the journey where we utilize a product or technique to allow the
patient to visualize the end result of treatment—their potential, future and
better self.

The timeline template is in keynote or powerpoint and is available to

download. It can also constructed in analog form on a white board or in a
practice journal.
CHANGE AND THE S TAGE OF
L E ARNING
Any time we implement change into our patient journey, I like to remind our
team that “Chaos precedes change.”
It can also be invaluable to have an understanding of the stages of learning—
any time we are learning a new skill we go through this process:

1. Unconsciously incompetent We don’t know what we don’t know

2. Consciously incompetent We know that we don’t know

 Consciously competent We can do it, but we have to think about
3.
every step

4. Unconsciously competent We can do it without thinking

Stage 1 comes before any learning – we are unaware of the things we do not
know.
To implement any change, there is a period of conscious incompetence where
you have recognized that change should occur, but you are not yet familiar
with the new way of being. At first you feel incompetent, and then you get
better with practice, but it’s not second nature yet.
Stage 2 is the most uncomfortable stage and it is worth remembering this
with new team members. Starting a new job where all the systems are
different can make anyone feel like they are incompetent despite years of
experience. New team members need support to get past this stage.
I felt this recently when introducing the global diagnosis screening into my
new-patient examination. I had bought the book by Dr. Bill Robbins and Dr.
Jeffrey Rouse years ago and read it cover to cover several times. I had also
enrolled in a live, online course to really cement my learning, and as part of
this, Dr. Robbins had us measure the midface and lower face of all our
patients. I made the commitment to do this, as well as the lip length, lip
mobility, and so forth. My dental assistant did not know what I was doing. I
had to keep repeating myself. It felt awkward at first to be measuring a
patient’s face with large calipers, particularly when they had come to see me
about a pain in the upper left, for example, but I had made the commitment to
myself. I was going to analyze every patient globally from a facial
perspective. Now it feels like second nature.
Today, I look at my full-face photographs and automatically start doing the
midface-lower face calculation in my mind. I had to implement change. I had
to hold myself accountable for repeated behaviors, even when they slowed
me down and felt chaotic. I made mistakes and forgot things at first, but
overall, I learned to implement a new habit and a new way of seeing and
analyzing, which has taken my diagnosis skills to another level.
VAL UE S AND L E ADE RS HIP
“Always treat your employees exactly as you want them to treat your best
customers.”
Stephen Covey
Your team culture begins with your leadership and attitude. If you do not own
the practice that you work in, you can still influence the team around you and
you can lead by example. We need the support of our team because when we
are busy working clinically. Our team members are the ones building rapport
with patients, answering enquiries and questions, and validating patient
decisions. Time spent building a team of professionals with shared values
will reap rewards, and by the same token, if you ignore issues within your
team, then all of your best efforts can be sabotaged.
Human resource issues can be very challenging, and often it is worth
considering external coaches or practice management resources to assist you.
My advice would be to face these challenges head on. Do not be in denial.
We cannot do this alone, and if we surround ourselves with talented,
enthusiastic individuals, our dentistry and our practices will be lifted to a
higher level.
I am so fortunate at my practice to have several team members who have
worked with me for over 20 years. I trust them completely and enjoy their
company and insights. I have also had team members who were with me a
long time, who needed to move on, sometimes for their reasons and
sometimes for mine. This is part of life and of being an employer. I have
learned not to take it personally, to be kind but firm, and also to remember
the business and patient care need to come first, as do the needs of the entire
team. Attitude is everything. Hire for enthusiasm to learn, genuine care for
patients and a belief in the good that dentistry can bring. Skills can be taught.
Jim Collins, who has authored several New York Times Best Sellers,
including Good to Great, has studied the differences between average
businesses and businesses that truly succeed. He describes how it is so
important to have not only the right people on your team, but also that those
right people are in the right role for their strengths. He describes a business
like a bus: you need to have the right people on the bus and the right people
in the right seats on the bus before you can plan the journey to your
destination.
HAB ITS
Implementing change begins with identifying behavior and habits that will
lead to a different end result.
In the book Atomic Habits, Random House Business 2018, James Clear
teaches us:

1. Start with an incredibly small habit. Make it so easy, you can’t say
no.

2. Increase your habit in very small ways.

3. As you build up, break habits into chunks.

 4. When you slip, get back on track quickly.

5. Be patient.

In my own implementation of the global diagnosis example, I started with

ordering the digital calipers and measuring facial height on every patient.
This then led me to also measuring the upper lip, and tooth display at rest and
at full smile. While I had my calipers out, I could then measure the lengths of
the anterior teeth, look at the gingival levels to the horizontal, and the skeletal
midline to the dental midline. Now this sequence is the first part of every
examination before I move on to the TMJ and muscle palpation.
I then went on to add an airway assessment. I would encourage you to do
similarly with the strategies outlined in this book. Utilizing building blocks
of learning, start where you are and build new habits piece by piece.
Depending on where you are now, identify some small habits that you will
have to change or implement to move forward. Start there and then build on
your successes.
Over the years, my team and I have worked hard to keep customer service at
the forefront of the benchmark that we hold our business to. We were very
inspired by dentists from the American Academy of Cosmetic Dentistry in the
1990s, who were practicing “spa” dentistry, which at the time had never
been heard of in the UK. Cherrybank Dental Spa was the first to call itself
that in the UK. It may seem like a dated name now, and indeed it is important
to stay fresh with your messaging, but I believe that the ethos is still valuable.
The ethos of a “dental spa” is to make everything around the experience of
dentistry as comfortable and spa-like as possible, remembering that, for most
people, a visit to the dentist produces a level of anxiety. If we can transform
the experience to that of a visit to a hotel or a spa by judicious use of smell
and ambience, then we should already be helping to allay their anxiety.
My team and I developed a “Comfort Menu” where patients can choose
which comforts they would like to have during treatment. Years ago, we were
even featured on the local television news channel for our efforts at baking
bread to disguise clinical smells!

We have also learned an important lesson. None of the critical nonessentials

that we offer in and of themselves deliver the experience of the dental spa. It
is the consistency, enthusiasm and professionalism with which my team
delivers the care to the patient that makes up the experience. And of the three,
consistency is both the most important and the most challenging. When our
day is going according to plan, it is relatively straightforward to implement
all of the little things, like applying luxury lip balm and offering a blanket
during a long treatment. The key is when we are running behind schedule and
the lip balm is not where it is supposed to be. What then?
It can be easy to think that it doesn’t matter. After all, these things are nice but
are not essential to the delivery of good clinical dentistry. However, imagine
if a patient was nervous and found your practice and felt completely cared
for and relaxed on their first visit when all of these courtesies were in place.
When they attended a second time, they felt rushed and that they weren’t
offered lip balm. They may not feel it is appropriate to complain about such a
little thing, but they are likely to leave feeling disappointed. Even worse,
imagine if the “storytelling” word of mouth has worked in your favor and
they referred a friend or a family member, telling them with great excitement
how different they will find the experience with you, only to discover that
their loved one attended on a different day and did not have the same
experience.
I cannot stress enough that this is the challenge of providing excellent
customer care. Once the critical nonessential has been delivered, it is a
“wow” the first time. But now you have raised the bar on expectation. Right
or wrong, the luxury lip balm is now a baseline expectation and if you fail to
deliver, this will count against you. It is relatively easy to create a “wow”
experience the first time. The challenge is upholding the expectation and
what’s even more challenging is to keep thinking of ways to exceed it.
The answer to the consistency challenge lies in systems and accountability.
Involve your team in creating a culture where the individuals care and make
sure to follow the systems required to keep delivering that care day after day.
It is important that they support each other on good days and bad days.
P E RS ONAL ITY S TY L E S
This is one of the most important things that I have studied and taught my
team over 25 years. An understanding of the four main personality styles or
traits. This was first introduced to me by Jameson Management, Inc. in Cathy
Jameson’s book, Great Communication Equals Great Production. Cathy
Jameson is from Jameson Management, a practice management company
based in Oklahoma. Cathy’s husband, John, is a dentist and they ran a very
successful dental practice for many years. Cathy studied the techniques that
helped to make him successful. She teaches these systems in dental practices
across the world, backed up by studies from the UK and the USA.
In her book, she describes that more than 2,000 years ago, Hippocrates
determined that there are four basic temperaments among men and women.

Choleric The driving personality that wants results and control

Sanguine The enthusiastic personality that wants attention and

positive “strokes”

Melancholy The congenial personality that wants compatibility

and harmony

Phlegmatic The steady personality that wants structure and

organization

My team and I have worked with the system based on the above, but which in
today’s lingo is known as the DISC system.
As above but D—Dominant (choleric)
I—Intuitive (sanguine)
S—Steady (melancholy)
C—Conscientious (phlegmatic)
There are other versions and different descriptions, but one that is easy to
remember is the description of birds, which helps to bring the topic to life in
team meetings.
• D—Hawk. The “D” personality style is like a hawk. “Ds” are fast
decision makers, are straight to the point and dislike feeling that their time
is being wasted. They are task-oriented. I imagine a hawk high above,
zoning in on its prey with laser focus! If you are working with a “D”
patient, it pays to be organized.
• I—Peacock. Like a peacock with its splendid tail feathers, appearance is
important to a high “I” personality. They can be motivated by looking
better and talk in terms of people and feelings rather than tasks.
• S—Dove. “S” personalities are conscientious, loyal and dislike change.
Like the symbol of the beautiful white dove, they are the peace makers and
look out for other people. They can often put other people’s needs before
their own. “S” patients may need validation from their family and friends
before making a decision about complex dentistry, and testimonials from
other patients can help to reassure them.
• C—Owl. “Cs” are all about the answers to the many questions they may
have. They can be very analytical and see the world as black and white, or
if it is not right, it is wrong. Accuracy is very important to a “C”—like a
learned owl wearing spectacles and peering over its glasses! Make sure
you know the answers to any questions that a “C” patient may have.
A working knowledge of these styles can help your team to understand that
each of our team members and each of our patients are unique.
Communicating with everyone in the same manner is ineffective.
The first step is to have a basic understanding of each style, then you can
adjust your presentation modality or approach to each individual. The end
result will be less conflict, fewer difficulties and more people who will
accept your recommendations. It is extremely helpful to understand your own
style so that you can recognize with whom you will converse easily and with
whom you may have to try a little harder.
Recently, I came across the book Surrounded by Idiots, by Thomas Erikson,
which uses colors to describe the four traits.
D—Red
I—Yellow
S—Green
C—Blue
This is an excellent book, as the author dives deeper into the characteristics
of all four styles, including differences in body language.
When working with team members, it is important that everyone remembers
that there is no right or wrong trait. No style is better than another. All have
strengths and weaknesses, and a balanced team will have representatives
from all four. It is also interesting that our dominant style at work may not be
the same as in our personal life, and that it can shift over time as we become
more self-aware and adapt to the challenges in life. We all have elements of
all four.
The absolute key is recognizing that we are not all the same. This can help us
to function better as a team and to communicate more effectively with our
patients. The best practices I know have really integrated these descriptions
into their culture and language. When we say this patient is a high “D,”
everyone knows we had better be organized and see them on time, but also
that they will be a fast decision maker. When a patient is a high “C,” they
will need lots of information, which we must ensure is accurate, and we
should not expect them to make a decision today.
For team members, the majority of good, loyal, long-serving team members
are likely to be “S” personalities who make up the majority of the
population. By the same token, “S” personalities can find change more
difficult. The difference between the styles was brought home to me in the
team lunchroom. My treatment coordinator Chloe’s salad plate was a work of
art! Everything was laid out like a rainbow in the “correct” order. By
contrast, I was scooping my random selection onto my plate in a hurry to eat
because I had, in my opinion, more pressing things to attend to. Chloe came
out as a high “C.” If things aren’t just so, the stress for her is genuine. This
was a wakeup call for me as I didn’t care as much about detail at that level,
but I could see that it was important to her. I have a higher “D” than “C,”
which is common for business owners.
To be the most effective in teams, it helps if we have the self-awareness to
adapt our style when relating to each other. This is also true when relating to
patients. If our style is always the same, we will gel with some people but
miss the opportunity to be effective with others. We have a chart on the wall
in our team room that has all of our personality styles on display and some
hints about how to best communicate with each other.
L E ARNING S TY L E S
As well as different personality styles, individuals have different learning
styles. These can be predominately visual, auditory or kinesthetic (touch).
I used to give people books all the time, assuming that everyone loves to
learn by reading. Listening to books is a favorite pastime and I make good
use of Audible and audiobooks when I’m traveling (high “D” personality—I
don’t like to waste time). When traveling, I particularly listen to books that I
might otherwise struggle to read—namely business books. I also feel that
hearing the words helps me to consider the ideas in a different way than
reading. I know it is a good book for me when I do both—listen to it but then
I want to have the actual book so that I can reread and highlight passages.
Eventually, I recognized that not everyone learns in this way. Some people
are much better being shown a technique and then getting hands on and doing
it. Like personality styles, people are different and it is worth developing the
self-awareness to recognize your own predominant style—and that this may
not be the style that works best for your team members.
Further Reading
Dave Logan, John King and Hallee Fischer Wright, Tribal Leadership,
Harper Business, 2007. TED talk link:
https://www.ted.com/talks/david_logan_tribal_leadership?language=en
James Clear, Atomic Habits, Random House Business, 2018.
Michael Levine, Broken Windows, Broken Business, Warner Business
Books, 2005.
Thomas Erikson, Surrounded by Idiots, Vermilion, 2019.
Jim Collins, Good to Great, Penguin, 2020.
Simon Sinek, Start with Why, Penguin, 2011.
C HA PTER 4
D EC ISIO N PO IN T:
SIN GLE TO O TH O R
C O M PR EHEN SIV E
A PPR O A C H
“Two roads diverged in a wood, and I—I took the one less
traveled by. And that has made all the difference.”
ROBERT FROST

There is a decision point that comes when we see a patient for a

particular problem or request. As described in the introduction, we can
determine whether this is a straightforward request with a single tooth
answer—or whether there is a wider issue where we need to gather more
information, study and come back with treatment options. This, in itself, is a
form of risk assessment.
Dentists often talk about the transition from single tooth dentistry to
comprehensive dentistry as being a progression in their personal and practice
development. The option to either treat the one isolated incident or to take a
wider diagnostic approach is essentially the difference between emergency
care and holistic care. If a patient has broken a tooth or is in pain, they have
an emergency condition. They are in survival mode. They don’t need to like
or even particularly to trust you as a dentist. They need your help, and
providing the cost is reasonable, they will accept care.
The potential issue with this care can be that it is reactive. If a tooth is
broken, why has it broken? For some people, the time is not right for a
holistic view. For many of our patients, nobody has ever taken the time to
explain, educate and give them options.
Author, neurologist, psychiatrist and holocaust survivor Viktor Frankl taught
us that “Between stimulus and response there is a space. In
that space is our power to choose our response. In our
response lies our growth and our freedom.”
In dentistry, that space gives us our opportunity to pause. The space comes in
between being presented with the patient’s complaint or request and
explaining the treatment options available to them for that particular
situation. It is the space between the initial, observational diagnosis and the
treatment plan.
For example, an emergency patient is booked into a busy, general dental
practice with a broken tooth.
DE NTIS T: DR. S MITH
Patient: Doctor, my tooth is broken. I was chewing on a soft sandwich and
the piece came right off. It doesn’t hurt, but it is sharp to my tongue.
Dr. Smith: We should check with a radiograph to see that the tooth is
healthy and that there is no sign of infection. But really it needs a full
coverage restoration—we call it a crown. This will help to hold the tooth
together and prevent further breakage. Let me prepare an estimate for you,
and if you agree, we could get started.
DE NTIS T: DR. JONE S
Patient: Doctor, my tooth is broken. I was chewing on a soft sandwich and
the piece came right off. It doesn’t hurt, but it is sharp to my tongue.
Dr. Jones: Ah yes, it looks like half of the tooth has come off. I don’t think
it would have been the sandwich that broke your tooth; that must have
been the straw that broke the camel’s back, and probably that tooth had a
crack in it already, around the large filling. Did you have any sensitivity or
symptoms before it broke?
When I look around your mouth, it seems like you have other teeth in
similar situations—were all these fillings done around the same time?
Let me show you here with our intra-oral scanner, which is an optical
scanner that takes pictures of your teeth and stitches them together. You
can see that there are several other teeth with fracture lines, and in fact, it
looks like you are wearing your teeth down. Are you aware of grinding
your teeth or clenching your jaw at night?
Sometimes, as teeth wear, the forces on the teeth change, and your tooth
breaking may be a symptom of that. I would suggest that this tooth would
benefit from a full coverage restoration that we call a crown, but I would
like to put it in the context of your whole mouth and your smile. This tooth
does show in your smile and perhaps you may want to consider whitening
before we choose the color for this tooth?
Patient: Oh yes, I was thinking of some tooth whitening as we have a
family wedding in a few months. I also don’t like the color of this tooth at
the other side. Is that something we could look at too? Although I am
concerned about expense.
Dr. Jones: Of course. With your permission, I would also like to take some
measurements, radiographs and photographs so that I can fully analyze
your mouth and smile, and make sure that there is nothing else we should
be considering at this time. I have some concerns that other teeth may
start breaking and that if we fix just this one, we are not taking into
consideration why it has broken and if there are any other underlying
issues. That doesn’t mean that we have to do everything at the same time,
but at least you would know all of your options right now and in the future.
I can certainly look at that other tooth, too, as well as your smile, and give
you all your options with pros and cons. We can put costs to all of that and
we can discuss ways of spreading the cost if that is of interest to you. I
appreciate you have a family wedding soon, so time is of the essence. Let’s
go ahead and gather the information that I need today and then we can
arrange a consultation time to go over everything and decide the best way
forward.
Dr. Smith’s treatment plan is a single tooth crown. A good use of an
emergency appointment and a happy patient.
Dr. Jones’s treatment plan is at least whitening and one crown and possibly
more, and possibly a full-smile design. At least the seeds are sown for future
options. I agree that this takes more time and effort, but once the case is fully
analyzed, that work is done and documented. The patient may be impressed
from a dental experience that is out of the ordinary and has a story to tell,
which may lead to other patients seeking care. Trust levels are high. The
patient has had the opportunity to say yes to more dentistry and understands
what the future risks for their own mouth are.
What information does Dr. Jones gather? What does she do between this
appointment and the consultation? How does she present the options to
the patient, and in effect, guide their thinking? How long does all of that
take, and does the dentist gather all the information, or can some be
delegated? All of these questions will be discussed in subsequent chapters.
An alternative term for comprehensive treatment planning could be
integrated treatment planning. I will discuss this further in Chapter 15. The
reason I lean toward integrated as a term rather than comprehensive is that it
reminds us that the teeth, surrounding structures and the smile are all systems
that work with the other structures and systems of the head, neck and body as
a whole.
The Oxford Dictionary definition of “comprehensive” is: “including all, or
almost all, the items, details, facts, information, etc., that may be involved.”
This is a good definition for the type of treatment planning that we aspire to.
First, we have to gather (I like to say capture) all the details and facts. Then
we need to study it, in effect, to do our homework, which will allow us to
comprehensively plan for treatment.
Is it single tooth versus comprehensive dentistry that is the decision point, or
a simple problem with a straightforward solution versus taking a step back to
do a fully comprehensive analysis, diagnosis, risk assessment, and then plan
how to present the possibly complex treatment options? In theory, both
strategies could come to the exact same end point. One will have taken a
great deal more time, effort and documentation than the other. In the example
given earlier, it is possible that Dr. Jones went through the thorough analysis
only to determine that everything else was completely stable and the option
was a single tooth crown.
Is this a waste of everyone’s time? This is the question that each of us needs
to answer for ourselves when that particular patient is in front of us.
What I can tell you is this: Having worked in the same general practice for
over 25 years, I have never regretted taking the time to do a thorough
analysis. It can be just as rewarding to demonstrate to a patient how thorough
you have been while delivering the good news that everything is within
normal limits and their risk factors are low. Every time you go through a
process of guided observation, you will learn something new.
E MOTIONAL INTE L L IGE NCE
Having said that, for which personality style might it be worth cutting to the
chase and getting on with treatment? High “D” (dominant) personalities will
not want to feel that their time has been wasted. It is very important to have
your boundaries and systems worked out but be able to read the body
language and emotional status of the patient you are working with and change
tack if required.
In 2010, I opened a second practice in Edinburgh, Scotland. This was in the
early stages of the banking crisis and global recession. We had to dig deep
into our values and work hard to build a private fee-for-service practice. I
was teaching the team in Edinburgh how to structure the two-visit new-
patient experience. We decided that it would be helpful to video the initial
visit so that we could give feedback. The dentist, treatment coordinator and
dental nurse had been through role-play training with my original team. They
were gathering the photograph and video information prior to the clinical
examination.
When I watched the video afterward, the new team members were clearly
doing their best to follow the system. On reflection, they were in the
“consciously incompetent” stage of learning. They were uncomfortable, and
so they were focused on themselves and what they were doing. As a result,
they were not reading the patient who was sitting with his arms crossed,
looking very unhappy and impatient as they struggled with the camera. They
were taking too long to do what he clearly was not happy about. The minutes
of uncomfortable viewing seemed to stretch into unbearable hours as his
obvious discomfort grew.
It was very hard to watch this recording with my experienced treatment
coordinator. She just wanted to jump in and change tack, and talk with patient
to re-engage him in the process. This is emotional intelligence and is in no
way meant to criticize the team members who were doing their best, but it
illustrates how very difficult it is to do something new and pay attention to
the subtle clues given by the patient. It taught me and my team that we had not
equipped the new team with enough of the skills to manage this situation.
They were following the system as we had laid it out, but we needed to put
each new person with a more experienced team member who could think at a
higher level than “what do we do next” and was able to intervene if we were
losing the engagement of the patient. It highlights the danger of sticking to
scripts and strict protocols. I am sure you have encountered this in the
businesses you have visited, where the system is more important than you as
an individual.
The challenge is not to abandon your protocols every time you have a tricky
patient. The challenge is to how to re-engage someone who is, for whatever
reason, unhappy and not engaged. In our team, we have a rule when
technology lets us down, we try something twice and then move on and work
out how to come back to that missing piece later. If the flash on the camera
isn’t working, for instance, we need a way to pass that problem on to a
different team member while we seamlessly move on to the next part of the
examination and can bring the photography back in at a later stage. Great
teams will solve these problems together, rather than risk losing a patient
because we are struggling with anything that detracts from their reason for
visiting us.
Emotional intelligence is extremely important. It builds on listening; it
includes empathy and being able to read body language. If your dominant
personality style is “S” (steady) or “I” (intuitive), then this will come more
naturally to you. If your dominant style is “C” (conscientious) or “D”
(dominant), then you may need to make more effort. Many dentists are highly
analytical “C” personalities—it fits well with our need to have attention to
detail, which is an essential part of our clinical care. However, it can also
mean that we have a tendency to prioritize getting a task right over our
relationship with our patient. As a patient, I want my endodontist to be a high
“C” off the scale. Never mind me under the rubber dam, I’ll be fine, just
irrigate my canals and don’t miss an inch! But I needed my childhood dentist
to have more empathy for me! As dentists, we need to have that level of
emotional intelligence to read body language, empathize with patients and be
aware of the need to stop the process and go to plan B.
S INGL E -TOOTH P ROB L E MS
There is absolutely a place for single-tooth (or in fact two or three teeth)
dentistry.

1. For relief of pain or emergency stabilization.

2. When a patient is stable and healthy except for a simple concern.

3. When a patient has previously been through a comprehensive

evaluation and treatment and is well maintained.

4. When finances or circumstances prevent a more thorough diagnosis.

5. When the patient understands but declines a more comprehensive

approach at this time.

A key in the above list is “when a patient is stable and healthy.” I believe that
the only true way to know this and make sure that you have not missed any
early indications that the patient may not be stable is by taking the time to
think through a thorough analysis.
WHE N TO IMP L E ME NT A DIF F E RE NT
S TRATE GY
I am often asked, do I just implement the analysis strategy when a patient is
asking for smile design? The truth is that it doesn’t matter to me what the
patient is asking for; my diagnostic process is always the same.
Christian Coachman is a dual qualified dentist and dental technician from
Brazil who developed the Digital Smile Design concept. He is a visionary
thinker in terms of digital workflow and developing systems to make
dentistry both more engaging for the public and more predictable for dentists.
To quote Christian, “The smile design should be the primary driver of the
restorative treatment plan.”
I don’t separate the smile from the mouth as a whole. I don’t analyze or plan
any differently if the patient is primarily interested in esthetics or is
definitely not interested in esthetics. If there is damage to the anterior teeth,
then I need to plan for the smile. If the anterior teeth are perfect and no
changes are required, then I will discover this in my analysis, which includes
asking questions, such as are they in the correct spatial position for function.
Function and esthetics are integrated in health.
What will be different is my expectation of the treatment that the patient will
accept and how I will present the story. My treatment coordinators and I have
learned not to judge. We are constantly surprised by the patient who is on a
tight budget but opts for porcelain smile design, or the patient who simply
wanted one tooth fixed but chooses full orthodontic care. Sometimes patients
need to wait until their finances or lives are in the right place for more
extensive clinical dentistry, but at least they are educated and motivated as to
what their options are and the risks for the future. I have seen patients return
after three months and someone who has returned after twenty years saying,
“Now the time is right.”
When a patient is seeking improvements to their smile, it makes sense to me
that we design a smile according to the landmarks of their face. Facially
driven smile design has been taught and described by many of the great
thought leaders in our profession. I will discuss this more in Chapter 10.
Once we have identified the ideal smile and its components, we can compare
the “ideal” to where we are now. We can then brainstorm all the ways that
we can achieve this, and if we cannot easily achieve it, what are the
compromises that we can make. I then consider the patient’s values and
views and try to have an option that is close to their initial request. I try to
have a very clear recommendation as to why that would be successful or not
make sense.
At the initial consultation with a patient, it is helpful to ask some open,
probing questions to gain some understanding of how much the patient has
already considered and what they are interested in at this time.
Presenting to patients without visual aids is not a good strategy; therefore, I
consider my comments in the initial examination as “sowing seeds.” I am
probing and asking questions to determine my best strategies for
communication with this patient.

• If moving your teeth was an option, is that something you would

consider?

• Have you looked into dental implants previously?

 If the way to correct that (jaw discrepancy) was surgery, is that
• something you would consider? Or, even more gently, “Sometimes
the only way to correct that is with surgery, which many adults
may not be keen on (pause and read the body language), so our
compromise is to work with the teeth to try and compensate.

AP P OINTME NT S TRATE GIE S F OR

TRANS ITION TO GUIDE D TRE ATME NT
P L ANNING
For new patients, there are generally three strategies for integrating smile
analysis into your working week. For existing patients, the same approach
can apply. These patients may be referred from hygiene or may attend with a
single-tooth problem that requires a more considered opinion. There is that
decision point again—what are the potential red flags that may help us to
know when to go ahead and when to change gears? I will get to that, I
promise!
The three possibilities for appointment strategies

1. Two-stage new-patient examination

2. Initial screening appointment with an option to convert to two-stage

3. Initial screening appointment with an option to convert to three-

stage

1. TWO-STAGE NEW-PATIENT EXAMINATION

This is by far the most effective strategy to set as your default. Spend the time
adequately analyzing the data and designing the presentation to be the most
effective communication tool.
Stage 1: Information gathering or capture
Guided observation: Diagnoses, smile design, risk assessment, problem list,
treatment options, storyboard presentation (without the patient).
Stage 2: Case presentation or second consult, which leads to the definitive
treatment plan, including financial arrangements and consent.
The design of the detail that I capture in my new-patient experience is
constantly evolving. By the time this book is published, there will be changes
and additions. My aim for you is not to be prescriptive in giving you a
checklist to follow blindly, but to try and instill in you the vision for the
overall experience. Think about capture. Think about here I have an
opportunity because this patient has trusted me with their time because they
have a need and an expectation. It is my responsibility to listen, be curious
and gather the information.
It is my responsibility to capture in an effective, organized,
kind and timely manner all the data that I will need to be able
to evaluate, diagnose and propose treatment options or next
steps. What tools do I have at my disposal that I could use?
That is the essence of capture. What do I need? When I am
sitting down to do my analysis, what questions do I wish I
had the answers to?
As your knowledge and interests evolve, you can change your templates,
change your forms and tools, and make best use of digital technology.
Discipline yourself to do better next time. Make a list of the things you still
need to ask.
The benefit of this approach is that because the process is explained to the
patient in advance of the appointment, objections will have been dealt with
in advance. The patient is not expecting you to have all the answers. The
patient understands that you will be studying the information. You have the
opportunity to ask questions and listen so that you approach the case
presentation appointment with a good understanding of how to present the
information to the patient, in the manner in which they will engage with. You
and your team can also be organized with all the information-gathering
equipment ready. If you have an intra-oral scanner, it will be ready and set up
for every patient. You will have developed the capture protocols described
in the next chapter.
At the very first contact, my front desk team explains to the patient that this is
a two-visit appointment. The first visit is for gathering information. Dr.
Halley will then study the information, think about all the options with
pros and cons, and when you come back, we can then give you our detailed
assessment with all the options and costs so that you can decide the right
path forward for you.
There are very rarely any issues with this but if there are any objections, such
as “Won’t she tell me what I can have done on the first day?” we may
counter this with “Certainly, if it is very straightforward, then we will, but
often we find that we need to study X-rays or other information so we can
give you an idea. To be absolutely certain, we ask for some time to study
the information. Is the return visit an issue for you in terms of time or
travel?” Generally, when patients understand that the level of care involves
studying their whole mouth and all their concerns, and that due care and
attention is being delivered, there is no objection and they are excited to
return for the second consult.
Sometimes there is an issue if a patient is traveling from far or is very busy.
In these cases, we aim to accommodate by having both appointments in one
day, with me analyzing and planning over a lunchtime or by scheduling a
virtual second consult using Zoom. We would prefer to have the time to study
the case and to present the findings in person, but of course, if it really is a
single-tooth type of case or if everything is healthy and only hygiene is
required, then we are not going to labor the case and create unnecessary
appointments. However, our default is two appointments. This works well
for the strategies of smile analysis to be consistently implemented.
The initial appointment is for information gathering, I then need scheduled
time in between to do my analysis (diagnosis and observation, risk
assessment, treatment plan suggestions, and building the patient storyboard),
and we have a second appointment for case presentation or consultation. At
the end of this second appointment, we may have a definite treatment plan
with costs agreed, a second step to gather more information, or phase one of
a treatment agreed on, with a view to further consideration.
The downside of this approach is that your schedule needs to allow for both
appointments to be booked. Our rule is that, ideally, we would like the
patient to return within a week. We aim to build a level of excitement at the
first appointment and we do not want too much time to elapse before being
able to present our findings back to them. Our case presentation/second
consult takes place in a consultation room. The dentist is present at the
beginning of the appointment for the first 20 minutes to present the clinical
information and the treatment coordinator completes the appointment with
time to present the financials. Sometimes the treatment sequence will be
obvious; sometimes there will be a second appointment for consent after the
next steps. We will consider the details of this appointment in Chapter 10.
2. INITIAL SCREENING APPOINTMENT WITH AN OPTION TO
CONVERT TO TWO-STAGE
This means that when you recognize that the patient requires a comprehensive
approach, you can immediately switch gears to gather the information in the
initial appointment. If you are unable to convert to a two-stage new-patient
appointment system for every patient, either because you do not own the
practice you are working in or you prefer not to, I would be very clear about
how you are screening your patients. Know when you are able to present a
single-tooth option there and then, and when you will switch to a more
thorough information gathering and invite the patient back. A huge barrier to
capturing the required information is not having the equipment ready and on
hand, especially when you are working against the clock and appointment
times are short. It is not an effective strategy to have your assistant running
around, bringing in the camera and the scanner or setting up for impressions
because you have decided that this is a more complex case.

3. INITIAL SCREENING APPOINTMENT WITH AN OPTION TO

CONVERT TO THREE-STAGE
If your initial appointment is so short that you cannot easily gather all the data
that you require, then you may have to switch to inviting the patient back for a
“fully comprehensive evaluation,” followed by a case presentation. If this is
the case, it is better to be completely up front about it and motivate the
patient with enough information that they remain engaged in the process. An
intra-oral scanner or camera can allow you to visually highlight some of the
challenges, such as fractured restorations or worn teeth, and you can explain
that in order to provide all of the options you need to gather more
information, which requires a longer appointment in order to do that
thoroughly. You will then study the information and make a second
consultation appointment, where you will be able to be much more specific
about all their options, pros and cons, associated risks, and all of the costs
involved. From there, you can help them to decide the best way forward.
Sometimes I say:
“I like to look at all of the options both for now and the future. That
doesn’t mean that you need to do all this dentistry now, but at least you
will understand what the future holds and can plan accordingly.”
Patients like this approach as I am taking out the fear that they would have to
commit to too much right now. Nobody has ever objected to “finding out
what the future may hold.”
Effective communication can be defined as: The message received is the
same as the message sent. As dentists, we cannot help ourselves but use
dental jargon which is almost impossible for someone from a nondental
background to comprehend.
DIGITAL CAP TURE
With the advent of digital capture devices, we can truly consider “capture” to
be creating a digital version or clone of our patient. This is a gamechanger.
Utilizing digital photography, video and intra-oral optical scans that we can
have access to remotely allows us to switch our minds into “information-
gathering” mode during the patient exam.
Depending on your ethos and clinical skills, you can intertwine asking
questions with prescripted data points that will be captured for every patient.
I have a template for my clinical exam notes that guides me to record the
detail that I need to obtain with the patient in the chair. I am gathering data
and measurements and not making any diagnoses that require thinking time.
This means that I can relax and be genuinely curious and interested in my
examination findings without also having to be thinking about how I’m going
to explain the treatment plan. I have combined this template with teaching I
received throughout my career and the legal requirements in the UK to
produce a template in my clinical software that I follow for every patient.

1. Preclinical capture Dental history, medical history, experience of

prior dentistry, patient desires, presenting complaint, and estimate
of personality style.

2. Clinical photography and video Intra-oral scan.

3. Clinical data Airway, TMJ exam, soft tissue extra-oral, facial

measurements, intra-oral charting, perio screening, occlusal
screening.

4. Necessary radiographs

5. Further tests or diagnostic info Such as vitality tests, facebow

registration, CBCT—as appropriate at this initial appointment or
delayed to a second stage.

Analysis is a discipline. We, as dentists, are guilty of looking at a case or a

problem and wanting to jump right into the treatment plan, almost like an
eager child in a classroom with their hand up saying, “Oh, oh I know the
answer. Miss, please, Miss!” I have learned the hard way that if we jump too
quickly into solutions, we will make mistakes. We will make mistakes!
Maybe not every time, but we will have missed something. Full-mouth
dentistry is too complex and too multifaceted for you to know at a glance
what to do and have the verbal skills to be able to present it in a way that the
patient will understand and not feel like they are in a high-pressure sales
environment. Dentistry with integrity requires correct diagnosis. As I have
described earlier—what is the diagnosis in dental terms is almost a
misleading question. Diagnosis of what? Malocclusion? Vitality? Perio
status? Esthetics? The key is to follow a protocol—I call this guided
observation.
Many teachers tell us to think in terms of biology, structure, function and
esthetics. This can be useful. It can also be useful to start on the outside and
work in: medical history, global diagnosis, airway, TMJ, smile design,
orthodontics, missing teeth, tooth-by-tooth endo/vitality, risk of future endo,
caries, periodontal status, radiographic results, biomechanical status, tooth
loss from erosion/attrition and so forth, and signs of instability. There is a lot
to consider! I find that a template which guides me through these assessments
gives me the discipline to complete the information and really look.
Smile design, compared to a starting point, considering function and building
up a storyboard starts to identify the priority challenge list. You may decide
to explain some problems to the patient but accept others. Some are
deteriorating and take priority, such as caries or active disease. Some are
age-dependent; for instance, wearing facets on second molars may be
acceptable at age 70 but less so at age 24.
It will be interesting to see how the increasing use of artificial intelligence
will shape the world of treatment planning. Currently, we still require our
eyes and our thinking minds to work with our patients to define the big
picture, capture the information, identify the priorities, take into account the
risks and benefits of alternatives, and be able to present this to the patient as
a road map with easy-to-understand choices. Investing time in capture,
analysis and planning will allow the clinician and the patient to communicate
and work together toward a shared end goal. The implementation of the
clinical dentistry will have been well planned and considered, which will
set expectations, increase patient satisfaction and reduce stress!
S CRE E NING VE RS US DIAGNOS IS
There is a difference. In the outside world, screening refers to testing an
asymptomatic population for a particular condition in order to identify those
who have the condition so that they can be treated early. Common screening
tests may include taking blood pressure to check for undiagnosed
hypertension, skin cancer screening, and blood tests to detect diabetes.
Diagnostic testing, on the other hand, involves looking at all of the symptoms
in order to consider the differential diagnoses and to undergo further tests to
rule out the possibilities one by one, until a definitive diagnosis is reached.
Our challenge in dentistry is that patients often have no symptoms. For the
most part, caries, periodontal disease and occlusal wear are asymptomatic.
Our patients come to see us to “check” or “screen” to see if they have
problems that could be treated early. As mentioned, we are screening in
multiple areas:

1. Head and neck cancer screening

2. TMJ health

3. Muscle health

4. Periodontal status and intra-oral soft tissue health

 Structure of the teeth, presence of tooth decay, integrity of
5. restorations

6. Endodontic screening

7. Pathology in the bone and supporting structures

8. Non-carious tooth surface loss

9. Missing teeth and subsequent occlusal or functional problems

10. Esthetic concerns

One could also think of every specialty that exists in dentistry and consider
that the general dental practitioner is screening in all of those areas to
understand where referral may be appropriate:

1. Orthognathic

2. Orthodontic

3. TMJ and facial pain

4. Periodontal

5. Endodontic
 Missing teeth, worn teeth (prosthodontic)
6.

7. Teeth requiring extraction (oral surgery) or pathology

8. Teeth requiring replacement with implants (oral

surgery/periodontology)

9. Growth and development issues (pedodontic and myofunctional)

10. General health (medical/sleep)

If we understand what health looks like in all of the ten regions, then we can
start to identify when there are issues. We are qualified to diagnose some of
those deviations from health. Some of them will alert us that there is a
deviation, but it may be out of our scope or confidence to arrive at a
diagnosis and we can communicate this to the patient and initiate a referral.
Other examples of areas we may “screen” for rather than diagnose are:

1. Airway issues

2. TMJ dysfunction

3. Daytime sleepiness

4. Hypertension
A network of interdisciplinary specialists who can support our work is
invaluable. This can be developed by attending local networking events and
getting to know the relevant specialists in our area. Depending on our level
of postgraduate education and special interests, we may choose to diagnose
and treat in some areas, where others may prefer to refer. This is the beauty
of our profession. We can focus on an area of special interest or we can
refer. We can choose when to treat simple cases and when to refer.
You don’t know what you don’t know. The more we commit to
lifelong learning, the more we will be able to screen accurately, diagnose
more comprehensively and refer when necessary.
Communication skills are just as important when it comes to referrals. For a
patient, a referral means a visit to a different office, additional appointments
and additional unknowns. If referral is in your patient’s best interest, it is
helpful for you to visit your referring doctor’s office. Build a relationship.
Make sure that your patients will be treated with the same level of care that
you offer them. The practice you refer to will be a reflection of you in your
patient’s mind, so choose carefully. It is important that communication
between offices is clear and consistent and that the patient feels well cared
for. If you are fortunate enough to work in a multidisciplinary office, then this
problem is reduced.
A learned implantologist from London, Dr. Eddie Scher, a wonderful teacher,
taught me during my master’s degree that the general practitioner should be
the “captain of the ship.” These patients are our patients. Our job is to find
the right team to help us give patients the best solutions that will improve
their health, function and esthetics as appropriate.
RE D F L AGS
And so the promised red flags, which should nudge you away from
immediate single-tooth solutions and into investigation and analysis:

1. A broken tooth and other teeth with a history of fracture or large

restorations.

2. Wear of any kind, particularly in a younger individual. Look at the

lower anteriors. Look at the canines. Look at the guidance. If there
is wear through to dentine and the patient is younger than 80, then
this may be an issue worth analyzing.

3. Periodontal issues beyond localized gingivitis.

4. Missing teeth with spaces or a request to replace a tooth.

5. Any requests for smile design improvements.

I am sure that this list is not exhaustive. In principle, when you look at a
mouth as a whole, be curious and think, “Hmm, I wonder how this story has
developed?”
Take some time and do the analysis through guided observation, and the
answers will become apparent. To put this in context, there are ten steps in
total to take a patient through from initial contact to completion of treatment,
with four steps between capture and treatment planning. These steps are:

1. Capture the data

2. Guided observation–diagnoses and observations based on all the

 data

3. Smile design

4. Risk assessment

5. Challenge or problem list

6. Treatment options

7. Case presentation

8. Definitive treatment plan, including consent

9. Appointment sequencing

10. Implementation of the plan

Guided observation includes analyzing the smile and function, tooth by tooth.
Smile design includes designing the ideal smile and then considering how
this might affect and be affected by function, tooth by tooth.
However, guided observation and smile design are not the same.
Guided observation tells us where we are now: Point A.
Smile design gives us our destination or where we want to be: Point B.
Guided observation is turning every jigsaw piece the right way and seeing
the component parts.
Smile design is drawing the picture that will be made up from these jigsaw
pieces.
Guided observation leads us to diagnoses and risk assessment. Diagnoses
and risk assessment are the signposts along the route to point B. We cannot
drive the route to point B by ourselves. We, as dentists, are the guides to
point out the signposts and dangers (risks), and guide our patient through the
decisions that need to be taken in order to reach point B.
Treatment planning is problem solving. How can we get from point A to
point B? Which way or direction could we go, and what are the risks and
benefits of those routes?
Case presentation is how we tell the story of the journey from observation
to design and map the route between the two. We present this to the patient in
a way that educates and motivates without overwhelming them so that they
can become co-pilots in the journey between point A and point B.
What our patients should have an understanding of

1. Their own individual risk status

2. How they may improve their risks in some areas

3. How those risk factors will affect their need for dental intervention
in the future

The agreed journey is the treatment plan.

Implementation is how we need to sequence the treatment in order to be
efficient and predictable, and how we quality assure our results as we follow
the treatment plan.
The following timeline identifies the processes involved in a thorough,
systematic smile analysis. We will consider each step in the following
chapters.

Further Reading
Daniel Goleman, Emotional Intelligence, Bloomsbury Publishing, 2020.
Adam Grant, Think Again, Penguin, 2020.
William Robbins and Jeffrey Rouse, Global Diagnosis, Quintessence
International, 2016.
C HA PTER 5
C A PTU R E THE D ATA
“Shame cannot survive being spoken. It cannot survive
empathy.”
BRENÉ BROWN
Of course, not every patient who comes to see you will feel ashamed of their
mouths or dental conditions, but it is important to remember that many do. A
percentage of the population may have avoided dentistry for many reasons,
and some may have experienced being made to feel ashamed of their dental
neglect in the past. Childhood memories may be of being scolded for not
brushing their teeth properly or for eating too much sugar.
Brené Brown’s research has proven that shaming or attempting to induce
shame in others is not an effective tool for social justice. I appreciate that she
has not been studying dentistry, but correlations can be made. I cannot see
any purpose in making a patient feel ashamed—that does not serve to build a
trusting relationship in order for us to be able to help them.
Add to this the vulnerability that a patient has to open themselves to at the
dentist and we can learn a great deal from Brené Brown.
The steps of our patient journey should ensure that patients feel safe and
listened to, and that their individual circumstances and history are not judged.
Capturing the data begins with the very first contact with the practice. The
more information that we have before the patient comes to see us, the more
we can immediately begin to build trust and tailor the experience for the
individual patient.
How capture can be broken down
 Preclinical—Patient’s reason for attending, dental history, medical
1.
history, social history, screening questionnaire

2. Photography and video

3. Digital intra-oral scan (IOS scan)

4. Clinical examination

5. Radiographs/CBCT

P RE CL INICAL
We need every member of our team to be prepared to listen and pay attention.
Appointments for a new patient may come from:

1. New telephone inquiry

2. Social media or email inquiry

3. Virtual consult

At the very least, we will have an idea of the reason why they are
attending

1. A second opinion

2. A specific esthetic concern

 A specific symptom or pain
3.

4. General dentistry (moved to the area, previous dentist retiring, etc.)

Our team is trained to explain that the process generally takes two visits; the
first to gather the relevant information, then the time we need to study it.
When the patient comes back for a consultation, we can be much more
specific about all the options with the pros and cons and specific costs. The
cost for the initial appointment is $X, and the second appointment is
included. This also includes all necessary radiographs.
It is very important that this process be explained right at the beginning of the
patient contact. Why? For two reasons. Firstly, it allows the patient the
opportunity to object. For instance, if they have symptoms that they need
treated that day, then we can change the appointment type or length to
accommodate this. Secondly, it can allow us to have both appointments on
the same day if need be, perhaps over a lunch break so that I can study the
data then. It also sets the expectation for the patient that we will not give
them all the answers at that first appointment. I often hear the objection that
patients expect to hear their options and will be disappointed if they do not.
In my 25 years in practice, I have only had two patients who objected. Most
are delighted that you are going to study the information and give them such
due consideration.
It is helpful to send medical information forms in advance, either as a link
which can be submitted online or printed. This allows patients the ability to
fill out confidential medical information in privacy. Part of our pre-
appointment care is to check that these forms have been completed. We also
ask about the patient’s dental history and their reason for attending. These
forms can be as detailed or as simple as you prefer. Some education
facilities produce very comprehensive forms, but some practitioners prefer
to save the information gathering to be done in person. The choice is yours,
but some structure to the questions that you ask is helpful.
However much information you gather pre-appointment, it is vitally
important that you or your treatment coordinator have that information at the
introduction and that they make reference to it and not simply ask the same
questions again. There is nothing more frustrating to a customer than to fill
out a form in great detail and then have the professionals concerned make no
reference to it or ask you the same questions again!
At Cherrybank Dental Spa, the preclinical part of the new-patient experience
is carried out by a treatment coordinator. This has been explained on the
initial call so that the patient’s expectations have been set. It is also carried
out in a nonclinical area so that the conversation is adult to adult and not
affected by the vulnerability that is often felt by anyone with any anxiety
about dental treatment when they are asked to sit in the dental chair.
All of my treatment coordinators are qualified dental nurses/assistants and
they introduce themselves as such so that the patient understands that they are
speaking with a dental professional. A treatment coordinator can separate the
clinician from the conversations about money, can act as an advocate for the
patient, and is able to answer questions that a patient may not ask the dentist.
In Chapter 1, we looked at the importance of a smile in human society. A
smile is an expression in motion. As human beings, we utilize facial
expressions in order to communicate our feelings and to be able to relate to
each other. Open expression allows us to relate to each other with genuine
communication, and the best way to capture this expression is with video.
P HOTOGRAP HY AND VIDE O
As we have considered, the “Duchenne” smile is well documented in the
literature as being a smile of the face where muscles, such as the orbicularis
oris around the eyes, as well as the muscles of the lips, are activated. This
type of smile is perceived as genuine (Bogodistov and Dost 2017). When
someone is trying to guard their teeth from showing, they may activate the
muscles around the mouth but not have a fully relaxed smile. This type of
smile can then be regarded as guarded or not genuine, and other assumptions
may then be made.
This lack of freedom in expression has traditionally not been connected to the
dental professionals’ “smile design” concept of an ideal smile. It is the
perception of the patient who does not have freedom of expression when they
are being observed. This lack of smile freedom can be detected if a patient
has a different “posed” smile in a photograph, compared to a dynamic smile,
which is more easily captured by video. Numerous studies have researched
the differences between static and dynamic smiling. In one study, there was
found to be a difference in maxillary lip position of over 30 percent in
dynamic smiling, compared with posed smiling, meaning that the lip rises 30
percent higher in the premolar area compared to a static smile (van der Geld,
Oosterveld et al. 2008).
This also applies to the mandibular lip line. The tooth display in speech can
be very different compared with a smile, and video diagnostics allow the
capture and analysis of this (van der Geld, Oosterveld et al. 2007). This may
be one of the reasons why patients often report that no one ever sees their
lower teeth. When we look at posed photographs of us smiling, we often do
not see lower teeth. But during speech and dynamic expression, many more
teeth are revealed.
Smile analysis therefore begins with capturing both technical and emotional
images, and then using a tool such as Keynote or PowerPoint, or a specific
software or iPad app (DSDApp, for example). Whichever method is chosen
will depend on the user, as they all achieve the same end point. The basic
philosophy is that if we standardize photographs from the front, we can place
lines over the face and smile. Our visual system is designed such that we are
constantly making comparisons, and as such, by placing lines on the face, we
start to recognize facial and lip asymmetries that we may otherwise miss. In
addition, as placing the lines in a systematic way is the start of the process,
this helps us to connect the position of the teeth and design the ideal smile
according to the face.
Technical versus emotional photography
In practice, we can separate the capture of digital photographic images into
technical and emotional images. Technical images are used for clinical
diagnosis and capture of standardized clinical photographs. For example, the
British Academy of Cosmetic Dentistry and the American Academy of
Cosmetic Dentistry have a series of clinical photographs that are required as
a before and after treatment sequence in order to examine the quality of the
dentistry for the accreditation protocol (Dentistry 2017). Technical images
are generally standardized in terms of magnification and field of view.
Emotional images are designed to capture the personality and expressions of
a patient. They are non-standardized and designed to allow analysis of the
dynamic nature of facial expression according to the personality of the
patient. Emotional images can include photographs, generally portrait in
nature, and video of facial expression. Still images can be captured as still
frames from video clips. In this way, the dynamic nature of lip movement,
tooth display, and how the position of the teeth relates to the face in
movement and speech can be analyzed.
Photography can be the weak link in implementing detailed
analysis and being able to involve the patient in the codiagnosis
process. It is worth investing in training and education to learn how
to take good, reproducible photographs. There is nothing more frustrating
than sitting down to do your analysis and finding that the teeth in the full-face

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photograph are slightly out of focus, the patient’s head is rotated to one side,
or specific images like the profile picture are missing.
My advice is to train your assistants, treatment coordinators and hygienists to
take the pictures but have systems in place to give feedback and further
training so that mistakes can be rectified. The difficulty with having multiple
people take the photographs can be consistency. In some practices, the dentist
likes to take control of this process. I have also seen it work well in a
practice where they had an in-house photographer who took all the pictures
and was responsible for putting the storyboards together. You will need to
find what works for you and your team.
In my practice, the treatment coordinators take the full-face smile
photographs, profile photographs, full face at rest, and a short video to
capture expression and phonetics. They then hand these over to the dental
nurse to take the remainder of the intra-oral pictures with retractors in the
dental chair.
Properties of the most important photograph for technical smile analysis

1. The photo should be taken directly from the front with the patient
looking straight at the camera.

2. The photo should be taken slightly from above the mouth to avoid
an artificial reverse smile.
 The camera should be focused on the teeth and not on the tip of the
3. nose, which can be checked by zooming in on the camera after the
photo is taken.

4. Hair should be behind the ears, glasses off, and chin down.

5. The patient should have their teeth slightly apart.

6. If the gingivae above the upper anterior maxillary teeth do not show
in full smile, then it can be helpful to have a full-face retracted
smile at the same head position.

7. This photo should not be taken in a dental chair as this tends to tip
the patient backward. Ideally, the patient is sitting on a stool or an
upright chair with a straight back and looking straight ahead.

Full-face smile photograph

Full-face retracted photograph
This image can be helpful in the design stage if the full gingivae are not on
display in the previous picture. Again, it is important to have the teeth
slightly apart and the head upright with hair behind the ears and chin down.
Profile at rest
The profile pictures will be used to consider the A/P characteristics of the
skeletal base. It is important that the patient be looking straight ahead and that
you see the angle and lower border of the mandible. The picture must be
taken with the patient sitting at 90 degrees to the photographer, not simply
turning their head to the side, as this distorts the neck and looks strange.

Full-smile profile
This picture allows us to see the position of the upper incisors in an A/P
relationship. It is taken as above with the patient at 90 degrees to the
photographer and looking straight ahead.

Full face at rest (M-position)

Tooth display at rest
Asking the patient to say “m” or “Emma” and just come to rest with their lips
and teeth slightly apart will show how much tooth display there is at rest (or
repose). You can record this as a measurement directly into your clinical
notes or take it as a full-face photograph and measure at a later time.
For example, this patient shows about 5 mm at rest.

This patient from the full-face picture above shows about 3–4 mm.
This patient had two central incisors avulsed and reimplanted when she was
nine years old. The two teeth became ankylosed, which restricted the
dentoalveolar growth. This resulted in a reverse smile curve and the
display at rest was –3 mm at age 16. This means measuring up from
the lower border of the upper lip, under the lip until the incisal edge is
reached—easy to do with a perio probe. This is obviously not ideal for a
young person and is one of the reasons they were seeking help.
Common mistakes in smile analysis photography

1. The patient isn’t showing enough of their teeth. If you have a very
shy patient, it is important that you have some tricks to get them to
show their teeth. Asking them to do an exaggerated “E” sound can
help.

2. Teeth not separated—this makes it difficult to evaluate the incisal

edges, especially during the design stage.

3. Mouth wide open—this distorts the face and makes any attempt at
smile design imaging look strange to the patient. Remember, the
 amount of opening in order to have the teeth just apart will vary,
depending on the bite status of the patient. An edge-to-edge bite
will need to open very little. A deep bite will need to open a long
way.

4. The head is rotated to one side or another, so the photograph is not

showing the true smile from the front.

There are many excellent photography protocols—for instance, the British

Academy of Cosmetic Dentistry and the American Academy of Cosmetic
Dentistry both teach a systematic method of recording clinical photography.
Exactly which photographs you choose to take will depend on your interests
and whether or not you intend to use the photographs for articles or
publishing.
My recommendation is that you have a laminated sheet in each operatory
where the photographs are to be taken which serves as a checklist to remind
everyone which pictures you need.
Note on occlusal photography: Full-arch photographs with mirrors can be
challenging pictures to do well. If you have an intra-oral scanner with color,
then it begs the question: Do we still need the full arch pictures? Showing the
patient with the scanner allows the teeth to be viewed from different angles
and is more complete viewing than an arch shot. Yes, the color is not true to
life, so this is a personal decision but one worth considering both for time
efficiency and the comfort of the patient.
F URTHE R IMAGE S
You may have your own preference or protocol for photography. I also like
the 45-degree or conversational angle. It can be explained to the patient that
this is an angle that people see of us in conversation with more than one other
person. It is taken with the maxillary lateral incisor as the central focus.

INTRA-ORAL IMAGE S
It is helpful to have a protocol that you follow in terms of intra-oral
photography with retractors. My aim here is not be prescriptive about which
photos you take, but I would ask that you take them consistently.
A word about dentures: If patients have partial dentures, I would take the
full-face smile analysis photographs with the dentures in, but take the intra-
oral photographs with the dentures in and with the dentures out. This also
applies to the intra-oral scan. This means that when you are in analysis mode,
you have all the information about the esthetics with the current solution and
also the condition of the underlying dentition and soft tissue.
The value of a video capture protocol
Remember, a smile is an expression in motion. There can be a significant
difference between a “posed” smile and a dynamic expression of emotion.
This is why for true smile analysis, it is essential to capture video expression
as well as making decisions from still, posed photographs. Video can be
taken either with a digital SLR camera on a tripod that has that capability, or
on a smart phone with appropriate lighting. I really like the Smile Line light
by Professor Louis Harding. It gives dynamic lighting solutions to any smart
phone and is extremely portable.

F RE E DOM—THE IMP ORTANCE OF

VIDE O
“Expression is like a butterfly, it is beautiful when it is free.”
FLORIN COFAR, DENTCOF, TIMISOARA, ROMANIA
We validate this concept as we prepare to take videos of our patients. During
the prefilming discussion, if we have the video running, we capture the
dynamic expression. When we ask the patient to give us their “biggest”
smile, the psychological restriction kicks in, and if they have any concerns
about their smile, the result is very different. This is not freedom. The ideal
situation, of course, is where there is no difference between posed and
spontaneous expression and individuals have the freedom to express
themselves, from a smile perspective, without reservation.
Examples of a posed smile
Examples of a spontaneous expressive smile—Note the difference in
gingival display
If you also look at the patients’ facial muscles, you will see that the second
picture clearly shows a Duchenne smile. The facial muscles are softer in the
first smile, and where the female is concerned, her eyes are not “lit up” in the
same way.
Uses of video

1. Short presenting complaint video—Taking a video of the patient

and having them explain in their own words what it is they do not
like about their smile can be very helpful to review during the
planning stage, as can sharing with a dental technician or a
specialist, if required.

2. Functional video—Taking a video, with retractors in, of a patient

chewing provides helpful information on guidance that can be
shared with a dental technician or colleague.
 Side view for phonetics—Asking a patient to count from forty to
3. fifty and then back again can allow you to study the “f” and “v”
sounds. When saying these letters, the tip of the upper incisors
should brush the wet-dry line of the lower lip. Observing this will
allow you to see if you think the case is additive or not, or if you
use this when evaluating a trial smile or phonetics, you can tell if
the incisal edges are interfering with phonetics.

4. Capturing the full, genuine smile. The reason for asking people to
go backward and count from fifty to forty is because this is not
intuitive, and if a person has taught themselves to guard their smile
by keeping their lips tight, they will be less able to do this when
counting backward. This is the perfect opportunity to make light of
the situation and give then a friendly reminder that it is not a test.
This might even be enough to generate a genuine smile free from
guarding.

5. Video is very helpful for try-in stages of clinical work, especially

where changes need to be made. The dental technician can hear it
firsthand from you and the patient without having to verbally
explain the visual changes required.

6. Video testimonials with patients are very powerful for social media
marketing.

The most engaging, empathetic person in your team should take the videos
where your aim is to capture that full, genuine smile. Sometimes this is better
done by a team member like a treatment coordinator with whom the patient
may be more relaxed than with the dentist.
Important keys for success with video

1. Adequate lighting—Without this, the video will appear grainy. The

Smile Line light is excellent for this.

2. Keep the videos short—One to two minutes max, otherwise the

files become very large and hard to send and transfer.

3. If you are recording in HD, you can use any still of the video as a
still image for your analysis.

4. Do not video from too close to the subject.

DECISION POINT If you are new to taking video, give some thought to
who, how and where you are going to implement this. Video is so helpful,
important and easy to do that it will pay dividends if you stretch your comfort
zone and make it an objective. Decide if you are going to use a practice smart
phone or a digital SLR with video capability. A tripod is an inexpensive
addition, as are additional lights and a backdrop.
DIGITAL INTRA-ORAL S CAN
The essence of taking an intra-oral scan is the process of “digitizing” your
patient so that you are able to study and proceed with the smile analysis
without the patient present (Suese 2020).
In my practice, we use the iTero intra-oral scanners. Whichever brand of
scanner you have, I would recommend having a protocol that includes taking
a full upper and lower intra-oral scan and a centric bite registration as a
baseline for every full examination.
DECISION POINT Intra-oral scan or study model impressions?
If you do not have access to an intra-oral scanner, then I would definitely
recommend being prepared to take upper and lower alginates for study casts
with a bite record. Depending on your experience and the focus of your
practice, you may also wish to take other records, such as a facebow and CR
record, or you may consider these for a subsequent appointment. It is
possible to take multiple bite registrations digitally with most scanner
systems. The crossover to the facebow and analog mounting is one of the last
pieces of the puzzle still to become mainstream with the digital workflow.
If you are considering the purchase of a scanner, then I would make sure that
you can access the scans remotely. With iTero, there is platform called
MyiTero.com that I can log in to from anywhere and access all my scans.
This has proven invaluable for me to be able to consider my cases without
needing to have access to the scanner or scanning computer.
CL INICAL E XAMINATION
This is your full examination, including notes about examination of the soft
tissues, TMJ function, dental charting, periodontal charting, and so forth.
Digital record keeping allows us to capture pictorial charts and written notes
about our patients. Periodontal charts can be captured with manual or digital
capture of pocket depths (Marks, Low et al. 1991).
Remember, while you are collecting the information, there are verbal skills
that can help you to “sow seeds,” and it is also important to avoid the use of
“minimizing words.” It is equally important not to start giving solutions. You
are in information-gathering mode. You will then be undertaking a
systematic analysis and will be able to report back to the patient with
specific options, including costs.
“Sowing seeds” is beginning the process of patient education. For example,
before carrying out a periodontal examination, it can be helpful to explain to
the patient that healthy gums should not bleed or be tender, and if they feel
any tenderness, ask them to raise their hand so that they are participating in
the process of discovery.
Be careful of minimizing words such as “just a little decay,” “some small
fillings” or “a little bleeding.” Often we use these words in an attempt to
encourage the patient, but it can backfire and leave the patient with the
feeling that everything is okay.
Ask questions to discover more about their motivations and their desires.
Find out if they know about dental implants, for example, or if moving their
teeth was an option, is this something they would consider. The more you
find out, the more equipped you will be when it comes to the second
appointment.
Using a template in your practice management software can help you to
capture all of the clinical data that you will need for the next step. The aim of
your words during the clinical exam is to say enough that your assistant can
record what is required, and then to say enough to the patient to begin the
education and also motivate them to attend for an initial periodontal exam
with your hygienist if that is appropriate and, especially, to be excited about
the second visit.
DECISION POINT In days gone by, we needed to do all of our
observations with the patient in the chair. This was time-consuming and
inefficient but was necessary because as soon as the patient left, all the data
went with them. Your decision, therefore, is what data you need to capture
with the patient in the chair so that you have everything you need when you
sit down to study. A clinical exam template will not be the same as the
diagnosis and observation (D&O) template that leads us through the smile
and mouth analysis. I have made suggestions in this book, but these templates
will be constantly evolving and will be different, depending on your
particular interests. Find what works for you.
RADIOGRAP HS / CB CT
The images captured can help to justify and explain the need for radiographs,
which can then be prescribed so that you have all the information that you
need to be able to study. If the options will include implants and the patient
consents, then you may prescribe a CBCT.
I explain to the patient that the radiographs are the last part of the puzzle that
lets me check in between the teeth, see the bone levels, and check under all
the existing restorations. Then I will have all the information I need to be
able to study and come up with some different solutions.
E ME RGING TE CHNOL OGIE S
MODJAW—There are a few emerging technologies which aim to solve the
“virtual articulator” part of the digital capture of information. There are some
issues with transferring the TMJ arc of opening and closure using traditional
facebows. Printed models do not mount well on traditional articulators that
are meant for plaster models. Calibrated photographs can help a dental
technician to align the true horizontal of the maxilla and reduce canted
midlines, which can occur without this detail.
MODJAW, for example, uses a system of sensors and cameras to record the
movements of the jaw, which can then be integrated with the lab planning
software Exocad to allow the technician to virtually mount models to the
patient’s movements rather than the average values in a generalized virtual
articulator.
There are likely to be more emerging technologies in this field in the near
future.
There are also methods of digitally capturing the face, such as the app
Bellus3D Dental Pro and Planmeca’s Face Hunter, so again, these could be
utilized to aid your planning.
COMMUNICATION S K IL L S TO
E NHANCE CAS E ACCE P TANCE
Although you are only just beginning to build a relationship with your patient,
the path to case acceptance starts now. Every little part of the patient’s
experience will contribute to an increase or decrease in trust. Codiagnosis
begins now, and just as patients will have different needs and personality
styles, your ability to tailor your communication strategy to the individual in
front of you will determine your success.
There is a saying that I find helpful to consider and share with my team. It
helps us to consider emotional intelligence and the best communication
strategies to motivate or reassure the patient: “Afflict the comforted and
comfort the afflicted.”
The application of this begins in the capture appointment. I want to sow
seeds of problems, if I see them, so that the patient can begin accepting that
there are some issues, particularly if there seems to be a mismatch between
their expectation of health and the reality. On the other hand, if the patient is
very nervous and fearful, I want to give them hope that there are definite
solutions and that they have come to the right place.
In other words, if someone is completely unaware that they have problems,
they can be considered as “comforted,” and we need to begin the process of
showing them the difference between health and their situation. Remember, to
do this effectively, it is helpful to move carefully and have visual evidence.
On the other hand, if someone is sure that they are a lost cause, then they can
be considered “afflicted,” and they need more reassurance. If we are too
heavy handed and start pointing out all the problems, we may send them into
a downward spin of despair!
The digital tour of the mouth with the intra-oral camera is very helpful to
continue “sowing the seeds” after the clinical exam. I can sit the patient up at
the end of the appointment and say, “Let’s have a look at the scan. You can
see here how much tooth structure has been lost. The other issue I need to
think about is how your teeth come together when you bite; you can see
here that although we would want your tooth to be longer, when you bite
together, there is no space. If moving your teeth to create space was an
option, is this something you would consider?”
The “if... consider...” question is very helpful in gathering the information.
Even if the answer is no, that doesn’t mean this isn’t a treatment option, but it
means the educational and motivational part of the storyboard presentation
will need to be strong!
I end the appointment by saying, “Well done. That’s all the information I
need now to be able to look at everything and figure out what all your
options are. When you come back next time, we will be able to be much
more specific about your options, including costs, and then we can see
where you want to go from here. Do you have any questions?”
Once the “capture” is complete, the patient can leave. You have everything
that you need to proceed to the next step.
HOW TO ORGANIZE THE CAP TURE D
DATA
Once we have captured all the images, we need to have a system in place to
be able to download them and store them. It is good practice to immediately
download the photographs into a patient file on your system or in a secure
cloud storage system such as Dropbox. From there, the images can be copied
into a template which we call the storyboard.
Too often, I see dentists who have the information scattered—some on their
phone, radiographs on a practice management system—and clinical notes
being recalled from memory. When they try to study the case as a whole, they
find it impossible.
DECISION POINT Consider how your team can help with this stage
 Who is taking the pictures and with which device? If the photos are
1. being taken on a practice iPhone, then a practice iCloud account
can be set up. If they are being taken on a digital SLR camera, then
a card reader may be required.

2. How do we export the radiographs from our software?

3. Can our dental nurses take the intra-oral scan?

4. Are we able to access the scan remotely or do we need to take

screenshots?

It is good practice to make this assimilation of all the images part of your
patient appointment because if these jobs stack up, then they become time
consuming and the images risk becoming muddled.

There are PowerPoint or Keynote templates available from many of the

leading educational faculties. I have used and adapted the original template
shared by Christian Coachman and Digital Smile Design (you can download
it by scanning the QR code). You can also develop your own. The key is to
have a standardized format where you can download your images and have
access, ideally remotely. You can add your logo to every slide or just the first
slide.
After the examination, the images can be loaded into the presentation
software. Radiographs can be exported, or screenshots taken. The file can
then be saved as patient name. At the time of writing, we have a practice
Dropbox account with a folder for each treating dentist, and inside those
folders are two further folders: one called Diagnosis and Observations and
one called Ready for Presentation. Each dentist can then access these folders
from their laptop or workstation when they have time to plan. Once the
Diagnosis and Observations form has been completed, the dentist moves the
storyboard file into the Ready for Presentation folder, which is the indication
for the treatment coordinator that the case is ready for presentation.
To summarize, you have now captured and organized the data. What you
have recorded

1. Preclinical—Patient’s reason for attending, dental history, medical

history, social history, screening questionnaire

2. Photography and video

3. Digital intra-oral scan (IOS scan)

4. Clinical examination

5. Radiographs/CBCT

Example of a storyboard in early development. Keynote.

 You have it ready and accessible so that you can schedule time for the
next stage.
Further Reading
Louis Harden, Protocols for Mobile Dental Photography with Auxiliary
Lighting, Quintessence International, 2020.
Amanda Seay, Art Esthetics Dental Photography, Edra Publishing, 2022.
C HA PTER 6
GU ID ED
O BSERVATIO N
“Art is born of the observation and investigation of nature.”
CICERO
I live in Scotland where the winter daylight hours are very short. Around the
winter solstice and the Christmas holidays, the sun rises just before 9:00 a.m.
and sets again at 3:30 p.m. One of my favorite pastimes when the world is
dark is to light the fire, and before my dining room table is required for
Christmas day, I like to spread out the pieces of a 1000-piece jigsaw. It is a
family effort (although mostly me), and I’m quite particular about the jigsaws
I like to do. The one waiting for us this year is an inventor’s cupboard—
shelves packed with gadgets and tools. I don’t enjoy blue sky, one-color
jigsaws or maps with blank spaces as I need lots of detail to hold my
interest! Last year, we did a book shop, and the year before that, a sewing
cupboard filled with yarns and threads of different colors.
Here’s the thing with a jigsaw puzzle. You tip all the pieces out on the table.
Step 1—Turn all the pieces over, and in doing so, find the edges and the
corners. Step 2—Assemble the edges and the corners. Step 3—Look for the
colors and the patterns, and build the picture. A jigsaw makes you look at
every single piece in turn and figure out how they relate to each other. We
cannot simply look at the box and get the gist and muddle a few similar
pieces together. There are no shortcuts. We have to look at the detail in
painstaking, repetitive order and find the pieces with connections that fit
together. And as we are doing that, we notice little details about the image
that were never apparent when we first took in the picture as a whole. The
beauty of the finished product comes from the detail of every single piece,
like every single brush stroke made by an artist when creating a masterpiece.
As the observers, we take in the whole, but that whole was conceived as a
series of smaller parts, delivered in sequence.
This is my point about investigation—it is the systematic analysis of the
smile and the whole mouth (and holistic connection to the person). Indeed, I
often explain to my patients that their mouth is like a 3D jigsaw puzzle. We
have to study it, figure out what changes need to be made in order to achieve
the desired outcome, but also make sure that all those changes can fit together
in harmony.
This is the pathway to design. We cannot design the beautiful smile that
functions predictably if we make assumptions about where we are starting.
We need to be disciplined in analyzing the starting point.
DEFINITION: Analysis means to examine (something), methodically and in
detail, typically in order to explain and interpret it. Analysis is the process of
breaking a complex topic or substance into smaller parts, in order to gain a
better understanding. Other words for analyze are scrutinize, study and
examine. The process of analysis requires a discipline, or a system, to help
us bring some order to the vast amount of information that can otherwise feel
chaotic. This is the process I have termed guided observation.
For most of us in dentistry, with our varying personality styles, this is not
easy to do. Human beings look for patterns, and we are hard-wired to gather
enough of the facts that we jump to conclusions and make up the story to fit.
That is very natural and how we make sense of the world. Add into that a
busy schedule of patients and the assumption that we are supposed to come
up with answers quickly, and it is no wonder that this step is often
overlooked.
It is true that with experience, we can look at a mouth with a certain
condition and very quickly see the answer. With inexperience, we often think
we are supposed to be able to look at a mouth and see the answer. The
danger in both these situations is that we miss the detail and then fail to
address certain conditions, or neglect to give the patient the opportunity to
address conditions that may worsen over time.
The truth is, we can see what we have been educated to see. Yes, we can
have a pretty good idea as to the answer. But there is no way that we can
have thought about everything and analyzed comprehensively without some
system to guide our thinking and record the results.
Guided observation follows capture of the information. This systematic
analysis will lead us to diagnoses and, more importantly, allows us to risk
assess. We have captured all of the information. Using as much digital
technology as we have available, we can pull together all the information and
study it to find and define point A. Remember, point A is where we are
starting from. This is the crucial step that is so often missing in our busy
practicing lives. Like the jigsaw analogy, we need to spread out the pieces in
front of us and then have an order in which to review them.
DECISION POINT Keynote or PowerPoint? I am a Mac and Keynote
user. I have a MacBook Pro laptop for my lecturing and home use. You can
equally use a PC and PowerPoint. If this is your preference, please substitute
PowerPoint every time I say Keynote! And the shortcuts are generally the
same, with CTRL instead of CMD. Personally, I have found that Keynote is
more intuitive and handles images and video in an easier way, but if you are
familiar with PowerPoint it works too. Our office and practice management
system is PC based, and I have a couple of MacBook Airs for my treatment
coordinators to work from. We use Dropbox to share key files across the
cloud.
System for analysis of clinical data: Guided observation

1. Have your data in front of you.

2. Have a comprehensive form to fill out. This will guide your

attention to look at everything in sequence (I call mine the
Diagnosis and Observations form).

3. Have access to guidance notes, particularly if you have introduced

screenings that you are less familiar with or are in the process of
integrating new knowledge into your everyday clinical practice.

4. As you work through filling out the form, annotate pictures and
radiographs. Take screenshots of key findings from your intra-oral
scanner so that you can simultaneously build a visual story for the
patient in the Keynote storyboard.

5. Once the form is complete, distill the main points into a diagnosis
or diagnoses, and a challenge or problem list.

6. Now the treatment planning can begin.

The key is to have everything you need at your fingertips.

This is essential—to be able to fully analyze, you need to have
everything available to you.
System for analysis of clinical data: Guided observation
 Photos and videos
1.

2. Clinical records and periodontal charts

3. Radiographs and/or CBCT

4. Intra-oral scans or study models

In the pre-digital time, my treatment coordinator would get the photographs,

study model casts and radiographs, and we would sit together at the practice
computer. She would read from her preclinical notes, we would read my
notes, and I would think out loud while she took further notes. This was
effective for its time but not very systematic or time efficient. The process
was laborious, took two of us, and I had to be in the office to do it. Making
use of digital capture and workflow has allowed me the flexibility to access
the information I need from any location. There is some work in practice
required to be sure that all the data is where it needs to be. Systems and
protocols can be set up to ensure that this is done efficiently.
TIME MANAGE ME NT
One of the very real barriers for this process is lack of time. I encourage the
young dentists (often associate dentists) whom I work with to consider
themselves as a whole business, which requires clinical time and admin
time. They will be most effective with their clinical time and more
productive if they take some time to plan, away from patients. This is
admittedly hard to do in a busy practice, where a room or chair is reserved
for them for certain times. The expectation is that in order for the practice to
meet its overheads, they will be seeing patients for all available hours. The
advent of digital means that they should be able to set themselves up to
access the relevant information remotely. They can consider their working
week as clinical patient time and schedule planning time, perhaps from home
where they are focused, uninterrupted and unavailable to patients. It is not
sustainable to think that all of this important work can get done in the evening
or during lunchtimes. That may be possible if your working week is mostly
single-tooth dentistry and you see very few new patients, but it is not optimal
and can lead to increased stress and rushed thinking.
Uninterrupted time can be difficult to find, even for practice owners. The
excellent online course, The Science of Happiness at Work, taught by the
University of California, Berkeley, showed that even the mere presence of a
mobile phone on your desk next to you decreases productivity by 30 percent.
We all know this. Even with the phone on silent, the temptation to check
alerts and messages is there. Before we know it, we are completely
distracted from the task at hand and stress levels increase, as we are now
aware of other “tasks” we should be doing or people we need to answer. It is
then harder to drag our focus back to the analytical thinking that is required.
My advice would be to schedule some blocks of time in your week for
analysis and treatment planning. How much time you need will depend on
how many patients you see in a week. Find a time and place when you can
have quality, focused, uninterrupted time, turn off your email, and leave your
phone in another room!
My personal checklist when I sit down to investigate/analyze is on my laptop
(it could also be on your home computer or at the office) and includes:

• Photos and video downloaded into a Keynote or PowerPoint

 presentation (we call this the patient storyboard, which we share in
Dropbox), along with radiographs added as screenshots by my
clinical assistants. • Access to CBCT software if appropriate.

• Access to web-based intra-oral scans (I use the MyiTero platform)

or study models. • Access to practice management software where
you store your clinical notes.

• Access to fill out a digital template (or manual form) to guide

my observations and thinking to comprehensively diagnose. I use a
Diagnosis and Observations Form (Tab. 2 on page 77) that I have
transferred as a template into my practice management software.

• Guidance notes—Any guidelines on how to diagnose from the

clinical screening information gathered, for example, the new
periodontal classification flowcharts, normal values, smile design
steps, TMJ classifications.

• Access to smile imaging software (for example the DSDApp by

Coachman).

• Risk Assessment form.

Today, many practice management systems have a cloud-based capability so

that you can log in securely from any location. For others, you may need to
set up remote access, which should be possible if you have permission from
the owner of the practice server.
I like to use my Mac laptop to plan cases. I have access to my clinical
practice management software remotely. In Google Chrome, I can open two
tabs of the software at once so that I can read clinical exam notes while
typing. Also on Google Chrome, I can open the MyiTero platform and access
the intra-oral scans, and I can have the storyboard open in Keynote so I can
slide between that and the clinical data.
Any of the above could be paper based. The important thing is having access
to everything that you need in order to fill out the Diagnosis and
Observations form. If you are missing anything, you will not be able to move
on to the treatment-planning stage while being confident that you have seen
everything.
S CRE E NS HOT OF MULTIP L E
S CRE E NS OP E N IN GOOGL E CHROME
On my Mac, if I also have the Keynote storyboard open, I can use three
fingers on the trackpad to slide between this slide and the template.
In Tab 1, I can access the preclinical information, clinical notes and medical
history. In Tab. 2, I can enter information in my Diagnosis and Observations
form. This form is intended as a guiding checklist. To answer the questions, it
helps to be able to alternate between these screens and the photographs and
radiographs in the storyboard presentation, which you can have open in
Keynote. Remember, you can use three fingers on the trackpad to swipe
between the Keynote storyboard and the Google Chrome tabs.

Tab 1. Reviewing clinical exam notes (Dentally software)

Tab 2. Diagnosis and observations clinical note in full screen mode
(Dentally software)
Tab 3. MyiTero web access for virtual study casts.
K E Y NOTE S TORY B OARD OP E N F OR
THE PATIE NT
Images and radiographs

Note: The easiest way to take a screenshot on a Mac is to use the shortcut
CMD-Shift-4. A little cross bar comes up, which you can click and drag
across your screen to capture the area you need. This image appears in the
bottom right of your screen, and if you have the storyboard open, you can
drag it into the slide where you want it. If you wait, it will move to your
desktop and you can drag it from there.
On a PC, there should be a Windows key and a Print Screen button.
It can be useful to Google “How do I take a screenshot on my...” if the above
do not work or if you forget!
See the appendix for a blank copy of the Diagnosis and Observations
template.
S TE P S F OR ANALY S IS THROUGH
GUIDE D OB S E RVATION
Three comments before we begin:
Comment 1: Above the form in my clinical notes, I make the following
entry:
EH reviewed clinical notes, patient history, photographs in storyboard,
radiographs, and MyiTero.
My recommendation would be to enter this like an appointment, but making it
clear that the patient is not present. It is entered as a dedicated time during
which you reviewed the data and is date-stamped by the software. It also
makes its clear that the storyboard, photographs, and intra-oral scan are part
of the clinical records. Should anyone ever need to review the patient notes,
there is a clear indication of the level of consideration that went into the
analysis process.
Comment 2: The Diagnosis and Observations form that I use has been
developed from the many suggested versions that I have encountered during
my educational travels! For example, when I was training at the Dawson
Institute in Florida, we would be given manual forms to fill out in order to
analyze tooth by tooth and occlusally. Most of these forms from all of the
different teaching institutes are excellent and have been devised by practicing
clinicians. All of us are battling with the same problem—trying to find a
system of analysis that works in the real world.
Depending on your educational pathway to this point, some entries in the
form may resonate more with you than others, and you may already use some
that are different from mine. What I wanted was a method of starting globally
with the face, bringing in the smile at an early stage, but still having a link to
missing teeth, orthodontics and tooth-by-tooth structure. A method of
considering esthetics, structure, function and biology.
Comment 3: Consider that you are filling out the form for your use. Use it to
guide your investigation/analysis and review, and to aid your treatment
coordinator’s or any colleague’s understanding of the case. The answers do
not need to be entered in patient-friendly language. I use abbreviations and
dental jargon. The storyboard will be developed to turn these findings into an
explanation.
The Diagnosis and Observations form takes us through the nine sections of
analysis that I believe we need to pay attention to if we are to complete a
comprehensive analysis of our patient. The phases are named as steps of the
form.

Step 1: Global diagnosis

Step 2: General risk factors (MACRO)
Step 3: Macroesthetic considerations
Step 4: Global function
Step 5: Orthodontic overview (MID)
Step 6: Missing teeth
Step 7: Tooth-by-tooth analysis (perio risk, existing endo, endo risk,
restorations, caries, tooth surface loss [erosion, abrasion,
attrition, abfraction])
Step 8: Microesthetic evaluation (MICRO)
 Step 9: Summary risk assessment

The Diagnosis and Observations template or form is a tool in the system. You
should feel free to adapt the tool according to your own preferences and
clinical expertise. The following chapters outline my recommendations on
how to use it.
C HA PTER 7
MACRO
O BSERVATIO N S
“I would not give a fig for the simplicity this side of
complexity, but I would give my life for the simplicity on the
other side of complexity.”
OLIVER WENDELL HOLMES JUNIOR
S TE P 1: GL OB AL DIAGNOS IS
( F R O M T HE BO O K G L O B AL D I AG N O S I S BY D R .
BI LL R O BBI N S A N D D R . J EF F R EY R O US E)
My initial clinical notes and measurements are taken as described in Chapter
5. Filling out these details from a combination of my clinical exam notes and
looking at the photographs directs my initial analysis in terms of global
diagnoses. The book Global Diagnosis covers, in a very systematic way, all
of the diagnoses that one can make from these measurements, including the
different treatment options.
The order in which I note

1. Global: Midface to lower face

2. Lip length

3. Lip mobility

4. Tooth height

5. Presence of CEJ

6. Maxilla canted R or L or level (to the horizon)

7. Buccal corridors

1. Midface to lower face

The face height, measured at rest from the glabella to the base of the nose,
equals the measurement from the base of the nose to the inferior border of the
chin. This means that the middle third of the face should approximately equal
the lower third of the face.
The lower third of the face is approximately 1/3 above the mid-commissure
line (maxilla) and 2/3 below the mid-commissure line (mandible).
The midface measurement from the glabella midpoint to just below the
nose
The lower face measurement from under the nose to under the chin at
rest
The ratio between the two should be 1:1. So if the measurements are 59 mm
midface and 60 mm lower face, then the ratio is close to 1:1. But if the lower
face instead measures 75 mm, then the ratio is no longer 1:1, and we have a
longer lower 1/3.
2. Upper lip measurement
The lip length measured at rest from the base of the nose to the inferior
border of the maxillary lip in the young adult is approximately:
20–22 mm for females
22–24 mm for males
The lip lengthens with age—approximately 1 mm per decade from 40 years
old.
3. Calculating lip mobility
Lip mobility is calculated by knowing the length of the central incisor: How

www.dentalbooks.org
much is exposed at rest, and how much (or not) the lip moves above the
gingival margin of the central at full smile.
For example, if an upper central measures 10 mm, and at rest there is +2 mm
visible, and at full smile there is +3 mm of gum visible below the upper lip,
then the lip starts at 10 – 2 mm = 8 mm and moves to 8 + 3 mm = 11 mm.
This is therefore a hypermobile lip, as the “normal” range for lip mobility is
6–8 mm.
In another example, if a tooth is 10 mm long, nothing is visible at rest, and
there is still 2 mm of tooth under the lip at full smile (–2 mm), then the lip
mobility is 10 – 2 mm = 8 mm. This is within the normal range.
For example, if a patient has excessive gingival display, our starting point
should be to ask why. The reason why will shape our treatment plan
options. In this case, the patient has excessive gingival display; however,
measurements show that she has normal upper lip length and normal lip
mobility, but the lower face is longer than the midface. The diagnosis is
likely to be vertical maxillary excess (VME).
This is very different from a patient with normal facial structures and a
hypermobile lip whose resulting treatment plan options will be very
different.
4. Measuring the upper central length—The average length is 10–12 mm.
Measuring distal to distal of central incisors. This measurement is useful
for calibrating a smile design plan. The DSDApp by Coachman uses this to
calibrate the design, as we shall see in Chapter 11.
5. Is the CEJ palpable? The presence or absence of the CEJ as
palpable in the sulcus with a periodontal probe, in combination with the
tooth length, should prompt us to consider altered passive eruption as a
diagnosis. Teeth can be short because they have worn and lost length
incisally or because the gingiva has not retreated properly during eruption
and there is gingiva attached to the enamel. The treatment plans will be very
different depending on the diagnosis, as we shall see in later chapters.
6. Canted maxilla
It is very important to know if we have any level of cant in the maxilla. This
can be detected by looking at the gingival levels to the horizon.
In this MyiTero picture, even without the face in place, you can see that the
maxilla is canted down on the left-hand side.
The anterior gingival levels are not level to the horizon, as can be seen
by the red line.

As a quick aside, the above gentleman came to my practice as an emergency

with a “single-tooth” problem. He had lost the adhesive bridge that had
replaced his missing upper right central incisor for the last ten years. He
came to see whether an implant was an option. Using the process described
in this book, I was able to walk him through the current condition of his
mouth, including lower incisor wear and dentoalveolar compensation of the
lower anteriors. I was able to explain that his bite now was not the same as it
was ten years ago and that his lower incisors likely worn through to the
dentine; the wear accelerated and the weak link was eventually the adhesive
bridge that failed. Through the process of storytelling, I was able to explain
the challenges and risks that now exist. He understood and is now going
through prerestorative ortho in order to improve his occlusion and give me
space to restore the missing tooth structure in a predictable way. To try and
explain why I could not simply replace the bridge or place an implant
without this process would have been a challenge.
7. Buccal corridor
This is a difficult assessment, as there is no way to measure it empirically.
From a smile analysis perspective, we would want to see a full buccal
corridor with little dark or negative space between the cheeks and the buccal
surfaces of the maxillary premolars and molars. The flip side of this is if the
buccal corridors are excessive, it would indicate that the maxilla, which we
could think of as a denture wax rim, is narrow. A small or narrow maxilla
often means a high, vaulted palate, which could lead to breathing and/or
sleep difficulties. Depending on your level of education in these areas, you
may want to ask further questions and make further observations relating to
airway. For most of us, attempting to treat this functionally would include a
referral to specialists, but if we can at least recognize and discuss the issues
with our patients, we are doing them a service.

Example 1: Narrow maxilla with excessive space in the buccal corridor

Post-treatment: In this case, the patient declined orthodontics and we elected
to leave her central incisors where they were, whiten, crown lengthen, and
do additive veneers upper 2–5 both sides. The effect is an artificial widening
of the buccal corridor, which is esthetically more pleasing and detracted
positively from her presenting complaint of the midline shift. However, it
may have been more biologically appropriate to have considered surgically
facilitated orthodontics to expand the maxilla and improve her airway. She
may still have chosen the cosmetic option, but I am now having these
discussions with patients as I learn more about the possibilities and links to
airway management.
Example 2: Narrow pre-op buccal corridor in the premolar region

After smile analysis and new veneers—wider, brighter smile filling the
buccal corridor

S TE P 2: GE NE RAL RIS K FACTORS

1. General risk factors: Medical history and further research
In the practice management software, I can review the medical history form
and any particular medication and do some further research into possible
dental implications. My guidance material for this step is Dr. Lesley Fang’s
Ultimate Cheat Sheets. I found this publication to be so helpful that I worked
with medical colleague Dr. Jonathon Bell to have it translated into UK
protocols.
2. General risk factors: Parafunction
Is the patient aware of bruxing or clenching and have they ever had a
nightguard? In my practice, I often see patients with terminal dentition.
Sometimes, their teeth are in such a poor state that they are unable to chew at
all. I have learned from experience that it is possible to miss a powerful
bruxer at this stage, but replace their failing dentition with something fixed
and “yippee”—the muscles think they can resume full destructive action!
This is why I force myself to answer and detail this question at the beginning
of the analysis. I do not want to miss any history of parafunction, as it will be
critical at later stages when considering the various different treatment
options. Sometimes, I will have noticed considerable wear on the teeth, a
crenelated tongue and powerful masseter muscles, but the patient will deny
any knowledge or awareness of bruxism. I also want to know this early on,
as I will need to provide evidence for the patient in the storyboard.
3. General risk factors: Periodontal classification
Periodontal classification refers to the basic periodontal examination (BPE)
screening, radiographs, and the new classification flowchart.
The BPE will be recorded in the clinical examination notes. I refer to that
and then work through the flowcharts to give me the diagnosis, which I
record. You can access the BPE examination guidelines at
https://www.bsperio.org.uk/assets/downloads/BPE_Guidelines_2011.pdf
World Health Organization (WHO) BPE using WHO perio probes with black
bands.
Reproduced with permission.
In anything other than localized gingivitis, I need to refer to the radiographs
to be able to calculate the severity of the grading. This is where I would
slide between the screens of the Keynote storyboard template and to fill in
my form.
4. General risk factors: Soft tissue concerns
Note anything else, like tongue tie, low upper frenal attachment, crenelated
tongue, geographic tongue, and cheek chewing lines, along with any other
concerns that might influence the treatment planning at the next stage.
Gingival biotype observations and facial asymmetries can also be noted
here.
You may wish to note further airway assessment such as the Malampatti
score or tonsil grading in this section.
Further Reading
J. William Robbins and Jeffrey S. Rouse, Global Diagnosis—A New
Vision of Dental Diagnosis and Treatment Planning, Quintessence
International, 2016.

S TE P 3: MACROE S THE TIC

CONS IDE RATIONS
Under this heading, I remind myself of the patient’s main concern. If it has
nothing to do with esthetics, I still work through all the sections but
remember not to construct the storyboard with a focus on esthetics. If the
patient had a particular request like veneers, then I assess as I go to see if
this is a viable option, while also thinking about alternatives.
We can now begin our smile analysis. To fill in these sections, I refer to the
smile evaluation slide with the full-face picture and the profile pictures in the
storyboard, together with MyiTero for the upper and lower models.

1. Midline

2. Skeletal base

3. Molar and canine classification

4. E-plane/Andrews Line

Arnett’s True Vertical

 5.

6. Arch form

7. Smile curve (alterations in tooth position for ideal)

8. M-position (or tooth display at rest)

9. E-position

10. Gingival positions

11. Papillae positions—Maxillary anterior teeth

12. RED proportion observations

13. Width/length proportions

14. Phonetic observations

15. Crowding/spacing/rotations

16. Compensations/overeruptions/alterations in occlusal levels

Crossbites
 17.
1. Midline
This refers to the upper midline in relation to the face, but you can also note
any observations you have about deviations of dental midlines.
I start by looking at my clinical notes and the photographs in the storyboard
presentation. I make sure there is a good full-face smile of the patient on the
first slide.
Next, I want a technical smile photograph. For smile analysis, I prefer a
photograph taken from the front, chin down, hair behind the ears, glasses off,
teeth slightly apart. I cut and paste this photograph into the facial analysis
slide (inspired by Christian Coachman, DSD).
It is good practice to learn the basics of the presentation software that you
are using so that you can copy and paste, resize, crop, or mask group items,
and “send to back.”
The sequence in this slide is to copy the photo in, send it to back, mask/crop
out any excess background, and resize it so that the face fits in the circle. The
circle is not diagnostic; it simply acts as a guide.
Components of the above image

1. A circle to allow for the face to fit within and act as a guide to the
size of the photograph.

2. Vertical lines—Used to assess facial landmarks in the vertical

plane and to identify the facial midline.

3. Horizontal lines—Used to level the picture to the horizontal and

assess facial landmarks according to the horizontal.

4. A grid based on the recurring esthetic dental proportion. This is

used to assess the relative widths of the six anterior teeth, when
viewed from the front.

5. A curve—Used to assess the smile curve, and is duplicated to

assess the gingival curve and papillae levels.
Initially, it can be useful to import the smile photo into the facial analysis
slide, which has two horizontal lines and a vertical line. This is effectively a
digital facebow, and the power in it relates to our visual system. We are
evolved to compare visually. Just like we have a tendency to look only at
certain details and jump to assumptions, faces are particularly hard for us to
assess. It does not require a computer for us to look at a picture hanging on
the wall to know if the upper edge is parallel to the horizon. We compare to
the join between the ceiling and the wall and we know in an instant if the
lines are parallel. It is not as easy with faces, as they are different shapes and
complex. But if we simply put some lines over the face, and if we rotate the
face to have the interpupillary line level to the horizon and the facial midline,
we can automatically see facial asymmetries that we may not have noticed
before.
Face photo sized and “sent to back”
The first step is to look at the photograph and see if the interpupillary line is
horizontal. This is known as calibrating the picture to the horizontal. You can
use the horizontal line to slide up and down the face and check the top of the
ears, the top of the eyebrows and the intercommisural line. In the example
above, I need to rotate the picture to the right to improve the calibration to
the horizontal.
Keynote tip: If you hover over the white box at the corner of the picture and
hold down the CMD key, it turns to a rotational arrow and you can use two
fingers on the track pad to rotate the image.)
Picture rotated to level the horizontal
(Keynote tip—if you double-click the photo so that the boxes at the edges go
black, hover over a corner box and press CMD. The same double arrow
comes up and you can correct the outline of the photo so that it no longer
looks rotated.)

The next step is to align the long vertical with the facial vertical to define the
facial midline. The guideline for this is the center of the glabella, the tip of
the nose, the philtrum, and the tip of the chin. There is a degree of judgment
in this, as people can have deviated noses and chins, so these points are
guidelines. Therefore, ultimately look at the face as a whole and decide
where the middle is.
Once this line is plotted, you can assess whether the dental midline is in line
with the facial midline.
Note: The skeletal midline is defined by the frenal attachment and the
philtrum. The dental midline is defined by the tip of the papillae between the
central incisors. This is because the angulation of the central incisors may
throw the embrasure off midline, but it can be corrected. It is harder to
correct if the roots and, therefore, the papillae have shifted away.

Note: It is important when placing all these lines to have an awareness of the
quality of your photograph. If you see more of one ear than the other, then
perhaps the photograph has not been taken absolutely in front of the patient,
and you may need to refer to the video and your clinical observations to
check the midlines. Always double check the conclusions you are drawing
and be sure that you are not making assumptions based on errors in
photography.
In doing so at the start of smile analysis, the discipline of putting these lines
on the patient’s face helps our eyes to see, as it gives us a basis to compare
one side with the other. When I plot the facial midline, if there are large
deviations of facial structures and I need to make a judgment, I note my
assumptions. For example I might write “nose is deviated to the right” or “in
the picture the chin appears deviated to the left, but the photograph may be
angled—to double check.”
At this stage I can go back to my form and make comments about the dental
midline. Is it coincident with the facial? Is it shifted but parallel to the facial
midline? Is it canted? Is the whole skeletal midline shifted, that is, is the
maxilla rotated?
Example of facial asymmetry noted when applying the facial
midline line

Also note the lip asymmetry in the above picture

If there is a significant deviation between the facial and dental midline, I can
go back to the storyboard and duplicate the slide (click the slide in the list of
slides to the left so that the outline of the slide turns yellow and press CMD-
D to duplicate the slide). I can then annotate the shift on the next slide. I can
insert a shape by clicking the SHAPE button in the toolbar and choose a line
to demonstrate. Sometimes it is better to duplicate the slide again and
mask/crop into the smile so it is more obvious.
Facial midline identified and related to dental midline

Smile with the facial midline showing a very slight shift and a cant
Note: When cropping or masking a picture that is annotated, remember to
group all the items together before making it larger, or they will lose their
relationship to each other. The Group/Ungroup button is on the toolbar, or by
two-finger click on the trackpad.
Looking at this picture more closely, I would now notice that there is lip
asymmetry, with more gum showing on the left above the maxillary teeth than
on the right. This could be due to a maxillary cant or lip asymmetry. In this
case, her lip seems to lift higher on the left than on the right. I would note this
on the form.
In summary, the discipline of leveling the face to the horizontal and plotting
the facial midline gives you three bits of information:

1. Dental midline compared to facial midline

2. Facial asymmetries
 Lip form and asymmetries
3.
Placing lines over photographs of patients’ faces helps our eyes to see more
clearly. It is worth the effort, as with practice, you will train your eyes to see
better.
2. Skeletal base
Most of us in general dental practice do not take baseline cephalometric
radiographs and may not have access to this readily. Nevertheless, it is useful
to screen or look for tendencies in the facial/skeletal makeup of the patient.
Remember, if we are not sure of the diagnosis, it is okay to make
observations. We are not going to be orthognathic experts, but by training our
eyes to look and evaluate, we will constantly learn and be alerted to
situations where we may recommend a specialist’s opinion, or at least help
our patients to understand the limitations of treating only the teeth.
I have already noted any global diagnosis, so here I refer to the skeletal base
of the patient in the sagittal view.
Do I think this is a skeletal class 1, 2 or 3 according to the profile
photographs on the storyboard?
Nasolabial angle
At this stage, I also make reference to any observations about the nasolabial
angle. It is worth understanding the level of lip support that exists in the A/P
direction, as treatment-planning decisions that we may make about the
anterior teeth can affect the level of support.
Our patient below has a short upper lip (18 mm) compared to the average
(20–22 mm), but normal lip mobility (7 mm), so it makes sense that she has
an acute nasolabial angle.

3. Molar and canine classification

I note the classification of the first molars and the canines. If there is a
history of orthodontics, the tooth classification may differ from the underlying
skeletal base, particularly if there have been tooth extractions.
An example of occlusion from MyiTero showing a Class 3 molar
relationship

As I look at MyItero, I periodically take screenshots and add them to the

storyboard, thus building up the presentation that will be made to the patient.
On a Mac, this is CMD-Shift-4, and you can drag to highlight the area you
would like.

4. E-plane/Andrews Line
When I teach smile analysis, I often find that dentists have a hard time
deciding what the underlying skeletal pattern is. This is not surprising, as we
do not generally have access to lateral cephalometry. Having such access
would let us radiographically assess the relationship of the maxilla and the
mandible to each other and to the cranial base, which is, in essence, what we
mean when we say “skeletal.”
We do not need to be orthognathic surgeons in our diagnosis, but the more we
understand about underlying skeletal relationship, the more we can
understand the limitations of potential dental treatment as a means to correct
esthetics. This is why I like to look at several “guidelines” that may not give
complete diagnoses but definitely help us to appreciate our patient’s skeletal
makeup.
The first of these guidelines is the E-Plane , which was devised by an
orthodontist named Ricketts, and is used as an observational guide rather
than an absolute, as it has been criticized for producing flat profiles. It says
that if a line is drawn in profile from the tip of the nose to the chin, the
distance from the upper lip should be 4 mm and the distance from the lower
lip should be 2 mm in a Class 1. I note here if there are any observations to
the contrary.
The E-plane is simply a line drawn from the tip of the nose to the tip of the
chin which assesseshow far away the upper and lower lip are to that line. Dr.
Ricketts felt that to have a pleasing facial profile in the average Caucasian
face, the lower lip would be 2 mm behind the line and the upper lip 4 mm
behind the line, with variations being normal for patients of different ethnic
backgrounds, but with some similarities applying to all patients. The closer
to the E-plane the lips are, in some cases even being in front of the plane, the
lips and teeth will dominate the smile, with the nose and chin appearing
weak. And the farther behind the plane the lips are, the more likely the nose
and chin will dominate the smile. The key is to evaluate the E-plane
relationship prior to performing orthodontic treatment in order to dictate
whether to extract premolars and pull the teeth back, or to expand the arches.
For the non-orthodontist, the E-plane assessment is also valuable. In general,
the closer the lips are to the E-plane, the more dominant the teeth and lips
will appear, whereas the farther behind the E-plane the lips are, the more
dominant the nose and chin appear.”
An alternative to the E-plane is the Andrews Line , which considers that if
the head is in natural head position (NHP) with the alar-tragus line being
parallel to the horizon, then a vertical line dropped from the glabella should
pass through the buccal face of the maxillary central incisors. If the maxillary
centrals are behind this line, it could indicate maxillary deficiency; if they
are ahead of the line, it could indicate a skeletal Class 2.
In this case, the patient’s maxilla was behind the line, which led me to the
diagnosis of deficient or retrognathic maxilla in an A/P direction.
The maxillary incisors are behind the vertical line
5. Arnett’s True Vertical line
The third skeletal guideline I like is Arnett’s True Vertical line, which is
taken again in natural head position.
If a line is dropped from subnasale, there should be:
• +2–5 mm to the upper lip
• 0–3 mm to the lower lip
• —4–0 mm for the chin
These measurements help us to bring the cephalometric measurements to the
face.
6. Arch form
Refer to MyiTero for any observations on the upper or lower arch form.
My comments would be: Wide arch form, upper right 8 buccally
positioned.
My comments would be: Narrow arch form with severe crowding on the
upper right, missing teeth, and spacing upper left, second molars more
buccally positioned.
7. Smile curve (alterations in tooth position for
ideal)—alterations in tooth position from ideal.
Ideally, the curve of the upper maxillary incisal edges should follow the
curve of the lower lip. The central incisors and canines should be on the
curve with the laterals just short of it. The posterior teeth should flow into
the back of the mouth with no step up or step down of occlusal level.
On the storyboard full-face picture, I can bring in the half curve and lay it
along the incisal edges, fitting it from the left central to the canine and
curving back to the posterior teeth. If I then duplicate the curve and flip it
horizontally (CMD-D and Flip is in the Arrange menu on the far right of
Keynote), I can then position the exact replica of the curve on the right side,
line it up in the midline, and note if I have to alter it to fit the curve on this
side. This guides my eye to look at the symmetry of the smile. I may notice at
this stage if there is any asymmetry in the lower lip, which I can then make a
note of.
I also want to note if the curve is ideal, irregular, or reverse—where it is
higher in the middle than at the edges. Again, I must be aware if I see a
reverse curve that it is real and not due to the angle of the photograph.
Referring to the full-smile video and clinical notes can help me to check this.
Example of a smile curve following the line of the lower lip
In this example, I would observe that her smile curve is irregular.
Example of a reverse smile curve where the curve linking the incisal
edges of the central incisors to the canines is higher in the middle.
Sometimes, patients’ lower lips are asymmetrical, and this is worth
noting.

In the Smile Analysis template in the storyboard, there is a curved line which
you can move to start on the dental midline and lay it along the teeth to help
evaluate the curve of the smile.
First half of the curve in position.
Press CMD-D to duplicate the curve.

Using the Flip horizontal arrow in the Arrange menu, the smile curve is
flipped to the other side and lined up with the midline to assess the symmetry.
In this smile, the curve does follow the curve of the lower lip and is fairly
symmetrical.

8. M-position (or tooth display at rest)

For this, we ask the patient to say the letter “m” or the word “emma” and
relax, and we note the amount of central incisor that we can see at rest. In a
youthful smile, we see around 3 mm. Sometimes we cannot see any tooth
display, so we can note how far above the lip the teeth are inside the mouth.
This is noted in the clinical notes as a minus number, for example, 2 mm.
M-position: 2 mm of display at rest
The patient may mention that they do not show enough teeth, or I may notice
that there is tooth surface loss. When it comes to smile design, the first step is
deciding the ideal position of the incisal edge of the maxillary central
incisors in the smile. If the teeth are worn down but there is still 2–3 mm of
tooth display at rest, then there may have been some dentoalveolar
compensation, and so lengthening the teeth to their original size will not be
possible without moving them or considering crown lengthening.
9. E-position
Exaggerating saying the letter “EEEEE” gives us a picture of a wide smile. In
this position, the upper teeth should fill 50–80 percent of the space between
the upper and lower lips. I assess this from the smile photographs and video
and note if it looks appropriate.
E-position

10. Gingival positions

On the smile analysis slide in the storyboard, I duplicate the slide and begin
to work on the new slide. I assess if the gingivae above the upper anterior
teeth are visible. If they are, then I can duplicate the left side of the smile
curve and move it up to link the zenith (height of contour of the gingival
curve) of the central incisor with that of the canine and take it to the distal
extent of the smile. The gingival curve is generally flatter than the smile
curve.

I can then duplicate it and flip it, as I did with the smile curve, move it into
position, and note any variance from this line. In this case the canines are
slightly short of the line, which may indicate some altered passive eruption if
the CEJs of the canines are not palpable in the sulcus. In narrow upper arch,
the gingival level sometimes drops down in the premolar region. If any tooth
is proclined or retroclined, this will affect the position of the gingival curve.
This curve also draws our vision to any lip asymmetries. For example, in this
case, the upper lip is higher on the left than the right. There is more gingival
display on one side than the other. These observations should be noted.
If the gingivae are hidden by the lip in a full smile, then it is possible to
utilize the retracted image, either by observation or by cutting and pasting it
into the slide. This works best if the retracted and unretracted images have
been taken at the same angle. You can also orient the MyiTero models into
the same position as the smile and take a reference from there.
I prefer to substitute in the retracted image. If the smile curve works with this
image, then I know that the picture was taken at a similar angle.
I can then continue with my assessment and design on the retracted image.
11. Papillae positions—Maxillary anterior teeth
The tips of the papillae in a healthy individual should be about 40 percent of
the length of the tooth (Chu, Tarnow et al. 2009). This means that the contact
point between the adjacent upper anterior teeth should be at about the 40
percent mark of the length of the tooth. This can be observed visually. The
presence of black triangles may be associated with bone loss due to
periodontal disease and should be noted. Adjacent implants may also fail to
have papillae at the correct height, and this should be noted. Blunt papillae
can be a sign of underlying disease, as can swollen or puffy papillae.
An example of healthy papilla in the anterior, a little shorter on 22
because of the angulation.
In this example, there was a black triangle between the old veneers on
the upper central incisors. She also had retained deciduous canines.
The treatment plan involved removing canines from her palate so that the
deciduous canines could be removed, and implants and new veneers were
placed on upper 2–2. This also allowed us to correct the line angles and the
black triangle.
After implant placement and new porcelain veneers on upper 2–2.

Implants and papillae

One of the challenges with implants in the esthetic zone is being able to keep
the papillae, as was the case with this gentleman, who attended with a history
of multiple implant placement (in different parts of the world, as he traveled
for work) on the left. Note the loss of papillae compared to the right side
where he has a bridge on natural teeth.

12. RED proportion observations

RED stands for Recurring Esthetic Dental proportion and is a guide to the
relative proportions of the anterior teeth when viewed from the front. It is not
the actual widths of these teeth, but the perceived widths when viewed from
the front.
The RED proportion is similar to the golden proportion but has been shown
to be more relevant to smiles as they occur in nature (Lombardi 1973).
The RED proportion states that if the central is 1, the perceived width of the
canine should be about half of the central, and the lateral should be in
between the two.
We use a grid in the Keynote presentation which has been set up to these
proportions. As long as the Constrain Proportions box has been ticked in the
Arrange menu on the right-hand side of Keynote, then this box can be made
bigger and smaller and the ratio of the lines remain the same.
I bring this grid over the smile in the smile analysis and center the green line
with the dental midline. Next I alter the size so that the white lines either side
of the green lines are even with the distal of the centrals. Then I can look at
the lateral and the canine and see if they are sitting within the grid or not. Peg
laterals will be smaller. Canines that are rotated buccally will be wider. I
can note my observations about whether the teeth fit these proportions or not,
and if not, I try to figure out why.
Note: If there is a large median diastema, the proportion will be thrown out,
as the combined width of the centrals and the diastema will make the grid
very wide. This can be interesting to see if the diastema is actually in the
middle of the smile or whether it is off to one side.
Another guideline is that from a facial perspective; the distal lines indicate
the distal of the canines, which should be level with the inner eye and outer
of the nose. This can help to analyze the limit of the anterior six teeth,
particularly if there is a tooth-size arch length discrepancy.

In the above example, the canines are sitting outside the lines. This is
probably a combination of the canines being rotated buccally and the upper
centrals being crowded. If the upper centrals were straight, they would be
wider, and thus, the canines would be more within the lines. At present, the
upper left lateral is sitting within the lines as they are, so it may be that this
tooth is narrower than ideal.
It is important to remember that this is analysis. We are not going to design
our treatment plan so that every patient conforms to the RED proportion, but
it is a guide toward the ideal smile and helps us to recognize when
proportions are deviating away from ideal. All observations should be noted
even if you cannot explain them at this point.
Diastema cases
The RED proportion can be very useful when planning diastema cases as in
the example below. In this picture, I have lined up the distal of the centrals
with the grid, showing that the canines are sitting outside the guidelines.

However, the canines are sitting in a Class 1 position, and if I move the grid
to have the distal of the canines line up, this shows me the widths that the
anterior teeth would need to be in order to close the diastemas and keep
balance.
If my treatment-planning mind is considering treating upper 2–2 as an option,
then I will need to be aware that adding width will affect the proportions, as
in point 13.
I will show you the completed case in Chapter 10, Smile Design.
13. Width-length proportions
The ideal width–length ratio for a central incisor is 75–80 percent. In other
words, maxillary anterior teeth should be longer than they are wide. When
teeth lose length due to wear, they can become closer to 100 percent and
sometimes even over 100 percent if the wear approaches the contact point.
The other reason for the width–length ratio being incorrect is if there is too
much gingivae over the enamel. This can happen if a tooth is angled palatally,
or if altered passive eruption has occurred, where the gingivae and
sometimes also the bone do not migrate apically. This is the reason why the
Global Diagnosis form asks if the CEJ is palpable; if it isn’t and there is no
wear on the incisal edge but the tooth appears short, the diagnosis is altered
passive eruption.
TWO QUESTIONS

1. Is there wear on the incisal edge of the upper central incisor?

2. Is the CEJ palpable in the sulcus?

The average length of a maxillary incisor is 10–12 mm. In your clinical

notes, if you have a central that is measuring 8 mm, then you should be
questioning why. Has the incisal edge worn (look at the models or the
MyiTero with no color)? Is the CEJ palpable? Combined with the arch form
analysis for angulation, this starts to tell you whether the tooth is missing
structure, is in the wrong position, or has too much gum and possibly bone.
We focus on the maxillary central incisor, but this observation can be
extrapolated to all the anterior teeth. It is possible to annotate the retracted
smile picture in the storyboard to reflect your thinking here.

The blue box can be copied and pasted onto the central incisor in the
storyboard. As long as the Constrain Proportions box is ticked in the Arrange
tab on the right side, then you can make the box bigger and smaller, and it
will stay in the same proportion.
14. Phonetic observations
Note if there is anything significant, like a lip catch. Patients may describe
catching their lips on teeth that are rotated. Sometimes you can see it through
observation or by watching the patient video. You may also pick up a tongue
thrust or a lisp. All these observations should be noted.
15. Crowding/spacing/rotations
Refer to the upper and lower arch shots on MyiTero or study models, and
note any crowding, spacing, or rotations of teeth.
16. Compensations/overeruptions/alterations in occlusal levels
Again, referring to MyiTero, I start by looking at the lower arch from the side
and evaluating the curve of Spee, which runs from the molars to the anterior
teeth. I assess whether there is any step up in the occlusal level, as is often
seen in Class 2 or wear cases. I also look at the gingival levels of the lower
anteriors to see if there is any step up from the premolars to the canines or
anterior teeth, which can indicate dentoalveolar compensation. This can
happen with upper peg laterals when the lower canines overerupt into the
spaced upper dentition.
Example of a disrupted curve of Spee typical in skeletal Class 2 div 2.
Note the raised gingival levels of the lower anteriors.

www.dentalbooks.org
Other areas where the change in occlusal plane is noted can be between the
upper anterior teeth and the posteriors, for example, in a narrow arch where
the premolars are tilted inward. See next page.
How to diagnose a maxillary cant: when the smile picture has been leveled
to the horizon, if the maxillary occlusal plane or gingival plane is sloping one
way – this may be a maxillary cant.
It is difficult to analyze this with study models or scans alone as we have a
tendency to level the teeth to the horizon, which is a case like the one on next
page, that would be completely inaccurate and may lead to poor decision-
making.
Smile analysis slide showing significant maxillary cant.
An example of a screenshot taken from MyiTero and copied into the
storyboard to illustrate the different occlusal levels. Note the shapes that
have been added to illustrate the point. It is also important to use patient-
friendly language when annotating the slides; use bite instead of occlusion or
occlusal and moved up instead of overerupted.
17. Crossbites
I refer again to MyiTero, and note any anterior or posterior crossbites.
The first three sections have been more about analyzing and noting diagnoses
and observations rather than considering solutions. The next sections start to
focus thinking on what the possibilities for treatment might include, in terms
of TMJ health or further tests, missing teeth replacement, and orthodontic
options. It is helpful to note possibilities as options without being concerned
just yet as to specific treatment priorities. Once the entire analysis is
completed, the priorities will become more obvious.
C HA PTER 8
M ID O BSERVATIO N S
“If something is wrong, fix it. But train yourself not to worry,
worry fixes nothing.”
ERNEST HEMINGWAY

S TE P 4: GL OB AL F UNCTION
I globally assess the TMJ function for the case, reviewing here my
observations on clicks, muscle tenderness, limitations on opening,
deviations, and so forth. By noting my observations at this stage, I am
screening for any issues that may require treatment or resolution before any
further treatment.
Depending on your own interest and knowledge on occlusion and TMJ
issues, you may prefer a more detailed gathering of data at the examination
stage, and therefore a more detailed analysis at this stage. You may consider
recording the fully seated condylar position or first contact in centric
relation.
At the clinical examination, I screen for TMJ issues. If I feel there are
significant issues, then my next step may be a more detailed muscle and
occlusal analysis using the T-Scan (Tekscan, digital bite registration) and
study models mounted in CR.
At this stage I refer to my clinical notes and the MyiTero models and
notes

1. Guidance—Canine guidance both sides? Posterior nonworking

contacts?
 Signs of instability—Globally covering pathologic wear (we will
2. look tooth by tooth in Section 7.

3. Muscles—Any tenderness noted from the examination.

4. TMJ—Restriction on opening, deviation on opening, clicks or

crepitus in the joints, pain on loading.

S TE P 5: ORTHODONTIC OVE RVIE W

I write down my global orthodontic diagnosis, with a suggestion of whether
treatment is appropriate. I may write options including orthognathic referral,
or I may note specifics, such as Invisalign Full, to improve alignment and
prerestorative movement.
S TE P 6: MIS S ING TE E TH
I consider any missing teeth and make notes

• Risk of leaving spaces—Are there any risks?

• Is there a risk of tipping neighboring teeth or any unopposed teeth?

• Is the space large enough to replace the tooth?

• Is there interarch space available, or have opposing teeth

overerupted?

• ITI risk assessment: With reference to the ITI implant and

restorative risk assessment tool. Members of ITI have access to this
 tool and could use it at this stage to identify risks of utilizing
implants.

• I consider whether implants could be an option, taking into account

the relevant medical history, restorative space and apparent bone
width, and the next step which is generally a CBCT scan.

• Bridge options: Is this appropriate? What design? Would it be

destructive to neighboring teeth?

• Denture options: Are there any, and if so, what material options
might be considered?

Further Reading
https://www.iti.org/tools/sac-assessment-tool
C HA PTER 9
M IC R O
O BSERVATIO N S
“There is no magic in magic, it’s all in the details.”
WALT DISNEY

S TE P 7: TOOTH-B Y-TOOTH ANALY S IS

Working through each tooth, grouped into the sextants of the mouth, I refer to
the radiographs.
I assess each sextant

1. Pathology from the radiographs

2. Presence or absence of wisdom teeth

3. Bone levels

4. Presence or absence of implants

5. Site-specific periodontal risk

6. Endodontically treated teeth and the condition of the obturation

7. Teeth at risk from future endodontics, for example, deep

restorations
 Condition of restorations present, with reference to MyiTero
8.

9. Presence or absence of caries from radiographs and NIRI caries

screening on MyiTero

10. Tooth surface loss—erosion, abrasion, attrition, abfraction

If there are restorations with open margins or fracture lines, I take a

screenshot of MyiTero and add it to the storyboard with annotations. It can be
helpful to copy and paste radiographs of specific teeth onto the same slide to
help with explanations.

With iTero 5D I can use the NIRI (near infra-red imaging) to screen for
interproximal caries and take screenshots of any lesions that I see. I also
refer to radiographs, but note if this is early caries (which would be treated
with professionally applied fluoride or the ICON system from DMG, which
is a resin infiltration system that can seal the interproximal surface to prevent
caries progression), or caries requiring restoration.
To assess tooth surface loss, I can refer to my clinical notes and the HD
photo from MyiTero, and my preference is to take the color out of the scan in
order to see wear facets more clearly.
In this example, behind the central incisors, the definite wear pattern is
easier to assess without the color

It is easier to see the wear facets without the color

Example of a 5D NIRI scan showing early interproximal enamel caries
Example of annotated screenshot from MyiTero
inserted into storyboard
If any teeth appear “hopeless” at this stage, I will note that. If there are
multiple teeth of questionable prognosis, then I use the red, amber, and green
dots on the storyboard to label the OPT or screenshots of arch views from
MyiTero, or photographic arch shots. This visual exercise helps to analyze
how many teeth are hopeless, questionable, or dependable. We can also use
the amber and green dots to identify the healthy and more questionable
prognosis teeth.
Example of screenshot from MyiTero using red dots to identify hopeless
teeth

Predicting the prognosis

Whether a tooth has a good or questionable prognosis is a matter of opinion
and will depend on our own clinical experience. Individual teeth have a
prognosis. Prescribed treatments also have a prognosis. There is limited
evidence in literature on how we can determine the prognosis for individual
teeth, based on perio condition, loss of tooth structure, and so forth. There is
evidence in the literature about the failure rates of certain treatments. For
instance, bridge abutments, which are endodontically treated, are more likely
to fail earlier than teeth, which are not. This does not mean that we cannot
use an endodontically treated tooth as part of a bridge, but it means that if
given a choice, it would be better to use a vital tooth or at least to have this
discussion with the patient.
I was fortunate to have studied under Mike Wise in London’s prestigious
Wimpole Street. Mike Wise wrote a mighty tome that was recently featured
in the British Dental Journal as one of the fundamental textbooks in the UK.
It was titled Management of Failure in the Restored Dentition—and that
was his point. All restorations fail. We need to be honest and upfront with
our patients about what happens when the treatment we planned fails and
what comes next. In my opinion, any tooth that has more than a single surface
restoration is an “amber” dot rather than a “green” dot. Amber, in my
opinion, means that the tooth has been restored and so will need further
dentistry at some point in the future.
Pascal Magne from the University of Southern California and author of
Bonded Porcelain Restorations in the Anterior Dentition (Magne, Belser
2002) talks about the “circle of death” for teeth, where a filling is eventually
replaced by a larger filling, and that eventually compromises the
biomechanical properties of the tooth. Eventually the tooth cracks and is
replaced by an indirect restoration, the tooth becomes nonvital, endo is
performed and a post is placed. Finally, the restorations are so strong that the
only failure remaining is that the root fractures, and this catastrophic failure
leads to the extraction of the tooth. Then it is time for an implant. This
realization that simply using stronger and stronger materials to be sure that
our dentistry doesn’t fail, but that the underlying tooth does, has led to the
counter movement toward biomimetics and minimally invasive dentistry—
trying to use materials to restore teeth that have similar biomechanical
properties to the natural tooth structure in order to preserve as much tooth
structure as possible. This has been a notable transformation for the
profession, but it also requires careful communication to the patient. When
all our restorations were made from metal and couldn’t fracture—the “fault”
could be that of the patient’s weak tooth—the fact that we made it weak to
make room for our strong restorations seemed to go unnoticed. Ethical
dentistry now relies on adhesion and minimal or progressive techniques. We
will start small and get more invasive only if we need to. Trust is required
with this approach so that patients do not perceive our work as failing or as a
means to earn more money.
The key to predictability even in the face of minimal invasion is adequate
diagnosis and risk assessment, particularly in terms of occlusion and function
—and honest communication with the patient.
S TE P 8: MICROE S THE TIC
E VAL UATION
Color—It is helpful to note the base color of the anterior teeth.
Whitening—Here I make a quick note as to whether this is an option to be
discussed with the patient or whether it is not and why.
Individual teeth—white or brown spots—I note if there are any individual
teeth which may need particular attention.
An example of individual teeth with hypoplastic lesions causing brown
marks in the enamel

Other microesthetic observations

I would highly recommend further reading into smile design parameters to
train your observational eye for other details, such as those we covered in
Chapter 5 on smile design. Understanding how line angles, embrasure spaces
(Johnston 2010) and surface texture fit into the overall picture will help you
to be more analytical in your observations.
Embrasures
When maxillary anterior teeth wear incisally, for example, they lose their
curved embrasure form.
Note the difference between the form of the upper central incisors and the
upper left and lower left laterals that are not in functional contact.
In this case, this young man’s presenting complaint was the spaces between
his teeth, which he felt made him look childlike, just as he had graduated and
was pursuing a professional career.

DECISION POINT When considering options for closing diastemas, it is

very important to look at the position of the canines in relation to the face,
and to the width–length ratio of the upper incisors. In this case, there is
missing tooth structure and the contacts are very straight. What is the right
treatment to close diastemas? Orthodontics or restorations?
The answer, of course, is: it depends!
As we shall see in later chapters, designing a trial smile can be a helpful way
with these cases to check if the proposed changes will be harmonious.
In this case, I mistakenly used a shade of Luxatemp that was much whiter than
the patient’s own teeth. Although it was not my intention, the contrast served
as a motivation for whitening. However, the difference was not ideal in the
photographs so, as described in Chapter 12, I was able to take the color out
of the photograph in Keynote so that the effect was not as visually jarring in
the case presentation. This 45-degree angle photograph shows the surface
texture and detail of the wax-up, which has been captured in the temporary
material and demonstrates how natural the final veneers will look.

The definitive treatment addressed the functional and esthetic concerns

1. Whitening

2. Minimal prep veneers on upper 2–2

3. Bonding to the tips of the canines to restore canine guidance

4. Nightguard

Emax Veneers by Art Dental, Sheffield, England

Final results showing improved embrasure forms of the patient’s anterior
teeth while maintaining balance and harmony

Surface texture
In this example, there were some old, discolored veneers present over
mottled enamel. The relative tooth widths were good, but the surface texture
of all the teeth was mottled and uneven, and the patient complained that as a
child, he was always being told to brush his teeth as they always looked
unclean. He was looking for a more reflective, smoother surface for his teeth
so that he could smile with confidence.
In this case, the definitive treatment plan consisted of ten porcelain
veneers to cover the mottled enamel.
Ceramics by Rob Poland, Ken Poland Dental Studio, London.
Old dentistry
Some of the detail may also include observations about old dentistry. Old
porcelain bonded to metal crowns, which were made on a single-tooth basis,
can often be functional but not esthetic. Sometimes the old crowns are
bulbous and over-contoured.

Replacing the old restorations on the upper four incisors with ceramics
that have a better emergence profile and a more anatomic buccal
surface can rejuvenate a smile.
Luke Barnett Ceramics, Watford, England
S TE P 9: S UMMARY RIS K
AS S E S S ME NT
I use this section to make a note of my thoughts, particularly in the case of a
smile design patient. I note if there is a particular risk area, which helps me
to focus on whether this is a case that requires tooth movement. If the patient
has asked about bonding or veneers, I simply note if there are any specific
risks for bonding or porcelain. Risk can be considered in four main areas:
esthetics, function, structure, and biology.
Remember, these notes are for you as a clinician to refer to, as you build the
priority challenge list and start to brainstorm the treatment options.
Example case with storyboard and Diagnosis and
Observations form filled out
The following case is a real case example to demonstrate how I would use
the Diagnosis and Observations form to guide my thinking through all the
macro, mid, and micro observations and relevant diagnoses. In the example
form, I have used blue for macro, green for mid, and purple for micro so that
you can track the sections to the various entries. In reality, the form is a black
and white template in my clinical notes.
This retired physician visited my practice with some concerns about the
structure of her teeth. This is her presenting smile photograph and an example
of how I would build up the storyboard template with annotated screenshots
as I work through the form.
Diagnosis and Observations
EH reviewed photos, radiographs and MyiTero
GLOBAL:
Midface: Lower face: 1 :1
Lip length: 21 mm normal
Lip mobility: 8 mm normal
Tooth height: 10.5 mm
Presence of CEJ: Yes
Maxilla canted R or L or level (to the horizon): Level
Buccal corridors: OK
GENERAL RISK FACTORS:
Relevant medical history inc. smoking: No RMH or smoking
Is the patient a bruxist? Thinks she used to but not now
Do they already have a nightguard? No
General perio classification: Clinical gingival health with
recession/abfraction
Soft tissue concerns: NAD
MACRoesthetic Evaluation:
Patient main concerns: Front teeth and fractured premolar upper right
MIDLINE:
Facial to dental: Nose may be deviated, midline close to coincident with
facial midline
Skeletal: 2
E-plane: Class 2, increased mentalis activity
Arch form: Class 2 div 2, 13, 14, 15 palatally positioned, crowding 12, 13.
23, 24 better positioned
Smile curve (alterations in tooth positions for ideal): Looks good from
anterior
M-position: Incisors just hidden by upper lip
E-position: Teeth in a good position
Gingival positions: Lip just brushes the upper cervical margins other than
where palatally leaning in the upper right 3, 4, 5
Papillae positions: Good
Red proportion observations: Good LHS
Phonetic observations: NAD
Crowding/spacing/rotations: Crowding around the upper right 2
Compensations/overeruptions/lterations in occlusal levels: Step in lower
occlusal curve, 2-2 lower overerupted and occluding palatally
Crossbites: NAD
FUNCTION:
Guidance: Lower lateral and upper canine to the right – canine worn down,
same to the left
Signs of instability: Fracturing teeth, recession/abfraction
TMJ: NAD
Muscles: NAD
ORTHO CLASSIFICATION: 2
Options: Consider prerestorative ortho to improve arch form
Missing teeth: NAD
UPPER RIGHT POSTERIOR:
Perio risk: Low
Existing endo: 14, 15. PA xrr – Extrusion of cement 14 both roots when
compared with PA, no pathology other than denser bone, 15 apical puff.
Risk of future endo: 16 crown
Restorations: 14, 15 indirect, 17, 18 amalgams direct as charted
Caries+/-: 14 has fractured palatally
Erosion/abrasion: 14-16 as palatally inclined
UPPER ANTERIOR:
Perio risk: Low
Existing endo: None
Risk of future endo: Low other than history of trauma to centrals but many
years ago
Restorations: Bonding, some wear
Caries+/-: NAD
Erosion/abrasion: 13, 22, 23 abrasion and recession
UPPER LEFT POSTERIOR:
Perio risk: Low
Existing endo: None
Risk of future endo: 14, 15, 16 all large restorations
Restorations: As charted 15, 16 large composites
Caries+/-: NAD
Erosion/abrasion: Some abfraction all teeth
LOWER LEFT POSTERIOR:
Perio risk: Low
Existing endo: 35 with pin
Risk of future endo: 36, 37
Restorations: 35, 36 would benefit from indirect
Caries+/-: NAD
Erosion/Abrasion: Small amount abrasion/abfraction
LOWER ANTERIOR:
Perio risk: Low
Existing endo: None
Risk of future endo: Low other than 43
Restorations: 43 very worn with composites - consider indirect
Caries+/-: NAD
Erosion/abrasion: Some recession
LOWER RIGHT POSTERIOR:
Perio risk: Low
Existing endo: 45, no post
Risk of future endo: 46
Restorations: As charted
Caries+/-: NAD
Erosion/abrasion: Abfraction 44
MICROESTHETIC EVALUATION:
Bonding previously done in Switzerland has come off 11
PATIENT MAIN CONCERNS: Fractured teeth and anterior teeth
COLOR -
Whitening? Yes
RISK ASSESSMENT:
Tooth color/tooth shape and/or position: Deep bite with uneven curve of
Spee, abfraction throughout, multiple heavily restored teeth and large fillings,
apical puffs significant around 14, 15.
Porcelain options and risks: Indirects with a wax-up and nightguard. To
discuss ortho as an option for UR side.
Bonding options and risks: Could bond the upper central, risk is ongoing
wear
Are existing posts present: Yes see OPT
Once the Diagnosis and Observations form is filled out, in combination with
the notes I made chairside and the preclinical information, I know that I have
a comprehensive list of diagnoses and can begin the process of distilling this
down into a problem or challenge list.
For this patient, I was able to discuss all of the findings and involve her in
the process as we shall see in later chapters. We agreed on a staged approach
to her treatment, starting with upper and lower indirect restorations for the
teeth at highest risk, and keeping to a natural smile design. There is still some
posterior restorative work to be done, but she is feeling much more confident
with her smile.
After smile design.
Ceramics by Rob Poland, Ken Poland Dental Studio, London, England
In his excellent book, The Art of Examination, Barry Polansky teaches us
how to analyze the problems we have identified in terms of cause and
solution. I like this emphasis on cause, as it fits with my thinking about the
patient’s mouth as a puzzle or a riddle that has an answer. Understanding how
we got to this position can be helpful to understand how the mouth and oral
structures have compensated for an underlying skeletal discrepancy or early
loss of deciduous teeth, or how the teeth have been affected by nocturnal
bruxism.
In summary, we have been through a process of guided observation by
systematically analyzing the captured information

1. Preclinical information

2. Photographs and video

3. Clinical data, charting, perio status, muscle exam, TMJ exam

4. Radiographs and sometimes CBCT

Intra-oral scan or study casts

 5.
The discipline to follow a systematic analysis will ensure that there is no
stone left unturned, and that we have looked at and seen everything that may
be relevant.
I am describing each part as a separate entity, but in reality, when assessing a
case, I tend to move between all three—analysis, design and risk assessment.
There is a dynamic flow of thinking between all three, gradually building up
the diagnosis, the challenge list, and the possible treatment options, with all
of the risks identified.
By the time you get to this part of the form, you will have covered so much
ground and looked at every single tooth in terms of its own status and risk
that you will likely have an idea about your options. And if you don’t—that’s
okay too—the next step is design.
We have identified where we are—now we can look at where we want to go.
Further Reading
Christopher Johnston, Summary of: The influence of varying maxillary
incisal edge embrasure space and interproximal contact area
dimensions on perceived smile aesthetics, British Dental Journal, 2010;
209(3): 126-127.
Pascal Magne and Urs Belser, Bonded Porcelain Restorations in the
Anterior Dentition: A Biomimetic Approach, Quintessence International,
2001.
Barry Polansky, The Art of Examination, Word of Mouth Enterprises,
2003.
C HA PTER 10
SM ILE D ESIGN
“When we know where we’re going, getting there is easy.”
PETE DAWSON

When the patient’s request or the problems identified in the analysis stage
involve the anterior teeth, particularly of the maxilla, the step after analysis
is to design the ideal smile, according to the landmarks of the face.
Smile design does not mean that we are planning to use only
restorative dentistry-like veneers. Smile design is the blueprint or
template. We will then consider the “tools” that we have available
in the next chapters—which include all the disciplines of dentistry.
In this chapter, I am going to outline the process of designing a smile
according to facial landmarks. I continue this process in the storyboard
presentation.
The process of analysis through guided observation we have just been
through allows our thinking and problem-solving minds to flow into
considering solutions. Before we allow our minds to jump into treatment-
plan options, we have to identify the desired end point—the design. We
analyze a smile and a mouth to see where we are starting from. In order to
complete this process, we need to understand the benchmark of “ideal.” The
question is, naturally, how can there be an “ideal?” The ideal smile is not a
mathematical equation. How can we measure against an ideal? Against
harmony? Against the patient’s desires and what they have told us they would
like to change?
Three benefits to the smile design process

1. Designing a smile using lines and guidelines over the existing teeth
helps our eyes to see what component or components are deviating
away from ideal and, therefore, what exactly the esthetic
“problems” may be.

2. In the same way, designing the smile helps us to identify which

components are in harmony and working well.

3. Designing a more “ideal smile” that is made for the patient allows
us to involve the patient and let them “preview” the possibility, and
give input and discuss the possible outcomes. These emotional
touchpoints can strengthen the case presentation appointment, as
we shall see in the following chapters.

Again, designing the ideal smile does not mean we are going to be able to, or
desire to, treat to the ideal, but it alerts us to the deviations and shows us
where compromises may need to be made. It helps us to build the explanation
and set realistic expectations for the patient.
Like Schotter’s gravel stones described in Chapter 1, our eyes make
comparisons faster than our conscious mind can process, and we tend to
instinctively know if a smile is attractive and in harmony or not. The
challenge is being able to precisely identify what the issues are. It behooves
us to figure out what we are able to change or disguise in order to create a
more harmonious illusion.
Before we get to the step-by-step process of smile design, I would like to
share with you some concepts that can help to train your smile-designing eyes
to see more.
S E E ING B AL ANCE AND HARMONY
Every year, my family and I travel to the northwest of Scotland to a little bay
called Clachtoll. Between Clachtoll and Achmelvich, there is a tiny beach
we like to call the “hidden beach.” On one visit there, we came across these
stone piles—we tried to build our own, which was a lesson in balance and
harmony.
To explain harmony in terms of smile analysis, I would like to refer you to an
excellent article in the Journal of Cosmetic Dentistry, Winter 2017, by
Michel Rogé and François-Marie Fisselier (Rogé Winter 2017). Referring to
the art world, they explain why smiles can deviate from the textbook,
idealized perfect smile, yet still be attractive and in harmony with the face,
and how other deviations cause a visual tension, which is not pleasing.
In definition, harmony denotes a state of balance among forces influencing
and even opposing one another. When describing the harmony of a smile, we
are describing visual shapes that exert forces on their neighboring shapes.
The textbook definition of the perfect smile is built from very subjective
data. Many studies have asked lay people to rate the attractiveness of smiles
when given still images of the teeth without the context of the face. When the
studies were repeated using videos of expressions rather than stills of teeth,
the results were different. Therefore, we should consider all of the “rules”
of smile design as guidelines—benchmarks to fall back on when we are
analyzing and problem solving, but we must not hold them as rigid criteria.
Instinctively, if we take a step back and consider a smile in the context of the
face and personality, we know if there is harmony or something causing
visual tension. The hard part can be putting our finger on the problem when
there is one. It is helpful to understand some visual concepts in order to
understand what we mean by “harmony.”
1. Perceptual forces: Parallelism, repulsion, and attraction
2. Rhythm: Monotony and dynamism
In the following diagrams, I have used rectangles to represent the upper six
teeth.
The authors, Rogé and Fisselier, go on to discuss order and disorder, radial
symmetry, dominance, unity, and individuality.
In smile design, we learn about dominant centrals.
“Dominance is directly related to the ability of the teeth to reflect light,
which is dependent upon their proportions, line angles, relative size and
position in relation to the other teeth in the dental composition.”
(Rogé Winter 2017)
Sometimes I have patients who are maxillary deficient and who want their
teeth to look more obvious in their smile. I will have recognized this through
guided observation and will therefore be able to explain their orthognathic
options. I can then discuss, given the limitations of the small maxilla, what
can be done dentally to compensate for this compromised starting point. This
understanding of visual dominance helps me to consider the light-reflective
properties of the teeth and how I might influence those to have the teeth
appear more dominant in the smile. If the teeth are retroclined, for example,
there is less reflective surface available, and so a patient may whiten their
teeth in an attempt to make them brighter but still feel they are dull. This is
due to the position of the teeth and not the actual color. Some orthodontics to
upright the facial surface will allow for better light reflection.
Similarly, if the anterior teeth have worn down, they will have less reflective
surface available. It may not be possible functionally to add much length to
the teeth, but if they are restored with stronger reflective surfaces, they can
appear more dominant in the face.
That was the case with this next patient who came to see me because he
felt that his teeth did not show in his smile.
He had a low lip line and had some dentoalveolar extrusion of the lower
anteriors and a deep bite. His maxilla was retrognathic and he could have
had orthognathic surgery to improve the position of his maxilla.
He declined orthodontic or surgical intervention and instead we restored his
upper ten teeth with Emax restorations, equilibrated to function. We could not
add much length, but we did improve the dominance of his centrals with
more space between the line angles, creating more reflective surface.
Line angles were marked in pencil on porcelain.
Final restorations with improved dominance created by a higher value
and increased light-reflective surface.
Emax ceramics by Art Dental, Sheffield, England

Increased light-reflective surface aided by the line angles or the heights

of contour of the central incisors being further apart.
The final result is a more dominant smile for the patient.

S Y S TE MATIC S MIL E DE S IGN

Starting to plan a mouth full of dentistry without first designing the ideal
smile is like starting to build a house with no architectural plans. This is why
our patients end up with teeth of different sizes and colors, where
compromises have been made to “conform” to the existing condition.
Putting lines on faces, as we learned to do with the smile analysis slide in
Chapter 7, helps our eyes to see more clearly. Faces are not symmetrical or
mathematical. We can train our eyes to see harmony in a smile. We have two
eyes and have evolved to compare. Back in our hunter–gatherer days, we
needed to compare where we were according to the landscape so that we
could go out and return home again. We are always comparing; it’s how we
make sense of the world.
Facially driven smile design has been taught by many of the great teachers in
dentistry, including Gerard Chiche, Frank Spear, John Kois, Galip Gurel, and
Pascal and Michel Magne.
The premise of facially driven smile design is that the smile should be in
harmony with the landmarks of the face. A very asymmetric face does not
necessarily look in harmony with a perfectly symmetrical smile, and
therefore, mathematical rules for design need to be placed in the context of
the face.
As such, the traditional rules of smile design need to be considered more as
guidelines to help us to understand why a smile does not appear to be in
harmony. We can design the ideal smile according to the face and then
compare this with the existing starting point, taking into consideration the
underlying skeletal structure, the lip position and dynamics, and the position
and health of the current dentition. We may decide to compromise from the
ideal smile, but this can be identified at an early stage and discussed with the
patient to set realistic expectations before any treatments are decided upon.
Risks and benefits of treatment can be viewed in the context of the desired
and achievable end result to be sure that valid consent is obtained. If the
smile is designed before treatment, this also then serves as a quality control
for all stages in the treatment, that is, procedures such as crown lengthening
or orthodontics can be calibrated according to the planned end result.
I learned the following order of smile design from Christian Coachman and
the Digital Smile Design philosophy, and I use it every day when I am
analyzing smiles and beginning the design process.
You will have started this process in the smile analysis slide during the
guided observation, but it is important to remember that analysis and design
are two separate processes.
Stages of designing a smile according to the landmarks of the face

1. Calibrate a full-smile picture

2. Identify the facial midline

3. Ideal incisal edge position—Smile curve

4. Relative widths of the anterior teeth

5. Ideal proportions of the central incisors—Gingival curve

6. Position of papilla curve

1. Calibrate a full-smile picture

From the front with the teeth slightly apart to the horizontal. The most
reliable guideline for this is the interpupillary line. Other landmarks such as
the eyebrows and the tips of the ears can be analyzed, and a judgment made
as to the best guide.
2. Identify the facial midline
Once we have calibrated the horizontal, we know that the vertical line is the
true vertical, and we can plot this on the facial midline—generally using the
glabella, the tip of the nose, the philtrum, and the tip of the chin as guidelines.
This facial midline or midzone can then be compared to the existing dental
midline (Bidra, Uribe et al. 2009). The smile design literature tells us that a
dental midline should be parallel to the facial vertical midline (Flores-Mir,
Silva et al. 2004). Studies using photographs show that a 4-mm deviation is
acceptable to lay people (Kokich, Kiyak et al. 1999); however, new studies
using video and full-face images suggest that a 1-mm deviation is acceptable.
This does not mean that every smile should be treated to bring the midline to
ideal, but that it should be noted and diagnosed appropriately. The dental
midline is best judged by the tip of the papilla between the central incisors,
as this indicates the true mid position between the roots of these teeth. In
addition, the presence of facial asymmetries, such as a deviated nose or chin,
can have an effect on the perception of midline shift (Silva, Jimenez-
Castellanos et al. 2015).
DECISION POINT If the facial midline and dental midline deviate, then a
decision needs to be made about whether to design a correction to the
midline, or to accept the midline shift and design from there. Large midline
shifts are difficult to correct without comprehensive orthodontics, and it is
important to decide if it is a dental shift or if the entire maxilla is rotated.
The labial frenum is your guide in this case—if it is centered with the
philtrum and the midline raphe of the palate, then it is probably a dental shift
and could be corrected more easily. If the entire maxilla is rotated, then this
require a surgical correction. The article on facial flow (Silva, Mahn et al.
2019) explains why the case shown next still works esthetically, despite it
not confirming to the ideal in terms of midline position.
This patient came to see me and asked if I could correct her deviated
midline. She had a very narrow maxilla and I knew that, visually, her shifted
midline was more pronounced because of the contrast between her very
prominent centrals and the rest of her smile. Of course I would consider
correcting the midline, but I also wondered what she would look like if we
accepted the midline but brought the buccal corridors out to give more
balance to the volume of her smile.
She was treated before I learned about the concept of facial flow, but
interestingly, this helps to explain why accepting her midline worked in the
context of an asymmetric face.
We analyzed her facial flow by placing dots on her glabella, the tip of her
nose, her philtrum, and the tip of her chin.
Her face can then be characterized in terms of the convex and concave side
of the curve—red and green:
Her midline shift is to the inside of the curve of her face—the green zone. I
treated this lady in 2014 before we had an intra-oral scanner, so the design
was carried out in 2D and transferred to the analog wax-up through a process
of calibration, as taught by Christian Coachman and Digital Smile Design:
Through this technique I was able to work with my technician Luke Barnett
from Luke Barnett Ceramics in Watford, England, to plan for crown
lengthening and a trial smile to evaluate the esthetics. In the following
diagram, we are considering the ideal long axis orientation of the teeth,
which will give us the ideal position of the height of the gingival zenith. This
case predates my use of an intra-oral scanner and demonstrates how digital
smile analysis can be calibrated to an analog workflow.
Luke was able to give me precise measurements for correcting the soft tissue
heights with the wax-up, and we did a trial smile to assess esthetics, wherein
the temporary material is laid over the gingival margin to simulate crown
lengthening.
The patient was delighted with the trial smile and decided not to go for
orthodontics to correct her significant midline shift but to choose the
restorative solution.
Final restorations—Emax veneers on upper second premolars to the upper
laterals with crown lengthening. We opted not to restore the central incisors,
as they were so dominant that prepping them would have been aggressive.
We whitened the centrals and the lower anteriors.
A beautiful smile in harmony with her face.
3. Ideal incisal edge position—Smile curve
We can use video analysis to decide on the ideal incisal edge position for the
maxillary incisors and canines. These two points give us the smile curve
(Passia, Blatz et al. 2011), which can be plotted on the picture. The decision
should be made from the dynamic and take into account phonetics, E-
position, lips at rest, and other characteristics, such as the age of the patient
(Chetan, Tandon et al. 2013). Note that these decisions are not based on
function in the first instance. The decisions as to whether the desired ideal
smile can fit within functional guidelines must be addressed at the treatment-
planning stage, when the lower arch is taken into consideration. In the initial
design stage, however, the smile is being designed according to esthetic
parameters. Plotting the smile curve often reveals underlying issues, such as
the maxillary premolars having overerupted, bringing the gingivae to a lower
level. There is a degree of judgment as to where this curve is placed, as there
is no absolute right answer, but degrees of harmony.
4. Relative widths of the anterior teeth
These can be planned using the grid we use in the smile analysis in Chapter
7, similar to the “golden proportion,” which is the Recurring Esthetic Dental
proportion (Lombardi 1973). This has the central as a value of 1, the lateral
0.7, and the canine 0.5—apparent widths when viewed from the front. The
grid can be checked against other facial features, such as the distal of the
canines being in line with the outer of the nose and the inner of the eye. All of
these are guidelines for the apparent width of the anterior teeth.
5. Ideal proportion of the central incisors—Gingival curve
Once we know the width of the centrals, we can then use the natural
proportions of the width-to-height ratio of the central incisors, being 75–80
percent. This will then give us the position of the gingival curve, which links
the cervical of the canine and the central. The lateral incisor ideally will sit
about 0.5 mm inside each line.
6. Position of papilla curve
This can also be added, which is about 40 percent of the length of the
incisors (Chu, Tarnow et al. 2009, Hochman, Chu et al. 2012) down from the
gingival curve and is of particular interest when planning cases with missing
teeth or papilla.
The above steps describe a systematic approach to designing a smile using
the landmarks of the face and available literature as a guide. Throughout this
process of design, the clinician will be alerted to various diagnostic
realities, which will influence the treatment-planning options and ultimately
the feasibility of the designed smile. This then allows for a considered
approach to treatment planning, and a basis for discussion with the patient
about what is possible and where the compromises may be. If the biological
cost of achieving the “ideal” smile is too great, then the esthetics will need to
be compromised in favor of health and function. However, it is advantageous
for this to be recognized and identified early in the process, and discussed
with interdisciplinary colleagues and, of course, the patient.
Digital planning of the desired outcome allows for connection with digital
systems, such as orthodontic planning tools, implant 3D planning tools,
CAD/CAM manufacture, and so forth. In this way, a predictable outcome for
the patient, and utilizing inter- or multidisciplinary approaches, all stem from
systematic planning.
All of this gives us a 2D smile design that we can draw over the existing
dentition and that begins to show us how our preexisting condition differs
from our possibility of the “ideal.” For example, in this case, this patient was
complaining of worn upper anteriors.
I analyzed and planned her case on the storyboard using smile analysis
and then sent her .STL file to the laboratory for them to convert my 2D
design into a 3D wax-up.
DSD Planning Centre, Madrid

This 2D design can be translated to 3D if the .STL file from an IOS scanner
is calibrated to the 2D design. This can then be printed and a trial smile can
be manufactured. Christian Coachman and the DSD philosophy have
identified many key strategies about how this system can engage the patient in
the emotions of a smile transformation. If we can show them, with a trial
smile, their “potential, future, better self” in context, with their eyes, then we
engage with the right-brain, emotional side of the mind where decisions are
made. This is very powerful.
This is the 3D rendering of the digitally designed smile over her existing
teeth so that we can use a stent for a trial smile. These images are for our
planning. I tend not to show these images to the patient as the color mismatch
looks strange and can be off putting.
DSD Planning Centre, Madrid

It is important, however, to bring in the lower jaw for function and occlusion
and consider the limiting factors. It may be that the biological cost of
achieving the ideal design is too great, and the design should be adapted. It
may be, too, that there are limiting factors that we cannot change. It may be
that the patient’s budget does not warrant complex, extensive dentistry. Or it
may be that there is a simple solution, which will have great impact. Start
with the ideal, problem solve, compromise, document, and be ready to
explain.
In this example, with 3D planning and quality assurance, we could perform a
combination of orthodontics and restorative treatment to achieve an esthetic
outcome for the patient.
DSD Planning Centre, Madrid
Trial smile using the above design (explained in detail in Chapter 12), which
helped to motivate the patient to commit to ortho and restorations to replace
worn tooth structure.
The patient completed a course of orthodontics with Invisalign, which was
calibrated to the desired prerestorative position of the upper anteriors. I then
restored her upper incisors with minimal prep veneers and some bonding on
her canines to maintain canine guidance.
Luke Barnett Ceramics, Watford, England
NON-RE S TORATIVE S MIL E DE S IGN
The benefit of having been through the guided observation system is that by
the time you are designing the ideal smile, it will become obvious whether
the case is restorative or not. Because you have assessed the data carefully,
the diagnoses will lead you away from jumping to conclusions and perhaps
making a mistake.
For example, in this case:

This young lady came to see me after having her fixed braces removed
because she was deeply unhappy with her smile.
After capturing all the data and going through the guided observation, it was
apparent that this was an exaggerated case of altered passive eruption
(Morrow, Robbins et al. 2000). Her gingivae had possibly been aggravated
by the fixed braces—she was not on any medication, so this was not a
pharmacological response. The CEJ was not palpable, and with a CBCT, I
could see that there was bone lying over the enamel, and thus, the diagnosis
was altered passive eruption.
The beauty of the digital workflow is that the DICOM file of the CBCT can
be calibrated with the .STL file from the iTero scanner to produce a crown-
lengthening guide, which could show me exactly where the bone needed to be
recontoured and the soft tissue removed to respect the biologic width (DSD
Planning Centre, Madrid).
Digitally designed printed guide in place to indicate soft tissue level and
desired bone level according to the digital calibration (Digital planning:
DSD Planning Centre, Madrid, Spain).
Soft tissue six weeks after surgery with the enamel revealed and the
central incisors back to the correct width-to-length ratio.
Follow-up three years after surgery.
Further Reading
Gerard J Chiche and Hitoshi Aoshima, Smile Design—A Guide for
Clinician, Ceramist and Patient, Quintessence International, 2004.
Galip Gurel, The Science and Art of Porcelain Laminate Veneers,
Quintessence International, 2003.
Pascal Magne and Urs Belser, Bonded Porcelain Restorations in the
Anterior Dentition—A Biomimetic Approach, Quintessence International,
2002.
Rafi Romano, The Art of the Smile, Quintessence International, 2005.
C HA PTER 11
D EN TA L IM A GIN G –
THE PO W ER O F A
V ISU A L IM A GE
“A work of art which did not begin in emotion, is not art.”
PAUL CEZANNE
Touchpoints for patient education and motivation are points in the patient
journey where we can connect the right and left sides of the brain to aid
decision-making. People make decisions emotionally (right brain) and justify
those decisions logically (left brain).
In this chapter, I highlight the emotional touchpoints in the patient journey
where we can use the design process as part of patient education and
motivation.
Emotional touchpoints for smile design

1. Dental imaging

2. Trial smile (Chapter 9)

3. Outcome simulation with iTero

Visual imaging is an important part of treatment planning and gives our

patients a strong, unambiguous communication of what’s possible.
Dental imaging describes the act of digitally enhancing or altering a patient’s
teeth in order to demonstrate how they could look if certain changes were
made to their teeth and smile. In the early stages of discussing the possible
outcomes of dentistry affecting the smile, it can be a very useful aid to case
presentation and serve as a tool to discuss possible outcomes.
Dental imaging is a tool to help patients to understand the impact of changing
their smile in two dimensions. This is often confused with but is not the same
as digital smile design as advocated by Christian Coachman and team. A 2D
design is part of the process, but digital smile design is a philosophy and an
ever-developing clinical workflow that involves designing the ideal smile
maximizing interdisciplinary communication, and then being able to link this
design to a prescribed 3D process involving a trial smile and ultimately the
clinical end result. The ethos of DSD is about showing the patient the
potential end result in their mouths, ideally with two videos side by side
where the contrast is focused on the teeth.
Nowadays, the imaging technologies can use libraries of natural teeth rather
than digitally altered images. This means that imaging is no longer just a
motivational tool; it also becomes part of the design process. Due to the
ability to link with natural libraries, this design tool can be used to try
different arrangements and morphologies, and this can be carried through into
the manufacture of provisionals and final, monolithic restorations.
Remember that for everyone who is not in the dental profession, the smile or
the teeth make up part of the picture of the face. The smile is an expression in
motion and the teeth are part of that expression. They can appear either to be
in harmony and pleasing to the eye as part of the human expression of that
entire face, or they can appear in disharmony, obviously in different degrees.
But the smile must be taken in context, or it is largely meaningless.
For this reason, it is very difficult for lay people to identify with our words
when we are describing changes to teeth, for anything more than the very
simplest of changes. Obviously, if there is one dark tooth or stained filling,
then the proposed change can be understood, but when we start talking about
changing the position of teeth or closing spaces, this is much harder to
visualize if you have no prior experience to draw on.
In order to visualize something based on words, we, as
humans, need to draw on past experience to create an image
of that possibility in our minds. Those of us in the dental
profession have that experience. Most of our patients do not.
It is therefore very important to use actual images, such as photographs of
smiles, to improve communication. It is also important to use full-face
photographs. Nobody outside the dental profession looks at pictures of
smiles only, and especially not of retracted smiles. We need to be showing
full faces with expression for our patients to make sense of what they are
seeing, remembering that the smile is an expression, that is, it reflects a mood
or an emotion.
Our patients do not want dentistry. Much like when we go to the doctor, none
of us want the operation or even the blood test. We do want to be healthy. We
want to enjoy our lives with a feeling of well-being. Dentistry is the same,
but because much of what we do in esthetic dentistry is elective, we may lose
sight of it and get very excited and animated about the wonderful techniques
and technology available to us, and we forget that patients don’t want any of
it. They don’t want the implant or the tooth whitening or the
bonding or the orthodontics. What they want is the end
result. They want health, comfort and the self-confidence to
interact with other human beings in a free and relaxed way,
without feeling self-conscious about their smiles. Obviously, this
means different things for different people. Fortunately, cosmetic dentistry
has progressed past the point of making everyone look the same restoratively,
and in recent times, there has been excellent research and development of
systems for analyzing, diagnosing and treatment planning with health, function
and conservation of tooth structure as the ultimate goals, in addition to being
able to enhance the esthetics of the smile.
When discussing the options with a patient who is considering or asking
about cosmetic or esthetic changes, our most powerful tool is photography
and video. A picture of the patient on a large screen can start the
conversation as to whether there is anything that the patient may change about
their smile, and even before that is asking the patient to rate their smile on a
scale of 1 to10. There are three things that make up the composition of a
smile: color, shape and position. The relative interactions of all of these
factors for every tooth in the smile give us the perception of harmony or
disharmony.
S O HOW DOE S DE NTAL IMAGING
HE L P US ?
Imaging software has been around for well over 20 years, almost as long as
dentists have been using computers. It is very easy now to take high-quality
digital images of our patients that include full-face smiles from the front. For
imaging to be effective, it helps if we standardize how we take these
pictures. Certain things can be altered digitally, but others cannot. Patients
generally have a pose position that they go to, having taught themselves with
selfies or in front of the mirror. Imaging currently works best on a fully
frontal image, that is, without any degree of head turning.
The operator can check this by looking at how much of either ear is showing.
Horizontal shifts can be edited in the software, sagittal shifts cannot.
Chin down is very important, as chin up can create a false reverse smile,
which is common when people are trying to minimize a double chin! And
finally, the teeth should be slightly apart so that the edges of the maxillary
teeth have a dark background. The degree of opening will depend on the
occlusion. Class 2 deep bites need to open much further than a Class 1 or 3,
and we only want enough opening to just separate the anterior teeth. Too
much, and again, the smile is distorted.
Once we have a good smile photograph, imaging offers several possibilities.

• Lightening the whole smile to simulate whitening. This can be an easy

and effective tool. Key reference factors, like the whites of the eyes,
can be used.

• Manipulating individual teeth, for example, duplicating and flipping a

central and lateral from one side to the other, simulating bonding to
lengthen teeth or close diastemas.

• Overlaying another smile to demonstrate large changes. This is

basically cutting and pasting someone else’s smile into this patient’s
face and can be very effective for demonstrating large-scale change.
Most software come with a smile library and the operator can
manipulate these to suit the patient’s smile. This type of imaging can
also be outsourced.

• Tooth-by-tooth design and complete control. The most sophisticated

systems like the DSDApp by Coachman allow the user to choose from
 a library that calibrates to 3D design. Everything from color to gingival
position can be controlled.

Criticisms of dental imaging often center around the idea that by showing a
patient a digitally enhanced image, we are creating a potentially unrealistic
outcome and leaving ourselves open to setting unrealistic expectations in the
eyes of the patient.
Steps can be taken to overcome these potential risks. First, before showing
the patient an image, it is essential to explain that this is an image created on
a computer to give us an idea of how the patient could look if dentistry were
carried out. Indeed, sometimes the images do look artificial, so we do not
want the patient to be put off treatment because they do not like the artificial
image. A disclaimer can be printed under every image to the same effect. In
addition, it is important that the person doing the imaging or showing it to the
patient have some understanding of what is possible. For instance, if there is
a large jaw discrepancy that can only be corrected with orthognathic surgery,
this may be simple to simulate on a computer, but the reality of the procedure
is much more complicated. This needs to be understood and communicated to
the patient sensibly so that there are no false expectations. Imaging is not the
treatment plan per se; the dentistry still needs to be diagnosed and planned
appropriately, taking biology and function into account.
There is various software available in the market today; some are free and
cloud based, some are subscription based, or you can outsource altogether.
In this example, I have used the DSDApp by Coachman to design three
different outcomes for a challenging esthetic case. This case is described in
more detail in Chapter 17.
Option 1: Looks strange because it highlights the underlying maxillary
deficiency (narrow buccal corridors), but it serves to educate the patient.

Option 2: The patient told me he wanted the four front teeth extracted—I
explained that in order to fit four teeth into the intercanine width, they would
be narrower than ideal.
Option 3: This was me brainstorming. I knew that the patient had a limited
budget, and although I would aim to persuade him to do orthodontics, I also
thought if I improved the color and alignment of his central incisors, that
might be enough of an improvement.
As you can see, dental imaging used in this way helps to brainstorm and try
out different options. This is much more valuable than just cutting and pasting
in a different smile, which is most likely unachievable.
Dental 2D smile imaging can also be outsourced to companies, which will
accept an emailed photograph with some simple instructions and return a
before and after for a fee. Third, images can be manipulated within Keynote
or using photographic software, such as Photoshop. This is generally less
intuitive and needs more understanding of the nondental software by the
operator but is also effective.
DECISION POINT Do some research. Most of the smile design tools have
trial periods before you commit to any regular payments. I recommend that
you learn how to do the design yourself because if you outsource it
completely, you lose the diagnostic/problem-solving exercise, which helps
with treatment planning. Remember there will be a learning curve, so invest
in time for training too.
If accompanied by an STL file from a digital impression or a model scan, the
2D images can also be converted to 3D, and this can also be outsourced to a
dental laboratory with a good knowledge of digital planning. This is
definitely the future for dentistry. Laboratory-based software such as
Nemotech or Exocad can be used to design the case in 2D and convert it to
3D for designing provisionals, guides and final restorations. The future
certainly holds other advances, which will make this process simpler for the
user. For example, the work being done by Disney where teeth are
constructed by artificial intelligence from simple photographs or video will
eventually impact the image capture capabilities of dentistry.
Although smiles can be designed digitally, it is not always possible to take
these to the mouth in the first instance. Trial smiles can be designed digitally
and photographed and videoed in the mouth to produce powerful 3D images
for the patient to view, but this is not possible for every patient. For non-
additive cases such as perio, where teeth have drifted forward, or to
demonstrate simple things like color change or bonding before going to the
mouth, 2D dental imaging can be used to increase case acceptance and is a
simple and effective way to initiate further discussion. 2D imaging can also
be used to demonstrate different outcomes such as four anterior veneers
versus eight or closing a diastema by only adding to two teeth compared to
improving the width–length ratios by treating the four anteriors.
The process of 2D imaging also trains our eye and mind to think about the
challenges of the underlying clinical situation. While trying to make a smile
look good, we notice things like excess gingiva in the premolar region or a
canted maxilla. Placing the outlines of the proposed teeth over the existing
teeth can illustrate where we may need to move teeth, and screenshots of this
can be very useful to add to our case presentation storyboard as part of the
educational part to explain to the patient. This also applies to width–length
ratio problems where we may need to lengthen a crown or move the teeth.
Remember, all of these are additional procedures that our patient would
rather not have, so we need to be able to explain and motivate so that the
benefit outweighs the perceived negatives of additional procedures. Imaging
helps with this, as we can simply show the difference with and without the
changes in gingival levels.
ARTIF ICIAL INTE L L IGE NCE OP TIONS
AI, of course, has no emotional intelligence, but it can be used to give the
patient a quick glimpse of how their smile could look. It is not diagnostic,
and the risk is that if it does not look good, the patient will be put off.
However, with the correct disclaimers, it can all be an entry point for
patients to discover the possibilities.
Smile View is Align Technology’s simulation tool. It is available via a link if
you are a registered Invisalign user. It uses artificial intelligence based on
face shape and all the data capture that Invisalign has built up over many
years of straightening smiles. The result is delivered within a few of minutes.
 Courtesy of Align Technology, Inc.
Smile View link—The patient submits a selfie image on a smart phone and
the result is delivered to them and to your practice email so that you can
follow up. Alternatively, it can be carried out when the patient attends the
practice.
These “quick” imaging options are not diagnostic but can be used as
motivational possibilities to educate the patient to move to the next step.
In summary, dental imaging is a very useful tool to be able to demonstrate to
the patient, in photographic form, the potential outcome of changing elements
of the smile. This is most powerful when used with the full face.
Courtesy of Align Technology, Inc.
C HA PTER 12
TR IA L SM ILE
“There are two distinct languages. There is the verbal, which
separates people … And there is the visual that is understood
by everybody.”
YAACOV AGAM

When the case is mostly additive, meaning that we are able to add to the teeth
to demonstrate the potential changes, the most powerful motivational tool is
to do a trial smile in the patient’s mouth and to take a video of them before
they have seen it. This can then be presented to the patient side-by-side so
that they can see the difference that dentistry would make. This puts the
changes that patients could otherwise have difficulty understanding into
context.
DECISION POINT Not all patients are suitable for a trial smile. Trial
smiles are great for diastema closures, retroclined teeth, wear cases, and
altered passive eruption. They cannot be used when old dentistry is
bulky or if teeth are proclined and need to be brought back into the arch.
In one of our hands-on courses, my colleague and digital smile design dentist
extraordinaire from the Glasgow Smile Centre, Dr. Jameel Gardee, had his
martial arts instructor come along so that we could demonstrate a live hands-
on trial smile to the class of dentists. When we presented the video and stills
on the big screen in front of the audience, our patient was moved to point and
shout out with enthusiasm, “I wanna be that guy!”
That is the difference that dentistry was going to make in his life. He could
see the difference in a snapshot image, and with it came all the rest of the
connotations that we have discussed in earlier chapters. He wanted to be that
guy, not look like that guy.
These days, trial smiles can be designed digitally and placed in the mouth on
a silicone putty designed from a printed model, or the trial smile itself can be
printed in a PMMA format sometimes known as a “shell.” This can be
clicked into position so that the photographs and video can be taken. This is
the essence of the Digital Smile Design philosophy by Christian Coachman,
and you can learn how to design and deliver trial smileas in their courses,
many of which are now online at www.digitalsmiledesign.com.
In most cases, if the try-in looks right, then there is nothing major out of
balance. If the overall effect looks out of harmony, then we can apply our
smile design rules in the context of the face to investigate what could be
changed.
Another example—This patient wanted a brighter, whiter, more even
smile.
Her smile line is flat and somewhat irregular due to her missing upper left
lateral. Her trial smile was designed as an additive wax-up to be able to fit it
over her existing teeth and analyze the change in esthetics. Smile analysis
with the RED proportion guide shows the challenge of width distribution
when a canine is in the position of the lateral. A skilled technician can play
with line angles to create more balance in the smile.
A well-designed putty stent for the trial smile with notches cut to the
cervical margins to allow the excess temporary material to flow out,
which facilitates easy clean-up.
Some tips for trial smiles

1. Use a good-quality material that reflects the light well. I like

Luxatemp from DMG which comes with matching flowable
 composites so if there are any air bubbles they can be easily
touched up.

2. If you are going to use a stent, make sure it has been trimmed well
at the margins so that the excess will flow out and can be removed
easily.

3. Make sure the stent has been lined with a flowable or light-bodied
material so the natural surface texture is transferred to the mouth.

4. Fill the stent carefully, placing the tip of the dispenser to the incisal
edges and backfilling to minimize the risk of air bubbles.

5. Remove most of the excess, but try not to drill or start messing
around with the shapes, as this will make the patient remember that
dentistry can be noisy and unpleasant!

6. Warn the patient in advance that this will taste and feel strange. As
it is additive, in most cases, the teeth will feel thicker than normal
and the patient may not be able to bite properly. This is not how we
are proposing they will be after the dentistry; it is simply to create
an illusion so they can visualize their “future, better self.”

7. Do not let the patient look in a mirror but take good full-face
images and let them see on a screen so they can take in the full
effect. Looking in a mirror is like cropping out the face and all they
will see are the imperfections. Sometimes you have to be strong
with this and have all your team informed—you can make fun of it
and reassure them that they will be able to see but that you don’t
want to spoil the surprise!
 If it does not look good—which is unlikely unless you have made a
core design error—do not show the patient. You would be better
off to remove and mock-up directly in the mouth if you have the
skills. If you show them something that is wrong, your words will
not be able to replace the image they have in their mind of the bad
design and trust that you can provide a good result will be
undermined. For this reason, under-promise and over-deliver.
Explain that this is worth doing to see what the changes could look
like and to make modifications if needed. It is much better to under-
promise and have the patient be amazed than to over-promise and
have the patient disappointed.

8. Be careful with black triangles, pontics and recession. Block out

areas of undercut with soft wax, or you will need to drill to remove
the trial smile, which can be unpleasant.

9. If the plan is to shorten teeth and there is tooth sticking below the
trial smile, you can use a marker to block this out for the effect in
the photograph.

10. If there are dark teeth shining through the temporary material, you
can turn the pictures into black and white by reducing the saturation
in your Keynote storyboard.

11. Click the image on the slide so the white dots surround it. On the
Format menu on the right, click the Image tab and you will see two
sliders. The bottom one is Saturation, and if you slide it all the way
to the left, this will turn your photo into black and white (see the
picture on the following page).
12. When you show the patient the images or video of them with their
trial smile on the big screen—keep quiet. Give them time to
process what they are seeing.
Occasionally, even though you think the smile looks
amazing, a patient may not. If a patient cannot articulate
what they don’t like or why they don’t like it, be very
careful. It may not be their teeth that they are looking to change, or
maybe the changes in their teeth are not producing the change in
their face that they expected. Assess the situation, but if the patient
can only express disappointment and if you cannot see what you
would change or do better, then you would be better to refer the
patient elsewhere.
Keynote slide showing the Saturation slider
Example of a trial smile that looks better in black and white, as there is a big
mismatch in color between the temporary material and the teeth.
DECISION POINT Of course, trial smiles can also be performed directly
in the mouth freehand with composite resin or a stent made from an analog
additive wax-up. Any laboratory work will have a fee attached, so this is
usually a second-stage motivational tool as a “next step” following the initial
case presentation.
TRIAL S MIL E
In a restorative case, once the patient and you have approved the design, this
can be used to produce a diagnostic wax-up and preparation guides. In this
way, the final delivery of the restorations, in this case porcelain veneers, is
much more predictable.
In this case, the Emax porcelain restorations provided a more symmetrical,
balanced smile with the smile curve following the patient’s lower lip, fuller
buccal corridors, and more uniform tooth display. They were also whiter and
more light reflective to give her the white smile she was hoping for.
Ceramics by Art Dental, Sheffield, England
C HA PTER 13
O U TC O M E
SIM U LATIO N
“Do the best you can until you know better. Then when you
know better, do better.”
MAYA ANGELOU
For cases requiring orthodontic movement, particularly if this is why the
patient has attended, another tool to connect with a patient is to simulate the
orthodontic movements. Most orthodontic systems now have digital planning
tools that can be used. One of the best is the outcome simulator that is part of
the Invisalign system.
From an emotional point of view, simulations of models are not as powerful
as imaging or a trial smile. Changing teeth positions is out of context when a
patient is looking at virtual models of their teeth. It is harder for them to
consider the impact that this will have on their face and expressions.
Nevertheless, the technology is impressive, and it can enhance the
educational and motivational experience to demonstrate how a patient’s teeth
could be moved. The outcome simulator uses an algorithm to simulate the
teeth straightening, although the outcome can be adjusted by the clinician.
Once the patient has agreed to the next step in treatment, Invisalign’s
ClinCheck Pro software can put the outcome in the facial picture so that the
patient can be involved in decisions about final tooth positions. This is a
“next step” in a treatment plan, as there is a nonrefundable cost involved with
this.
Outcome simulation can be particularly helpful when demonstrating the need
for tooth movement and restorative dentistry. Many times when anterior teeth
have spent decades functioning in a malocclusion, the forces of wear are not
evenly spread. There has been differential wear. Some teeth have taken the
brunt of the force and suffered damage, and others, particularly if proclined
out of harm’s way, may not be damaged at all. When the teeth are
straightened, these differences will be more obvious, and the patient needs to
understand that the teeth may be straight, but the smile will still not be ideal
due to tooth surface loss.
The outcome simulator can be viewed live on the iTero scanner chairside,
and you can alter the end result. You can discuss it there and then with the
patient, or you can view it at a later date and send the patient a link. The
patient then receives a password-protected link, where they can click the
orange arrow at the bottom of the screen to view the current tooth position
and the simulated outcome in all of the different views, which are listed on
the toolbar at the top.
If you are new to integrating orthodontics into your treatment
planning, I would caution against using the outcome simulator
“live” with the patient in the chair. While this in itself can be a
powerful motivator, there is a risk that the algorithm produce movements that
are unpredictable and therefore set a false expectation or that results are
actually worse. Sometimes the software picks up soft tissue or a partially
captured tooth and this can cause an error with the long axes, and hence the
end result. An experienced user can pick this up and adjust, but if you are
beginning, it is safer to do the simulation on your own time so that you can
prepare how to include it in your patient presentation. In this way, you can be
sure that the tooth movements match the patient’s diagnosis and risk profile.
In the above example, I was able to prepare two outcome simulations, one
aligning the incisal edges of the centrals, and one aligning the gingival
margins of the centrals. Because the upper right central has lost tooth surface
due to wear, the patient can understand that if we line up the gums, which is
the correct thing to do unless she has a very low lip line and does not want to
do this, then we will need to consider some restorative solutions for the
incisal edge of the upper right central.
In these images of the same case, the patient can see the teeth from a different
angle, and the clinician can point out the wear on the incisal edge of the
upper right central.
The wear is even clearer on the MyiTero viewer with the color switched off
—I would take a screenshotof this and add it to the storyboard.
DECISION POINT You now have at least three ways that you can design a
smile for your patient and involve them in the process, which increases
education and motivation. For each case, you need to decide which tools are
relevant and which you may use initially or after the initial treatment option
conversation.
 Do not be tempted to show the patient images of how they could
look unless you are confident that the desired result can be
achieved and that you know how. That would be unethical and
could set you up for failure. The next steps of risk assessment and problem
solving may make you more realistic about what can be achieved, and
remember, there is always more than one option.
C HA PTER 1 4
R ISK A SSESSM EN T
“Whatever you can do, or dream you can, begin it. Boldness
has genius, power and magic in it.”
GOETHE
Once we have completely analyzed our starting point and have our diagnoses,

www.dentalbooks.org
we know point A, that is, where we are. Once we have considered design, we
know point B, where we, ideally, would like to get to.
Part of summarizing the challenges or problems and identifying the goals of
treatment is identifying the prominent risk factors for this individual and set of
circumstances. If we can clearly identify the risk status of the patient in
different areas, we can use that as a tool to help us to consider the treatment
alternatives and to set patient expectations as to the likely outcomes of various
treatment pathways.
Risk assessment and risk management are two phrases that are being
increasingly used in dentistry. I have some experience of expert witness work
and the legal profession often asks us to quantify the risk of requiring further
dental work following an accident or incident. Our evidence-based training
leads us to the literature, but there is not an overwhelming resource there for
us to refer to. We know some things. We know that if a tooth is endodontically
treated, we are more likely to lose it over a lifetime. We know that if a tooth
has a large restoration, it is more likely to require an endodontic treatment
over a lifetime. We can quantify risk in a very basic manner as low risk,
moderate risk or high risk, which is the easiest way to explain to patients.

Risk assessment
 This stage of the treatment planning process is important and often done
almost subconsciously. It requires the dentist to consider the likelihood of
success or failure of the various treatment options as shown preferably by
evidence-based studies, and to ensure that the patient fully understands the
probable long-term prognosis for each option.
Unfortunately, only limited information is available on the cost-
effectiveness of restorative treatment options, which takes into account the
long-term survival estimates of different treatments that have been
discounted for their initial treatment costs. In addition, the survival of such
treatments is influenced by the current oral disease risks present, such as
those for dental caries, tooth surface loss and periodontal disease.

P. Newsome, R. Smales, and K. Yip, Oral diagnosis and treatment

planning: part 1.
Introduction, British Dental Journal, 2012; 213: 15-19.
https://doi.org/10.1038/sj. bdj .2012.559

Sometimes it is possible to move a treatment from high risk to low risk. For
example, prerestorative orthodontics will move a patient from a high
biomechanical risk to a lower risk. Porcelain restorations can change from
being highly invasive to minimally so.
The ITI implant group has an excellent online tool, the SAC Risk Assessment
Tool, used to categorize implant patients in terms of risk. A version of it is
free of charge, and if you are a member, you can also print a report. This tool
takes into account many of the risks identified in this form but is specifically
designed for considering implants. I would highly recommend it also if your
patient has significant missing teeth.
Risk can be individual based and treatment based, which is what leads us into
risk management. Much like diagnoses, we can have the overall risks in all
categories for an individual, and we can have the risks of placing an implant in
a certain location for that individual. We also have the risks of doing nothing
when signs of instability exist.
I would urge you to consider that risk as the final stage in your analysis. Fill
out a risk assessment form to share with your patient. Mention risks of every
treatment in your consent forms, including the risks of no treatment. While this
is important for record-keeping and informed consent, it is also ethical. The
last thing we ever want to hear from our patients is, “Had I known there was a
risk, then I might have chosen a different path.”
I like to use a risk stratification sheet, which I highlight for the patient to
indicate their current risk status, and if appropriate, how we could reduce
those risks with different courses of treatment. I have adapted this sheet many
times, as I have attended postgraduate studies and identified new strategies for
treatment. Use it as a template and modify it for whatever your scope of
interest is. Beneath the form, I have provided some insight into how to
categorize your patient, line by line.
DECISION POINT You can decide whether to fill this form out for your own
benefit to help with narrowing down treatment options, whether this is a
patient you feel competent treating, whether this is one to refer, or whether you
want to share the form with the patient as part of their case presentation.
The premise of risk assessment and, most importantly, communicating risk to
the patient is that it helps us to explain how each treatment is different,
depending on the individual.
“Your friend may have had veneers, but their bite was not high risk from a
biomechanical standpoint.”
Risk assessment is central to the practice of individualized, patient-centric
care. It helps us to give an overview tailored to that patient, to be able to
identify where we can have some influence in reducing risk and where we
can’t. It helps us to communicate to the patient that there are certain things that
are out of our control. I believe that this really helps us to educate and
motivate our patients about what level of dentistry is right for them.
None of the lines should be taken in isolation. The intended use is for the
highlighted low and high areas to give an overview, a profile.
Some of the risk categories are almost self-explanatory. Some, I have found,
need more explanation so that the value of the screening can be understood.
Again, depending on your area of interest, you may choose to group some
together or to add more specific risk categories appropriate for your field. The
list is intended as a guide rather than a prescriptive form.
1. PATIE NT’S E S THE TIC
E XP E CTATIONS AS A RIS K
A smile evaluation tool is the most effective way to gauge a patient’s esthetic
expectations.
Smile Evaluation
This form can be sent as part of your new-patient welcome pack. It can also be
very useful to periodically use it with your existing patients as a way of
generating conversation about the possibilities. Often, we are very good at
talking to our new patients about new techniques or knowledge that we have
gained, but we forget to communicate this to our existing patients.
Shelly Short is a dental hygienist who is a coach for dental practices and now
teaches practice management at the University of Oklahoma Dental School.
She has visited the UK on numerous occasions and has taught me many pearls
of wisdom with her unique insights. One story I have never forgotten is that of
one of her clients who had been learning all about smile design and was very
excited to be able to put some of his new learning into action. Cases were
going well and he was very pleased with progress. One day, he was examining
a long-time patient in hygiene when he noticed she had had some dental work
carried out—some beautiful porcelain work on her front teeth. “Oh Mrs.
Smith, I notice that you have had some porcelain veneers done. Was there a
reason that you didn’t ask us about your smile?” and the reply was, “Oh
Doctor, I didn’t think you did this kind of work.”
It is so easy for us to let this happen! We assume that if our patients who have
been coming to see us for a long time wanted something, they would ask. It is
therefore so important that the entire team be on the lookout for opportunities
to check with existing patients to make sure that they have the same
opportunities that our new patients do.
Sometimes we are reluctant to talk about new observations with our existing
patients, as we fear they may question why we had not mentioned this
previously. For instance, “If the wear on my teeth is such an issue, why haven’t
you mentioned it before?”
The best response for this is, “We now know that once the wear breaks
through the enamel, the dentine wears at six times the rate of enamel, and so
the speed of destruction increases.”
Or, “The current thinking is...” as in, “We used to think that it was
reasonable to keep things under observation, but current thinking or current
studies show us that this a risky strategy. We now know that...”
The answers on a smile evaluation form will give a lot of information on the
patient’s expectations about esthetics. One of the reasons that it is important to
know this comes back to building trust and relationships. If a patient is
suspicious of our motives, they may believe that esthetics is frivolous or vain
and they do not buy into that culture. Health is the most important thing to these
people. If we start presenting treatment options to them, speaking about how
much better they will look, we risk them becoming frustrated and feeling that
we have not listened to them. We may also come across as doing a hard sell in
an area which holds little value for the patient.
Before I discuss esthetic expectations, I would like to issue a word
of caution. I will never forget the lesson where Jillian and I learned
this in the early days (Jillian was my treatment coordinator at the
time; she now moved on to become my practice manager). We were learning
how to present complex cases and we had the wife of a legal professional
come to see us. She had suffered from dental erosion, a resulting loss of
vertical height, and was very worried about her teeth becoming weak and
starting to chip. Because we were so enthusiastic about our newly learned
smile design skills, we sent out a brochure talking about smile design with her
new-patient information. She reminded Jillian that she was not interested in
cosmetics but was concerned about the health of her teeth.
The clinical examination went well and she was very engaged in the prospect
of articulated study models, a face bow record, and a diagnostic wax-up to
begin the planning of reconstructing her bite and protecting the remaining tooth
structure. We talked through multiple options including costs, and all that
remained was for Jillian to confirm the treatment plan and estimate in writing.
Unfortunately, we had named porcelain restorations “smile design
restorations” in our practice management software. The result was a furious
two-page letter from her legally trained husband berating me for not listening
to his wife who had clearly stated that she was not seeking treatment for
cosmetics! Both her and her husband left the practice in anger. Jillian and I
were taught a hard lesson. If people tell you they are not interested in
cosmetics—hear them! And make sure that every communication that you send
them from this moment on does not say otherwise.
It was an interesting situation because by default, her appearance would have
been better after our proposed treatment. She had little, chipped anterior teeth
which would have been stronger and protected, and would have looked better,
taking years off her appearance. However, I have learned my lesson. It is much
better to let the enhanced improvement be a secondary advantage, as it often is
when health and function are restored. That is how I would approach these
cases now. Make sure that your written messages are congruent with what you
are saying to the patient.
“By building up these broken teeth, it will not only protect the remaining
tooth structure but also strengthen your ability to chew without fear of
further chipping. I know that appearance is not the reason you are seeking
treatment, but as a side benefit, they will also look more in harmony with
your smile”—or something to that effect. Once the trust value is high, patients
will often smile and say, “Well, there’s no doubt that will be an improvement
too.”
In terms of esthetic expectations, it is important, therefore, to recognize when a
patient is telling you that they are not concerned by the appearance of their
smile. You can mark “low” on the form. Most people with any kind of issues
with their smile will generally tell you that they would like it to look better.
Or, they may have specific dental issues in their smile, and both you and they
can agree that improvements will be beneficial.
The alarm bell rings at the opposite end of the scale when patients
throw away the little remark, “I just want my smile to be perfect”
and they smile at you, and often they have just told you how terrible
their previous dentist (or even dentists) were. They say they have done their
research and believe that you are the woman or man for the job. They don’t
want much—just a perfect smile. The alarm bells should ring even more if
their smile is already healthy, white, and more or less aligned.
Some people continue to “see” in their mind’s eye a different image of
themselves than exists in reality. Photographs can really help with this. Asking
patients to be very precise about the changes they would make, particularly
when you can’t see too many, can help you determine if this is a patient you
can help or if you should either refer or walk away.
If a patient ever uses the word perfect as an expectation in any sense, be very
careful how you proceed!
2. ME DICAL CONDITIONS AS A RIS K
As we have all been trained, we need to pay attention to medical issues that
either affect the decisions we may make about dentistry or that may limit the
patient’s ability to care for their mouths or to tolerate our dentistry. It is
important to put any proposed treatment plan options in context with a patient’s
overall health.
There are a number of particular general medical issues that affect restorative
dentistry, and some are ones we may be in a position to screen for and refer as
necessary:
1. Hypertension—Often named the “silent killer.” As dental professionals, we
may be seeing the patient more frequently than their general medical
physician, so we can offer to take blood pressure readings as a screening. It
is worth bearing in mind that very nervous patients may have elevated
blood pressure that is not a medical condition and it can be useful to take
an average of three readings. I recently was preparing upper veneers on a
patient who was wearing a Fitbit—the Fitbit had registered from her
heartbeat that she had done a workout—even though she had been lying still
in the dental chair. She had seemed perfectly calm to me, and the veneers
were minimal preparation. Stress during dental appointments is real!
Dental hygienists can be trained to take blood pressure readings. It is worth
asking the patient first if they already have their blood pressure checked on
a regular basis, but if not, then ask them if they know what it is and explain
that we offer this as a screening service. If it is outside the normal range,
then we would recommend that they visit a physician for an overall check.
This can be an added-value service to patients.
2. Diabetes is relevant for reasons ranging from making sure it is controlled to
avoiding risks of infection.
3. Gastroesophageal reflux disease (GERD). Patients often mention this as a
remark in passing; it is surprisingly common and they often self-medicate.
However, the erosive power of long-term chronic reflux is very destructive
and patients should be encouraged to seek help, and not just for the sake of
their teeth. I have a lovely patient who had been ignored in this regard and
given mild over-the-counter treatments. We had discussed erosion to her
teeth and I had encouraged her to seek further treatment, but she was
dismissed by her medical doctor as worrying about nothing. I noticed she
was wheezy at one appointment and encouraged her to seek specialist
 attention. She was treated for asthma, but finally, it was discovered that the
acid in her esophagus had burned her trachea. She required an emergency
operation to reconstruct her collapsed trachea. This patient had spent years
trying to get help, and I ended up having to write a report about the damage
I had seen to her teeth to help her explain to her medical doctors all of the
symptoms that she had been experiencing.
4. Airway issues. This is an emerging area of interest for dentists across the
world and is linked to nocturnal bruxism and sometimes also to GERD.
5. Stress levels. I have learned about this the hard way too. Stress has a
definite physiological effect on the body. A stressed patient may not have
the ideal outcome if we are contemplating complex dentistry. Implant
surgery was something a stressed medical nurse who was a heavy smoker
suffering from grief due to a tragic bereavement was something that she
consented to, but it did cost us a few failures. I managed to persuade her to
change her diet and take multivitamins, and then she finally admitted herself
that she was not in the best place for treatment. Antidepressants have been
linked to the possibility that implants may not heal as well. The body is
complex, and again we are reminded to treat the whole person, not just the
mouth. Sometimes the best treatment plan is to wait for a while.
It is not my intention to include a comprehensive medical review here, but it is
useful in terms of risk assessment to know the general medical health of our
patient. Are they generally healthy or not? The risk varies accordingly.
Smoking is an interesting one. While I am keen that we encourage our patients
to stop smoking, I also think it is important not to judge or patronize. However,
smoking impedes healing, increases the risk of staining, and so forth. This is
relevant to our treatment planning.
The ASA Classification from the American Society of Anesthesiology is a
useful classification to consider your patient’s risk status in terms of
general health.

ASA PS Definition Adult Examples, Including, but

Classification not Limited to:

ASA I A normal healthy Healthy, non-smoking, no or minimal alcohol use

patient

ASA II A patient with Mild diseases only without substantive functional

mild systemic limitations. Example inlcude (but not limited to): current
disease smoker, social alcohol drinker, pregnancy, obesity
(30<BMI<40), well-controlled DM/HTN, mild lung
disease

ASA III A patient with Substantive functional limitations; One or more

severe systemic moderate to severe diseases. Examples included (but
disease not limited to): poorly controlled DM or HTN, COPD,
morbid obesity (BMI ≥40), active hepatitis, alcohol
dependence or abuse, implanted pacemaker, moderate
reduction of ejection fraction, ESRD undergoing
regularly scheduled dialysis, premature infant PCA <
60 weeks, history (>3 months) of MI, CVA, TIA, or
CAD/stents

ASA IV A patient with Examples included (but not limited to): recent (<3
severe systemic months) MI, CVA, TIA, or CAD/stents, ongoing
disease that is a cardiac ischemia or severe valve dysfunction, severe
constant threat to reduction of ejection fraction, sepsis, DIC, ARD or
life ESRD not undergoing regularity scheduled dialysis
 ASA PS Definition Adult Examples, Including, but
Classification not Limited to:

ASA V A moribund Examples included (but not limited to): ruptured

patient who is not abdominal/thoracic aneurysm, massive trauma,
expected to intracranial bleed with mass effect, ischemic bowel in
survive without the face of significant cardiac pathology or multiple
the operation organ/system dysfunction

ASA VI A declared brain-dead patient whose organs are being removed for donor
purposes

1. Abouleish AE, Leib ML, Cohen NH. ASA provides examples to each ASA physical status class.
ASA Monitor 2015; 79:38-9. http://monitor.pubs.asahq.org/article.aspx?articleid=2434536
2. Hurwitz EE, Simon M, Vinta SR, et al. Adding examples to the ASA-Physical Status classification
improves correct assignments to patients. Anesthesiology 2017; 126:614-22
3. Mayhew D, Mendonca V, Murthy BVS. A review of ASA physical status – historical perspectives
and modern developments. Anaesthesia 2019; 74:373-9

In dental practice, we are only likely to be dealing with I-III. Many patients
have complex medical histories with polypharmacy (more than five
medications) thought to be present in 30 percent of older adults (Quinn and
Shah 2017) in the US. It is essential that we recognize when those conditions
and medications affect our work directly or indirectly with side effects, such
as dry mouth.
Listen to your intuition
As we gain more and more experience, looking in mouths—some of them are
healthy, and some of them less so—we do gain an awareness of what we
expect to see. About ten years ago, I had a young dentist come to see me with
some smile design requests. He was working very hard and found it difficult to
make the two-hour round trip to see me but was very keen to improve his
smile and to work with me and Luke Barnett Ceramics. He had seen lots of
Luke’s work showcased at a conference, and when doing his research had
decided that this was the ceramist and team he wanted to work with for his
own smile improvements. On examination, he had fiery, red gingiva in places,
despite immaculate oral hygiene. I questioned him about this and he admitted
that he had been seen at the dental hospital recently, and they had said there
was nothing to worry about. He was working very hard and was tired, and
maybe his oral hygiene wasn’t always up to scratch. I accepted his explanation
and noted my concerns, and we carried on with some preparation for his smile
design.
At a subsequent appointment, my intuition was telling me that something was
amiss. This was a young dentist. He knew perfectly well how to clean his teeth
effectively. His mouth was clean and the color of the gingivitis didn’t
correlate, in my mind, with careless or tired, lazy brushing. There was no
plaque when I saw him, and yet his gums were fiery red. I carefully said to
him, “I’m just not sure that this is adding up. Would you do me a favor and ask
your GP for a blood test—just to be sure that everything is okay? In case you
have some anemia or something?” Again, he reassured me that the dental
hospital had told him there was nothing to worry about, he was overworking
and would try to get some life balance back.
A few weeks later I received a letter from him. He had finally gone for a
blood test and it was discovered that he had leukemia. He had quit his job and
gone home to his parents for treatment. He thanked me for encouraging him to
get the blood test and said that his tiredness had been because he was unwell. I
am very pleased to say that he responded well to treatment and is now
pursuing an amazing career in dentistry. I took that lesson to heart. I could have
dismissed the gingivitis as being down to his lifestyle, but it was nagging at
me. When something doesn’t add up, listen to your intuition and remember that
early signs of systemic disease may show orally. A blood test can do no harm.
3. P E RIODONTAL S TATUS AS A RIS K
The new classification of periodontal status is very helpful as it gives us more
than just the basic periodontal screening tool. We need to look at radiographs
to be able to work through the flowchart, so I do this at the analysis stage. I
have the flowcharts from the British Society of Periodontology pinned to my
office wall so that I can work through them.
It is important to note that anything more than gingivitis is considered to be
high risk. This is justified and can be explored in more detail with genetic risk
profiling. The important aspect at this stage is that the patient be aware that
their risk status is altered. Individuals with reversible gingivitis can improve
their oral hygiene and move themselves from medium risk to low risk. This is
part of educating and motivating patients to take responsibility for their own
risk status.
4. S MIL E L INE AS A RIS K
Remember that patients may have taught themselves to guard their smiles and
so part of the assessment is to double check the true level of lip mobility.
Here is an example of a true low smile line:
On retraction, this case revealed multiple challenges including teeth of
different colors, old dentistry, tooth surface loss, altered passive eruption
and dentoalveolar compensation.
Crown lengthening, whitening, four porcelain crowns, equilibration, and
bonding on the tips of the canines improved esthetics and function.
Luke Barnett Ceramics, Watford, England
Interestingly in smile design literature, the true incidence of high smile line is
much greater than we first thought. With the advent of ease of video and the
importance of capturing an expression and not a static pose, we find that many
more people can show a significant amount of gum. If the teeth are healthy, a
good color and well aligned, and the gums are pale pink and healthy, then the
smile may still be attractive. Nevertheless, it means that any dentistry that we
are doing is on full display. Low smile lines are much lower risk in terms of
dentistry, although they can also pose challenges if the patients present the
complaint that they want to show more tooth! In those cases, our best tool is
brighter, more reflective surfaces.
In the next example of a low smile line, the old dentistry was replaced
with brighter, more opaque porcelain, with more tooth display at rest,
resulting in a more youthful smile.
In terms of risk assessment, in a true high smile line where the patient can
show everything, we have more of a challenge with dentistry in the esthetic
zone.
High smile line—No hiding place
In this example, this lady wanted her upper space closed. Taking care to
preserve the width–length ratio of the anterior teeth, porcelain restorations
were utilized to close the space.
 5. L IP MOB IL ITY AS A RIS K
As described in Chapter 6, the best way to calculate lip mobility is by
measuring the length of the maxillary central incisor and how much tooth
display there is at rest (the M-position), and then how much gum shows
between the lip and the cervical margin of the central incisor at the fullest
smile position of the lip. Both measurements can be negative numbers if the lip
is covering the incisal or the gingival crest.
In terms of risk, we are simply interested in whether there is normal, low or
moderate lip mobility, or whether the lip is hypermobile. Average lip mobility
is 6–8 mm. If the lip moves more than this, there will be more of the maxilla
on display and a higher esthetic risk for the patient. Similarly, if the patient’s
desire is to show more tooth but they have a hypomobile lip, there is a
moderate challenge.
6. GINGIVAL L E VE L S AND B IOTY P E
AS A RIS K
Gingival biotype is talked about a lot in clinical articles, but there is very little
definitive information in literature and there is certainly no clinical test that
will tell us what biotype a patient falls under. However, there is a visual
difference between a thin gingival biotype, where the teeth are obviously
positioned at the boundaries of the alveolar bone, compared to a thick biotype,
where there is an abundance of soft tissue overlying the roots of the teeth.
It almost does not matter what type of dentistry you are considering, the risks
with a thin biotype are higher than those with a thick one. Areas of gingival
recession will be harder to manage in terms of appearance and long-term
stability than areas of good gingival coverage.
Example of a thin biotype—Tendency to recession and thin, scalloped
gingivae

The gingival biotype may actually be a reflection of the underlying skeletal

base but is a useful marker to indicate caution and can be used to explain this
to the patient.
 7. AND 8. S K E L E TAL PATTE RN AND
B UCCAL CORRIDORS AS A RIS K
We learn a small amount about skeletal patterns as undergraduates and then the
dentist’s level of interest in orthodontics determines whether it is built upon.
Orthodontists receive extensive training in this area, including cephalometric
analysis.
General practitioners are performing more adult orthodontics now, with the
advent of GP-focused systems of fixed wire and clear aligner systems, such as
Invisalign. I believe that tooth movement is an essential tool that we need
access to when planning complex restorative cases; we also need to be able to
screen for the limitations. Teeth can be moved, within limits, because certain
smile design issues cannot be solved with teeth alone. It is vital that we
understand how to screen and what the possible referral routes should be, as
appropriate. The more knowledge we have, the more informed we will be in
our discussions with our patients.
The relative position of the maxilla and mandible, termed the skeletal pattern,
has a large influence on the relationship of the maxillary and mandibular
dentition. The skeletal pattern should be assessed in three dimensions:
• Antero-posterior/sagittal
• Transverse
• Vertical
Diagnosis of the underlying skeletal base will help us to see where the
limitations of our treatments lie and also serve to communicate with patients
when referral to an orthodontist and/or an orthognathic surgeon may be
indicated to fully address the issues. It is important to realize that in adults, we
can improve the position of the teeth in the underlying skeletal base, but if
there is an underlying skeletal Class 2 or Class 3, then there will be limits to
where we can move the teeth.
We can learn a lot about the underlying skeletal base with some observations
of the profile.
A facial profile can be normal or straight, as in a skeletal Class 1. Crowding
or spacing in a skeletal Class 1 will therefore be of dental origin and can be
treated dentally.
A skeletal Class 2 will produce a convex profile and can be due to a retruded
mandible with a normal maxilla, a normal mandible with a protruded maxila,
or a combination of both.
A skeletal Class 3 will produce a concave facial profile where the mandible
is normal but the maxilla is retruded, the maxilla is normal and the mandible is
protruded, or a combination of both.
The best tools that I have found to help assess this without a cephalometric
radiograph are the E-plane, Andrews Line, and Arnett’s True Vertical,
described in Chapter 7.
There are an increasing number of procedures being developed under the
classification of surgically facilitated orthodontics which are producing very
interesting results as alternatives to orthognathic surgery, and in conjunction
with a greater understanding of the link between airway and skeletal pattern
(Mandelaris, Richman et al. 2020).
The two components of the transverse dimension that should be assessed are:
• Facial symmetry
• Arch width
It is quite common to find asymmetries in the face, but those that affect the
mandible and maxilla are particularly important when planning orthodontic
treatment.
The symmetry of facial structures can be assessed by constructing the facial
midline between the soft tissue nasion and the middle part of the upper lip at
the vermillion border, as we have done in the smile analysis slide. The chin
point should be coincident with this line. If there is an asymmetry of the chin
point, it is also important to check for a compensatory cant in the maxillary
occlusal plane. Asymmetries in the chin point may be produced by a lateral
mandibular displacement on closing, if there is an occlusal interference.
The relative width of the upper and lower arches affects the transverse
relationship of the teeth. If the maxilla is narrow, this can result in a crossbite
of the buccal segments if there has been inadequate dentoalveolar
compensation (see Chapter 7). On intra-oral examination, the maxilla should
be slightly wider than the mandible. It is important to remember that the
absolute transverse dimensions of the maxilla may be normal, but a relative
transverse maxillary discrepancy, manifesting as a posterior crossbite, may
exist due to incorrect AP positioning of the maxilla/mandible. The AP position
can affect the transverse relationship as the dental arches get wider, as one
moves distally.
Ackerman and Proffit developed a system of categorizing orthodontic
problems into five main groups (Ackerman et al. 2007):
1. The first is the dentofacial appearance, which includes symmetry, facial
proportions, incisor display, lip support, and soft tissue profile.
2. The second category includes the teeth and arch form, including alignment,
symmetry of the jaws, and spacing or crowding.
The next three categories include the skeletal and dental problems in the
transverse, anteroposterior (sagittal), and vertical planes of space.
3. In the transverse plane problems include:
• Posterior crossbites
• Torque of the posterior dentition (for example, negative torque of
the posterior dentition causes narrow arches and narrow buccal
corridors, when the smile is viewed from the front)
• Asymmetries of the maxilla and/or mandible
An example of bilateral posterior crossbite with an incomplete anterior
bite.

4. In the sagittal plane or anteroposterior dimension, classification of the

molar, canine, and skeleton are noted, as well as anterior crossbites and
overjet. A slide or shift forward from CR to MI would also constitute a
problem in the sagittal plane.
Molars can be Class 1, where the mesiobuccal cusp of the upper first molar
fits into the mesiobuccal groove of the lower first molar. With Class 2 molars,
the upper molar cusp is ahead of this groove. In Class 3, the upper molar cusp
is behind it.
Canines can be Class 1 when the upper canine fits into the contact between the
lower canine and the first premolar, Class 2 if it is ahead, and Class 3 if it is
behind.
These determinations can be made and noted during the clinical examination,
or examined with study models mounted in occlusion, or by viewing the intra-
oral scans in occlusion.
Anteroposterior dimension
Another way of thinking about screening for skeletal base is to relate the AP
position of the mandible to the maxilla, and the relationship of these bones to
the cranial base. Assessment of the position of each jaw, relative to the cranial
base, gives an indication of which jaw may be contributing to a malocclusion.
An assessment of the severity of the discrepancy will help to guide whether
treatment can be provided with orthodontics alone, or if a combination
approach that also involves orthognathic surgery is required.
It is important to assess the patient in the natural head position, which is a
standardized, reproducible head orientation, as the tilt of the head can greatly
influence the interpretation of the skeletal pattern. To achieve this, the patient
should be sitting upright, relaxed, and looking straight ahead at a distant point
at eye level, and the teeth should be lightly in occlusion.
The most anterior part of the maxilla and the mandible can be palpated in the
midline through the base of the lips. The relationship of the mandible relative
to the maxilla can be classified as follows:
• Class I - When the mandible lies 2–3 mm posterior to the maxilla. The
profile is straight.
• Class II - When the mandible is retrusive relative to the maxilla. The
profile is convex. The discrepancy should also be classified as mild,
moderate, or severe.
• Class III - When the maxilla is retrusive relative to the mandible. The
profile is concave. The discrepancy should also be classified as mild,
moderate, or severe.
Finally, the dental deviations in the vertical category would include overbite,
which would result in a deep or open bite. Skeletally, vertical problems
would include vertical maxillary excess or a steep or flat mandibular plane.
Some traits in malocclusions are not easily categorized. For example, open
bites can have both skeletal and dental etiologies. Cases such as this and other
skeletal issues are more complex and should be referred to the orthodontist for
comprehensive orthodontic treatment. Some problems do not meet the
qualifications for any of these categories. Such examples are periodontal
health and maxillary frenum attachments.
Although developed for the assessment of orthodontic treatments, the general
dentist can apply the same analysis to all cases, to identify the risk profile, and
build the picture of the possible treatment options.
The five categories of the Ackerman-Proffit analysis are also useful in
referring a patient to an orthodontic specialist. A list of concerns that the
general dentist has in regard to the patient can be listed comprehensively as:

1. Soft tissue, frontal and profile

2. Arch form, space analysis, and symmetry

3. Transverse dimension

4. Anteroposterior dimension/sagittal plane

5. Vertical dimension
When looking from the front, we can measure the midface, which runs from the
glabella to just under the nose, and the lower face, which runs from under the
nose to just under the chin. This measurement should be 1:1.
When this ratio is not 1:1, it can be because the lower facial height is
increased or decreased, or the midface is increased or decreased.
If the lower facial height is increased, it can be because there is a downgrowth
of the maxilla, such as in vertical maxillary excess. This is described
excellently in Dr. Bill Robbins and Dr. Jeff Rouse’s book, Global Diagnosis. I
would highly recommend this book for a systematic guide to treatment
planning from the facial perspective.
When looking at the lower 1/3 of the face, the maxilla should make up about
1/3 of the facial height, and the mandible should make up 2/3.
9. OCCL US AL P L ANE S AS A RIS K
Curve of Spee: This is one of the key observations I make using remote
observation of my intra-oral scans, and could equally be observed with study
casts.
Curves of Spee, Wilson, and Monson
Viewed from the lateral aspect, that is, the sagittal plane, the curve of Spee is
defined as an anteroposterior curve touching the incisal edges and cusps of the
dentition and passing through the mandibular condyle.
The curve of Spee was originally proposed with a radius of 2.5 inches.
A similar curve exists in the bucco-lingual plane, termed the curve of
Wilson.
The curve of Monson is a 3D representation of the curves of Spee and Wilson,
depicted by a sphere with a radius of 4 inches, contacting all incisal edges and
cusps of the mandibular and maxillary teeth.
The significance of these curves is that, in an unworn dentition, the
anteroposterior and bucco-lingual curvature allows unimpeded mandibular,
lateral and protrusive excursions. However, disruption of these curves due to
tooth wear, migration, or tooth loss causes occlusal disharmonies, which
require addressing to reestablish these curves.
 10. TMJ/ MUS CL E S AS A RIS K
An examination of the TMJ and facial musculature can determine whether this
is a suitable case for complex dentistry.
There are many excellent courses that teach the core aspects of this.
It is important to assess for pain in muscles, or pain or dysfunction in the TMJ
itself, and any limitations in range of motion, or clicks or crepitus in the joint.
Simply speaking, there are perfectly functioning joints, joints with minor
issues that you would wish to identify before embarking on any treatment, and
pathologies which require treatment or referral as part of comprehensive
treatment planning.
What a basic examination should include

1. Palpation of the TMJ. Place your fingers over the TMJ on either side
and ask the patient to open and close. You can alter the pressure on
either side and ask if there is any tenderness over the joint itself.
Note any clicks or pops. Can the patient open freely, or do they
hesitate?

2. Palpate the muscles of mastication, particularly the masseter and

temporalis, asking the patient to clench and relax and asking for
tenderness.

3. Measure the range of motion of ROM. Ask the patient to open as

wide as they can and measure the interincisal space. In most healthy
adults, this should be 40–50 mm; in a deep-bite patient, this may be
less.

4. Is the opening straight or is there deviation? If there is deviation to

one side, does it return to the center, or is it deviated at the end of
 motion? Is there an s-shaped motion with deviation to both sides but
correction at the end?

11. OCCL US ION AS A RIS K

This is where we recognize the difference between normal function, a habit
such as a postural speech position of the mandible, or a restricted envelope of
function (where the wear is on the anterior teeth but not the posterior teeth),
and deep-seated CNS bruxism.
Some occlusal wear patterns may be treated with dentistry, but some
individuals will always grind their teeth. As a profession, we have various
theories about how to tell the difference, and there are associations with
snoring, sleep apnea and medical conditions. In terms of risk, a bruxist will
put heavy forces on any dentistry that we perform, and so is a higher risk than
a habit, or a person who is avoiding a posterior interference, which could be
corrected.
12. GUIDANCE IN L ATE RAL
E XCURS IONS AS A RIS K
If we have a good relationship between the anterior teeth, with canine
guidance in lateral excursions, we can consider that we have a “canine-
protected” occlusion, which is lower risk. If the bite is deep and we have very
steep guidance profiles that involve other teeth, then the biomechanical forces
on the teeth will be higher. If we have very shallow guidance, the load may
also quickly be passed on to other teeth and the forces increased. Any
restorative dentistry where there is a crossover away from canine guidance
and onto other teeth will be at a higher mechanical risk.
13. B ITE F ORCE AS A RIS K
This is an easy one in terms of risk assessment. Does the patient have big,
strong masseter muscles or not?
Face shape helps with this. Square jaws (brachiocephalic) with muscles that
bulge are going to exert more force on the system than small, triangular or
long-shaped faces.
This may sound so simple that it is almost irrelevant. The ability to detect and
document heavy-bite-force individuals, compared to normal or low bite
forces, can be key in making decisions about what materials to use during
restoration.
Again, this is not an item to be viewed in isolation, but it helps to build a
picture.
A simple test, other than face shape, is to place your hands over the masseter
along the lower border of the mandible and ask the patient to clench. With
some patients, the power of the masseter almost pushes your hands off the
face. For others, it is a weak force.
Square face—Heavy bite forces (left); Long face—Weaker bite forces
(right).
14. CHE WING PATTE RN AS A RIS K
I love the classification from occlusion courses, of a cow and a rat, in terms of
chewing pattern. We know them when we see them. Imagine a cow in the field,
chewing the cud from side to side. A cow chewing pattern needs shallow cusp
patterns and close attention paid to guidance.
A rat chews in a vertical direction, with very little sideways motion.
There may be other risk factors in both types of chewing patterns, but
generally a person who chews like a rat is a lower risk than one who chews
side-to-side like a cow, and some individuals chew in all directions, which
increases the lateral forces on all the teeth.
15. TOOTH AL IGNME NT AS A RIS K
Looking at the arch form, an estimate can be made of the degree of crowding
or spacing.
A normal arch form, with good curvature and teeth with even interproximal
contacts, indicates a good growth pattern and access for cleaning.
Mild crowding can indicate restricted access for cleaning and provide more of
a challenge for teeth requiring restorations.
Crowding and spacing can be in one arch or both and may be different in
different areas of the mouth.
Severe crowding and spacing are an indication of underlying skeletal issues
and can lead to differential wear or esthetic challenges. Spaces in one arch
and crowding in the other may indicate a jaw size discrepancy. Spacing may
also indicate a tooth size/arch length discrepancy or microdontia.
Bolton analysis
This is a useful measurement that relates the mesial to distal tooth size of
upper and lower teeth. The concept behind the Bolton ratio is that,
collectively, the lower teeth need to be smaller mesiodistally than the upper
teeth; otherwise, it would be impossible for all of the lower teeth to fit inside
the upper arch, while simultaneously having a Class I molar relationship,
proper overbite and overjet, and closed interproximal contacts without
crowding. The Bolton ratio quantifies these relative proportions.
Bolton ratios have been determined for both the entire arch and for the anterior
teeth only. There is generally more variability in anterior tooth size than
posterior tooth size (within an individual), and because patients care more
about crowding and spacing in the anterior, the Bolton ratio for anterior teeth
is the one that is more often used.
To calculate the ratio, measure the mesiodistal widths of all the anterior teeth
and calculate the percentage of lower relative to upper. If the ratio is 77.2 +/–
1.65, then it is possible to fulfil all of the requirements mentioned earlier
(proper overbite, overjet, etc.) that make a functional occlusion possible,
along with ideal alignment and no spaces.
A common clinical presentation which demonstrates a deviation from a normal
Bolton ratio is peg or undersized laterals. In these cases, the proportion of
lower anterior M-D tooth mass to upper is too high, and the resultant Bolton
ratio would be greater than the desired 77.2 +/– 1.65. If the remaining
dentition is well aligned, this discrepancy is apparent, and it is not necessary
to calculate the Bolton ratio to know that the addition of M-D tooth mass in the
upper anterior is what is needed to satisfy all the other requirements of a
desirable relationship between upper and lower teeth.
However, observe the upper laterals:
They do appear small, but are they too small? In a case like this, calculating
the Bolton ratio prior to treatment does provide valuable information. It helps
to determine whether the lateral incisors should be restored with veneers in
order to avoid excessive IPR on the lower arch if all the spaces have been
prescribed to be closed.
The drawback of the Bolton analysis is that it was first devised and calculated
in 1958 and the samples used for the calculation were all Caucasian. The
Bolton analysis may therefore not be representative of other races and
populations, and this should be taken into account.
16. MIS S ING TE E TH AS A RIS K
Some teeth can be missing with no consequences. Some teeth can be missing
and the opposing tooth is held by the neighboring teeth, and there is no sign of
any tipping or compensation.
Sometimes teeth have been missing for so long that the opposing teeth have
overerupted (super-erupted) so much so that they are touching the edentulous
ridge in the opposite arch.
How risk-positive this situation is will depend on the goals for the case. If
whole segments of the mouth have undergone dentoalveolar compensation,
then this can be extremely complex to reverse, sometimes requiring advanced
surgery or even tooth extraction.
The World Health Organization has stated that humans can chew and function
adequately with a shortened dental arch—meaning at least 10 teeth, second
premolar to second premolar upper and lower. Any less than this is
considered a disability in terms of chewing and health.
17. B IOME CHANICAL RIS K S
Biomechanics is the study of the structure, function, and motion of the
mechanical aspects of biological systems, at any level from whole organisms
to organs, cells, and cell organelles, using the methods of mechanics. For
dentistry, this is the study of tooth structure, and the effects of losing tooth
structure during chewing and function.
Pascal Magne from the University of Southern California has published
research showing computer modeling, which demonstrates the changing force
mechanics as we lose tooth structure (Magne and Belser 2003, Magne and
Knezevic 2009).
Enamel protects the integrity of the tooth during chewing. Any time we lose
enamel, the tooth is weakened. The more enamel we lose or the larger the
restoration, the greater the risk of further fracture or crack propagation within
the tooth.
A patient who has limited or no restorations is at a low biomechanical risk. A
patient who has multiple large restorations, particularly if endodontics and
posts are involved, or loss of cusps on posterior teeth, will be at a higher
biomechanical risk. This means that even if there is no disease, no caries, or
no periodontal disease, the structure of the dentition has been compromised.
This increases the risk of further fracture, particularly if the dentistry is old or
combined with other risk factors such as bruxism.
A mouth with multiple restorations may also have other biomechanical issues,
such as overhangs or insufficient contact points leading to higher risk in
periodontal status. There may also be an increased risk of loss of vitality and
subsequent endodontic complications.
18. CARIE S RIS K
We know that caries is a disease. In my practice, any adult who develops new
caries is considered at risk and “unstable” and is offered a caries prevention
protocol. In the world of single-tooth dentistry, if caries is present, we
diagnose it, remove it as required, and fill the tooth. However, this does
nothing to prevent more caries from occurring. Fillings do not treat the causes
of tooth decay; they treat only a symptom of it.
In the UK, we find it difficult to charge our patients for prevention. There is a
psychology that seems to tell us that giving advice or preventive treatment isn’t
really doing anything, and thus, we may be overtreating or charging for
something that might or might not happen.
This is where educating our patients about the risk of caries is so helpful.

Dr. Edwina Kidd from King’s College, London, in her reflective paper on
caries control stated: “The carious lesion is a sign or symptom resulting
from numerous pH fluctuations in biofilms on teeth. The lesion may or
may not progress and lesion progression can be controlled, slowed down
or arrested. Control of the biofilm is the treatment of caries, the most
important measure being to disturb the biofilm mechanically using a
fluoride-containing paste.” (Kidd 1997, Kidd and Fejerskov 2013)

The informed patient controls caries, and the role of the dental professional is
to advise how this is to be done.
This is the non-operative control of caries and it is worthy of payment.
New carious lesions are a symptom of imbalance, which puts any planned
restorative work at risk.
In 2014, an ICDAS document that detailed how caries can be classified and
managed was published. I printed this document out to read on an airplane trip
when I was planning to discuss caries management in practice. It is a weighty
tome and suggests a comprehensive, individualized caries screening and
management strategy.
I am not sure that most busy dental practices have time to incorporate the cited
caries management into everyday life. Often, this is left to the hygienist to
implement, and again we still have the issue of patients agreeing to pay fees to
cover the time spent on professional care. Visual aids to explain and add value
to the care can help to justify the importance and hence balance the desire to
pay as an investment in health and wellness, rather than a transactional cost for
a product.
19. TOOTH S URFACE L OS S AS A
RIS K
Tooth surface loss can be classified as having single or multiple etiologies.
A certain amount of tooth wear will occur naturally over time, and so there is
a concept of age-appropriate wear. We would expect someone in their 70s to
show signs of tooth surface loss—but less so for someone in their 20s.
Causes of tooth surface loss

1. Attrition

2. Abrasion

Erosion
 3.

4. Abfraction

For the purposes of risk, any wear through to dentine is considered unstable.
Dentine wears six times faster than enamel, so what was progressing
relatively slowly in enamel can suddenly accelerate as the wear breaks
through into dentine.
In most adult mouths where we observe tooth surface loss, it is important to
identify where the loss is, and the quantity of loss helps to determine which
category it falls into. Of course, more than one cause is likely.
There has been an increase in awareness of tooth surface loss due to erosion,
and erosive tooth wear (ETW) is currently the third most commonly observed
oral condition (Bartlett et al. 2019). It can occur on clean, plaque-free teeth.
Therefore, detecting signs of ETW early and supporting patients with
education is key to protecting their oral health. However, early indicators can
be challenging to identify (Lussi et al. 2006). These include surface changes
(smoothing) (Lussi, Jaeggi, and Zero 2004), loss of structural features
(rounding), thinning, and translucency (Jaeggi, Grüninger, and Lussi 2006).
The evolution of modern lifestyles plays a significant role in the increased
prevalence of ETW. There has been a rise in the consumption of acidic food
and drinks, increasing the risk to tooth enamel (Neel et al. 2016). Indeed,
snacking in general, including healthy snacking, is on the increase globally.
Fruit is a leading snack; however, it is also a key source of dietary acid. Even
healthy diets can present risks for teeth as people consume fruit juices, fruit
smoothies, and snack on more fruit (Blacker and Chadwick 2013; Kelleher
and Bishop 1999; O’Toole et al. 2017).
The basic erosive wear examination (BEWE), originally introduced in 2008,
was developed for clinicians working in general practice as a quick and
simple method to record ETW severity in clinical notes. It is designed for use
alongside the basic periodontal examination (BPE), allowing for both indices
to be used simultaneously.
This patient, for example, had lost a considerable amount of tooth structure
through erosive wear. The strategy for her, while her appearance was
improved, centered around preserving and protecting her remaining tooth
structure. We placed some minimally invasive adhesive porcelain restorations.
Using the BEWE can help identify tooth wear and prompt patient discussion. It
is quick and efficient to use, with four scoring codes, aiding early detection of
ETW. It is important to record signs of erosive tooth wear in clinical notes,
and informed and preventative advice given to the patient in order to inhibit
progression of erosive tooth wear.
This is covered in the tooth-by-tooth section of the Diagnosis and
Observations form in Chapter 9.
20. TOOTH COL OR RIS K
AS S E S S ME NT
Tooth color is part of the reflection of the patient’s expectations. If color is not
a concern, then the risk is low. If color is a concern and the teeth are a natural,
healthy color, then this can be addressed, as long as the patient’s expectations
are reasonable.
If the patient is looking for artificial toilet-bowl white, and/or they have teeth
of multiple colors, then the dentistry required to make everything look uniform
will be more of a challenge.
In the above case, for example, we have multiple challenges—color, shape
and position.
Nonvital teeth in the smile will present a particular challenge, as often the
grayness of the root is still apparent after the ceramics match perfectly.
Sometimes it is necessary to educate the patient to this fact and demonstrate in
Keynote that if you block out the gum, the teeth are an exact value match, but
because our eyes compare, the blue/gray is coming from the nonvital root
under the gum. It is possible to restore the root with some very bright
composite or even to thicken the gingivae with a graft to attempt to hide the
gray. Usually, this is a perception of the patient, and in most social situations,
the color difference will not be obvious.
In this case, careful preparation design in communication with the dental
technician and the use of preparation guides allowed adequate preparation of
the teeth while preserving as much structure as possible.
Luke Barnett Ceramics, Watford, England

In this case, there are tooth shape issues, a black triangle due to insufficient
papilla between the centrals, and a nonvital upper left central incisor.
In the retracted view of the final result, the darkness of the root of the upper
left central is visible. Fortunately, her lip disguises this in the final result,
which would not have been the case if she had a higher lip line.
Luke Barnett Ceramics, Watford, England

Often the decision to treat the four anterior teeth or more can be explained to
the patient by way of color. If we stick within the canine teeth and treat the
incisors only, although we can go slightly lighter than the canines, there will be
a limit. This is why I very rarely treat 3–3 as if these teeth are whiter than the
first premolar; the difference to the patient can look very obvious from that 45-
degree conversational angle, whereas if you treat first or second premolars
side to side, the teeth can go much whiter.
The following is an example of a smile with old restorations and teeth of
different colors. Although the proportions of the teeth are relatively good, the
dental technician should be involved in the preparation design planning so that
the color of the final restorations can be planned for.
In this case the patient chose a narrower, softer shape for her central
incisors, and color balance was achieved. Ceramics by Rob Poland, Ken
Poland Dental Studio, London, England.
C HA PTER 15
THE PA U SE BEFO R E
THE PATIEN T
PR ESEN TATIO N
“Problems are like doors, you have to go through them to put
them behind you. If you try and avoid them, be prepared to
walk into a wall.”
E.A. BUCCHIANERI, Vocation of a Gadfly
Our analysis has given us all of our diagnoses and the ability to complete a
risk assessment. Our design has given us our end in mind. The “missing
piece” is the difference between the two.
After guided observation, you will have a huge amount of documented data.
It is helpful to identify the short-listed diagnoses that you and the patient wish
to address, the situations that are standing in the way or that need to be
solved in order to move from point A, where we are, to point B, where we
want to be (the smile design). We will call this first step the challenge
summary. This stage is sometimes called developing the problem list.
The second step is to ask the opinion of your colleagues, specialists or
dental technician if needed. Collective intelligence can be very helpful.
Consider checking your logic with peers or asking specific questions to
mentors. This will not always be required, but do not underestimate the
power of a second opinion.
The third step is to begin to formulate your recommendations and treatment
plan options as the basis for discussion at the case presentation. Negotiating
away from the ideal design may be required for biological reasons or as a
financial alternative.
The fourth and final step is to complete the storyboard as a patient
presentation tool, with pros and cons of the different options and financials.

1. Challenge summary

2. Ask for opinions

3. Treatment plan options

4. Patient presentation tools

Treatment planning really is an art and a science, and there are many books
dedicated to this subject with authors who can cover the breadth and scope
of clinical options for different scenarios. Comprehensive treatment planning
is complex and study clubs, such as the Seattle Study Club, provide excellent
sharing of the skills and knowledge required.
If you have ever prepared a case for presentation at a study club, you will
understand how much work goes into laying out all of the material in a format
that can be understood by your colleagues. If you have ever been a
participant at a treatment-planning session, you will no doubt have been
faced with pages of information, photographs and data. Then the “come up
with a plan” question begins the arguing and jostling. Of course, there is
generally no one answer to a plan for a patient, and that is what makes our
job so interesting and complex, all at the same time. Many cases require the
input of specialists and interdisciplinary planning, which further enhance and
complicate the plan.
And in reality, if we are seeing patients like those seen at study clubs, this is
exactly the process we are going through ourselves with our patients. It takes
time.
We need to prepare in order to bring the patient with us on this journey of
understanding, as ultimately the decisions, including the financing, belong to
them.
At its simplest, treatment planning is distilling our diagnoses into a challenge
list, as we compare it to our design. In other words, there may be
considerations or “problems” that we cannot fix or are not relevant to the
solution at the present time.
If we have taken the time to prepare, to really listen and give ourselves the
opportunity to “see” everything in the analysis stage, then we can think about
how to formulate our problem list with possible solutions. We can prepare
how to tell this story back to the patient in the most effective way, a way that
they will understand and not overwhelm them, and one that allows us to
educate and motivate them, but that ultimately helps them to make the right
decision for themselves.
This is the key to allowing patients to agree to bigger treatment plans, and to
doing dentistry with a view to long-term stability, and not just to “fix the
tooth that is broken.”
S TE P 1: THE CHAL L E NGE S UMMARY
Once the Diagnosis and Observations form has been completed, the case has
been designed and imaged as appropriate, and the risk assessment has been
considered, a list of the key diagnoses and challenges can be made. This is
often an “aha” moment where the mists begin to clear and the key challenges
to be overcome emerge. The diagnosis and observations analysis may have
some areas that require further investigation, but the clarity as to the
challenges that need to be overcome will be emerging.
For record-keeping purposes, I start a new note (called a clinical note) in
my practice management where I write, for example:
Key challenges based on my diagnosis and observations

1. The upper left premolar is fractured and requires a post core and
crown versus extraction.

2. The upper left molar has periapical pathology and should be

referred for re-RCT.

3. There is considerable erosion upper 3–3 all surfaces and

posteriors which has affected OVD. Smile design—The upper
anteriors are short and have lost enamel height. Function—
Overclosed with loss of vertical dimension and no room to restore
missing tooth structure.

4. Early carious lesions as noted.

Typically try to keep to three or four points for most patients.

My treatment coordinator and I would meet at this point to review the
storyboard, the patient’s reason for attending, and my suggested treatment
options. If this is not possible, then I record a video on Photobooth and insert
it into the storyboard. In this video, I explain in words more than I can say in
written notes what I think the key aspects of the case are and my reasons for
the various treatment options.
Note: Photobooth is software available on Mac laptops which allows you to
record a short video through the webcam and then to drag the video into the
storyboard. If you type Photobooth in the search bar of your laptop, you will
find it. You need to click the Film icon to record a movie rather than a photo,
and there is a 3,2,1 countdown. When you have finished recording, press the
Stop button and the video will move to the Photobooth library. From there,
you can click the most recent video and drag it to your Keynote storyboard.
It is important to note that I do not consider this to be the treatment plan. At
this stage, these are treatment suggestions that will be discussed with the
patient. I believe that for informed consent to be true, it is our responsibility
to think laterally and have more than one option, with the pros and cons in
mind, including the risks of doing nothing.
In the book Choice Theory by William Glasser (Glasser 1998), all of our
choices as human beings are made to satisfy one or more of our basic needs:

1. Survival. If a patient is in pain, there is no point in trying to educate

or have discussions about esthetics, as the patient is in survival
mode.

2. Love

3. Belonging

4. Power

5. Freedom
 Fun
6.
Other than point 1, points 2–4 can factor in the choices a patient may make to
improve a smile, self-confidence and self-esteem, and the desire to socially
belong.
Depending on the preexisting condition of the patient and the difference
between the starting and desired end point, those decisions and choices can
be simple, such as tooth whitening, or incredibly complex. Complex
decisions will not only be affected by the presenting patient, but also by the
clinician's own bias and personal experience, as much as by evidence-based
protocols. Even simple cases should ideally be considered in full to prevent
a condition or risk factor from being overlooked which if identified, could be
treated early. An example of this is tooth wear. Early identification of loss of
canine guidance can be treated conservatively, and this early intervention can
prevent more deterioration over the long term (Jackson 2000). How do we
know if this patient will be simple or complex? By gathering the information
and allowing ourselves time to consider what we find.
Considering integrated treatment planning
Often our treatments are categorized into an “ortho” case or “implant” case.
The power is when we begin with the end in mind. Diagnose where we are
starting from, brainstorm the different options with the help of the patient, and
consider the risks and benefits to the patient according to evidence and the
patient’s own priorities and values. Then all of the clinical tools that we
have available fall into place, depending on the diagnosis. For most patients,
perfection is not the end goal. The end goal is a healthy, beautiful smile that
looks like the best version of the patient and is comfortable, and ensuring that
they fully understand the maintenance requirements. That is success!
This is why the smile design is an important part of the diagnostic process.
Through guided observation and smile analysis, we see more. There should
be no division between smile and function. There should be no division
between esthetic dentistry and functional dentistry. Teeth in the front of the
mouth are seen and, therefore, are a smile. We need our teeth to chew and,
therefore, that is function. Esthetic dentistry without due consideration to
function will fail. Restoring single teeth without due consideration to the
environment that caused the single tooth to fail in the first place is
problematic. Restoring function with respect to biology by default restores
esthetics. Restoring function without consideration of TMJ health or skeletal
pattern would be unthinkable.
Many dental textbooks and articles have been written on case selection and
clinical techniques. The reality is that when a patient chooses a particular
practice for dental treatment, they are generally driven by one or more
factors.

1. Health—The patient may be healthy and be well motivated to keep

it that way.

2. Problem—The patient may have a problem or concern related to

health, comfort, or chewing.

3. Esthetic problem—The patient may want to look better and is

seeking an improvement.

One of the issues that we have in practice is that the above are not mutually
exclusive and patient-motivating factors may be very different, so the way
we approach these scenarios from a communication standpoint needs to be
flexible. Of course, they may be motivated by esthetics and be unaware of
health issues, or they may be purely interested in health and function and not
at all interested in appearance.
The beauty of general practice, and what makes this an art, is that we meet all
of these possibilities on a daily basis. Evidently, if our practice markets in a
particular way or tells a particular story about our expertise, then we may
have a leaning toward more patients with similar problems that need to be
solved.
S TE P 2: AS K F OR OP INIONS
Whatever stage you are at in your career, it is very important to be part of a
collective intelligence that is larger than yourself. I have always considered
it important to benchmark my thinking, both clinically and in business, against
the thoughts of others. Why? It is a safety net to be sure that you do not have
any blind spots or that you are too focused on a particular outcome. Make
this a lifelong practice. Stephen Covey, in his book The 7 Habits of Highly
Effective People, talks about synergy—the whole is greater than the sum of
its parts. This is true for treatment planning. There is always more than one
way, and it really helps to gather different perspectives.
Effective ways to gather opinions

1. Study clubs—Belonging to a local (or online) study club which is a

safe environment for sharing and learning. The Seattle Study Club
is an excellent example of this.

2. Peer-to-peer learning and review—Having a few friends and

colleagues with whom you can share cases and discuss ideas.

3. Mentors—More senior dentists, who may be specialists or more

experienced in certain areas. I work as a clinical director for a
 group of practices in Scotland, and part of my role is to be a
sounding board for all the associates, with regard to treatment
planning.

4. Senior partner/practice principal. If you work within a group

practice or have a senior person working with you, make the most
of the opportunity to share your cases and thinking.

5. Dental technicians—I have learned the most in my career by

forming good learning relationships with dental technicians. They
see many more cases than we as dentists do on a daily basis, and
also see how other dentists solve similar problems. Take the time
to invest in your relationship with your dental technicians and you
will come to understand that dentistry is a team effort. If, as
dentists, we understand what our dental technicians need, then
together we will achieve better results.

6. Educational continuums—There are many excellent courses in both

general and specific areas of dentistry that take place over multiple
sessions in order to compound learning.

7. Speak to your colleagues and do some research—Conferences can

be a good way to hear lots of different speakers and then decide
who to follow more closely.

8. In the pursuit of further knowledge, you will find colleagues who

share your values and philosophies, and probably many who do
not. For me, the colleagues that I met through my pursuit of
understanding smile design led us to start the British Academy of
 Cosmetic Dentistry, and I am very proud that this organization has
grown to be one of the largest of its kind in Europe. I belong to
many organizations in dentistry but favor a few where my closest
friends and colleagues can share our experiences and learn from
each other.

9. Further education—A bit like driving a car, the real learning begins
after you pass your BDS/DDS. Taking further certificates and
qualifications in your areas of interest will force you to share cases
and learn.

10. Specialists—Most specialists are very willing to give initial

opinions on your patient, particularly if you are likely to refer
patients to them and if you give them the information they need. If
you send a few poorly taken photos and some sketchy information,
then they are likely to need to see the patient, but if you ask a
specific question and find out what the options are so that you can
guide the patient, this really elevates the service you are providing
to the next level.

DECISION POINT Who and how are you going to ask or check your
thinking about cases? Form relationships and set up communication pathways
in advance so that you can share cases and receive feedback in a timely
manner. The digital workflow helps with this too because if you have a
storyboard and your Diagnosis and Observations form, you can share your
“digital patient.” Of course, make sure that you have the consent of your
patient and that your sharing methods are secure.
I use a combination of Dropbox, WhatsApp (no patient-identifying images)
and Zoom calls to discuss cases with my network of dental technicians,
multidisciplinary specialists, and peers. The key is to foster the relationships
and give people time to respond—but also act quickly so that you gain the
information before the second patient appointment.
Be careful with sharing and asking questions on social media
groups, particularly when they are large groups and you do not
know the other members. These groups can be useful for general
questions, but I have seen some terrible responses and people being very
negative and derogatory. It is easy to be a keyboard warrior from a distance.
Surround yourself with people who want to see you grow and who will take
the time to understand. By the same token, never be too proud (or too shy) to
ask for help.
Even after thirty years in practice, I come across situations where I am
unsure, and that is part of what makes dentistry so interesting. Always be
willing to learn new things, to be curious and to learn from your mistakes.
S TE P 3: TRE ATME NT P L AN OP TIONS
Once you have identified the challenge list and asked any specific questions
that you weren’t sure of, you can begin to list the possible treatment options.
There will be problems, such as skeletal discrepancies, where the next step
would be a referral. You can note this down, as it requires more conversation
with the patient, and then move on.
There may be problems that are hard or unnecessary to fix. There may be
points you need to educate the patient on but are unsure of how to proceed
until you gain their feedback. This will form part of the codiagnosis journey,
which will be discussed further in the next chapter.
Think laterally and broadly. Think of the ideals as though money was no
option. Think about alternatives and the risks and benefits of each—and of
doing nothing.
I hold in my mind the four “R”s as taught by the late Pete Dawson from the
Dawson Institute in Florida. These are four questions that can be asked when
considering how to solve a comprehensive treatment-planning problem.

Can we obtain the desired outcome by:

1. Repositioning the teeth

2. Restoring the teeth

3. Reshaping the teeth, or

4. Reconstructing the jaw positions?

For some cases, you will have the options clearly laid out. For others, this
may be hard to do. For these cases, I try to narrow down at least what the
“next steps” would be. This may be a CBCT, or further diagnostics with a
facebow, a more in depth TMJ exam and records, or it may be an initial
referral to a specialist. Even if you do not have all the answers, you can be
confident with the first steps, disease stabilization, periodontal therapy, and
then after the conversation with the patient, you can further define the options.
DECISION POINT Think about all the treatments that we have in
dentistry as “tools” to be used to solve problems:
Biological diseases • Treatment and prevention strategies
Missing teeth • Dentures, bridges, implants
Moving teeth • Orthognathic surgery, fixed ortho, specialist ortho, Invisalign
or other clear aligners
Color • Whitening, direct or indirect restorations
Shape or loss of tooth structure • Direct or indirect restorations,
microesthetic contouring changes, functional/occlusal changes
Gum levels • Tooth movement or surgical options
In reality, most of our patients will require a combination of many of the
above once we move away from single-tooth strategies, all of it driven by
looking at the smile as it relates to the face (facially driven smile design).
Treatment planning as a process is similar to decision-making. We make a
series of decisions which we then need to explain and present to our patient
in order to coach them through their own decision-making process.
In many leadership courses, the process of decision-making is broken into
seven key steps. It is helpful to understand the steps that we all go through
when making a decision and to consider how they may apply to us and to our
patients.
The seven steps of Decision-making

Identify the decision—What is the problem we are trying to solve?

 In dentistry, this is a combination of the patient’s perceived
1. problem and our diagnostic data. It is worth clarifying the values of
both ourselves and our patients—esthetics does not come at the
expense of health, well-being, comfort, and predictability.
Ethically, we might say we would always have health as a priority.
Predictability, however, can be hard to determine, even with an
evidence base—one patient may choose saving a tooth at all costs
even with increased unpredictability, whereas the traveling and
busy lifestyle of another patient may mean that predictability is a
key priority.

2. Gather the relevant information—We have done this with our

history and clinical examination.

3. Identify the alternatives—Only possible after a thorough analysis

and problem solving.

4. Weigh the evidence—Risks versus benefits and individual risk

assessment.

5. Choose among the alternatives—We need to involve the patient in

this as part of codiscovery and codiagnosis. The financial
considerations will also have an influence on the patient’s choice.

6. Take action—The point we want to arrive at, where we can secure

the finances and make the sequence of appointments.

7. Review the decision—It is important to remember that we do not

have a crystal ball. Sometimes, despite our best intentions, we
discover that we need to change course. This will happen, and if
 met with clear communication and upfront explanations, most
patients will understand. This is why the risk assessment and
communicating the risk assessment are so important. It highlights
the areas of uncertainty. In the end, we can only make decisions
with the best intentions, but we cannot predict the future.

Early diagnosis and minimal intervention/prevention strategies

I was fortunate to be part of the beta-testing group in Europe for the iTero 5D
intra-oral scanner which has near-infrared technology built into the image-
gathering head. With one scan, the STL file, the HD camera image and the
near-infrared image are captured. I use this as an early caries screening
device. Interproximal caries shows up as bright white, almost like the
opposite of a radiograph. Enamel is mostly transparent to NIRI and appears
dark. Dentin is mostly scattering to NIRI and appears white. Proximal
carious lesions scatter the NIRI and appear bright in contrast to the healthy,
dark enamel. In addition, unlike radiographs, the images can be viewed from
different angles, so lesions can be scrutinized from all angles by moving
through the .STL file and the corresponding HD intra-oral picture.
Near-infrared technology has had many applications over the years. It is used
in night-vision goggles and in agriculture and astronomy. What is new is its
incorporation into intra-oral scanners. iTero 5D is the one that I have
experience with, although similar technology is available in other systems.
This in itself can be controversial, as the increased price of the scanner
needs to be weighed against the increased benefit to incorporating the
screening, and again, what cost can we pass onto the patient that will repay
the investment in this equipment?
As we discussed under Caries Risk, sometimes it is difficult to motivate
patients to pay for prevention, whereas if we can clearly demonstrate early
deviation from health, as we can with the NIRI images, there can be a more
highly valued benefit for early intervention.
There are numerous advantages to screening. Early decay can be difficult to
detect on bitewing radiographs. Bitewings are more sensitive once the decay
has broken through into the dentine. While the NIRI screening does not
replace bitewings, it certainly means that the frequency with which they are
required is decreased, as NIRI scans can be taken at more regular intervals
and are completely free of radiation. This benefit can be explained to
patients.

If we detect early enamel caries with NIRI, what are our options? It can
provide part of the overall risk profile. It can also give us options to
encourage professionally applied fluoride.
There is another option—DMG, a company based in Hamburg, Germany.
They have designed a product called ICON, which was originally produced
as a means of sealing interproximal enamel to prevent the ingression of
nutrients to cariogenic bacteria and halt early caries in its tracks. ICON has
been studied for over 10 years now and has excellent results (Theodory,
Kolker et al. 2019). ICON was subsequently discovered to change the
optical properties of the tooth structure when applied to smooth surfaces, and
so it has become well known as a minimally invasive treatment for white
spots, particularly on anterior enamel.
The first case I treated with this combination of screening with iTero 5D and
ICON was my 18-year-old daughter. She had early enamel lesions on her
lower premolars. The lesions were so definite on the 5D that I opened the
first side up with a microbur, expecting to find significant decay. It was, in
fact, a lesson in how sensitive the technology is because it was so minimal
that I opted to treat the other side with ICON rather than doing any drilling.
This is my protocol now. I screen all my patients with the iTero 5D, and for
any early enamel caries we detect, ICON is offered as the preferred option,
followed by professional fluoride at regular intervals with our hygienist.
S TE P 4: PATIE NT P RE S E NTATION
TOOL S
It is worth reviewing the storyboard and thinking what else a patient might
need to see to understand your message. Before and afters of similar cases,
examples of normal compared to their situation, as well as models of
implants or Invisalign, may give context to allow for the kinesthetic learners
to really understand what you are proposing. Patient advice leaflets or
website links for specific treatments are helpful, as are testimonials from
patients who have been through the same treatment.
This is also the step where my treatment coordinator would check to ensure
that we have the risk assessment, outcome simulation, smile design, and any
other visual prompts that we need to fully explain our findings and the
subsequent options.
Treatment planning is a creative process and often requires creative thinking
and excellent communication to derive a result that fulfils the biological,
functional, and esthetic ideals. Attending study clubs, where you can discuss
cases with colleagues and learn from each other, is an excellent way of
learning and building confidence. There is always more than one way.
As Albert Einstein said, “Imagination is more important than knowledge,
knowledge is limited. Imagination embraces the world.”
C HA PTER 16
C A SE PR ESEN TATIO N
“People do things for ‘their’ reasons, not ours. So find their
reasons.”
DALE CARNEGIE
Case presentation is how we tell the story of the analysis and design and
route map between the two, back to the patient, in a way that educates and
motivates without overwhelming so that they can become the copilots of the
journey.
What our patients should have an understanding of after a carefully
designed and executed case presentation

1. Their own individual risk status.

2. How they may improve their risks in some areas.

3. How those risk factors will affect their need for dental intervention
in the future.

The final, agreed journey from point A to point B is the treatment plan. This
should be the definitive treatment plan after all other possibilities have been
considered and dismissed.
A case presentation begins with sharing where we are starting from—Point
A.
From a communication standpoint, it is best for the case presentation to be
carried out away from the clinical area. Ideally, it should be conducted in a
place with a large screen to share images, and it is important to refer back to
the patient’s initial reason for attending. We may have a lot to share, but it is
important to start by checking that we have a good understanding of why the
patient has come to see us. This helps to build trust that we have listened to
them. We can then ask permission to share the information that we gathered
last time. A few, very anxious patients may feel ashamed or have strong
negative feelings about looking at their photographs, so do remember to stay
flexible, be kind, and also reassuring.
CODIAGNOS IS
Codiagnosis is a term that dates back to a dentist from Illinois named Bob
Barkley and his friend and clinical psychologist, Nate Kohn, who studied the
concept of relationship-based dentistry. Codiagnosis, often used with the
term codiscovery, describes how effective it is to involve patients in the
discovery of the conditions of their mouths. Codiagnosis continues to be
taught across the world as a “best practice” concept when considering how
to interact with patients.
Codiagnosis is key to having patients accept comprehensive dentistry. The
process should begin at the initial examination appointment and be carried
through to the case presentation appointment.
WHO OWNS THE P ROB L E M?
It is very important for us to recognize, identify and be able to explain the
problems to a patient, but it is also important for us to use language that
demonstrates that we are clear about who owns the problem. The condition
of the patient’s mouth, particularly if we have never treated them before, is
not our doing.
I recently had a conversation with a young dentist. We were looking at
photographs of a case where a patient was missing an upper left lateral
incisor. There was some crowding present, and we were looking at options
to begin to align the teeth in the arches.

The young dentist explained: I’m trying to decide whether I should open
space around the other lateral because the patient has told me that she
wants both sides to look exactly the same. She wants me to make the
canine on the left and the lateral on the right look exactly the same, so
I’m trying to figure out if I should make the lateral look bigger, and I’m
not sure what to do with the bulbosity of the left canine.

To my mind, the fundamental problem here is that the patient is missing a

tooth. It is not a realistic expectation to be able to make both sides look
“exactly” the same. There will be compromises. There have to be. Canines
are bulkier teeth than lateral incisors. A canine’s height of zenith is much
higher than that of a lateral. Who owns the problem?
This young dentist was teetering on the edge of accepting unrealistic
expectations on behalf of the patient. In an effort to please and be able to
meet expectations, she was inadvertently teaching the patient to expect
something that may not be achievable.
The risk of missing that expectation is reduced if we take the time to explain
to the patient the limitations and difficulties of making a canine look like a
lateral, and indeed a first premolar look like a canine—particularly when
“minimal intervention” and “I don’t want my teeth drilled” are brought into
the mix.
The aim in a case like this is to strike the balance between hope and realism
—we can make improvements, absolutely. With some tooth movement,
adjustment and judicious bonding, we can make the canine look more like a
lateral. With some prepping and smile design veneers, we could be more
aggressive and make the canine look even more like a lateral (with a greater
risk of devitalization if we really prep out the bulbosity). We could even
undergo more intensive orthodontics and open the space for an implant or a
bridge, to place a false tooth that resembles a lateral. All of the above can
improve the current situation and have benefits and risks, with biological and
time and cost effects.

However, if the patient declines the second two options, then the
recommendation could be: Mrs. P, you are asking me to make a canine
tooth look exactly like a lateral. As you can see from the differences in
tooth structure, I cannot promise to make them look exactly the same.
You are missing a tooth. There is fundamental asymmetry in your smile.
What I can do, however, by bonding here and adjusting there, is to
decrease that asymmetry and increase the harmony of your smile so that
the eye is not drawn to the difference on the two sides. Alternatively, I
could drill away more of the larger tooth and we could look at smile
design veneers...”

As soon as you start treatment, you are sharing ownership of the

problem. If you do not take the time to use your verbal skills before
starting to set expectations and have a documented discussion
about the limitations of treatment and the limitations dictated by how the
patient is when they come to see you, then you are effectively allowing the
patient to hand you their problem and make it yours.
KEY WORDS: Improvement, increase the harmony, disguise the reality,
camouflage the true underlying situation.
The same psychology can be applied to the nonvital central incisor or the
single anterior implant. While we can of course do our absolute best to
improve any esthetics, the plea of, “I want it to look exactly like the other
tooth” can be answered by, “I know. It is so difficult when we have this
kind of situation or trauma (empathy). However, the challenge is that it is
not the same. You have one dead tooth next to one live tooth. You have one
dental implant next to one live tooth. The materials are completely
different.”
Sometimes the skill can be to have the patient realize and be appreciative of
the fact that they still have their tooth or that they have had the tooth replaced.
It is sad and such a shame—we would all hate to lose vitality in an anterior
tooth. The key to communication here is to demonstrate empathy but also to
hold your ground as to what is possible, to be sure to demonstrate the
challenges, and not be led into overpromising.
Some patients are so clever with their verbal skills that they will try
statements like, “So you can definitely make it look the same as the other
tooth,” or “So you can definitely get rid of the gray shining through the
gum.”
It is so easy to be beaten down to saying yes, almost to close the
conversation and be able to move on.

I sometimes say: I want to be very careful that I am not giving you false
expectations. As I’ve explained, there are challenges here. What I can
say is that I know I can make an improvement and that I will do my very
best. But I cannot say that it will be perfect or that it will look exactly the
same as the other side. It’s very important that you understand that. I
would hate for you to spend your money and time here and be
disappointed in the outcome. My concern is that if you are looking for
that level, with these circumstances as they are now, that you are going
to be disappointed and that you will blame me. What I am saying is that I
will do my very best, and I know I can make it look better, but I need to
know that you are realistic with your expectations before we begin.

This may sound harsh, and if you are new in practice, you may be fearful that
it makes you sound inexperienced or underconfident. These words need to be
delivered in an assertive manner in a calm, “Here’s what I can do, but here’s
what I need you to understand.”
You can particularly use the information if several dentists have tried and
failed before you. Again, the temptation can be to be portrayed as the hero by
the patient. It is more powerful to say, “If your previous dentist has tried
and failed, I’m sure they were doing their very best. That highlights what a
challenging issue we have here.”
You will find that if you do this well, patients will start to say things like,
“Oh, I know you can’t perform miracles. Oh, I completely understand, but
to be honest, any improvement would be better than this.”
Write it down. Make sure your consent reflects the conversation and
move on to the next stage!
Remember: Under-promise and over-deliver.
S TE P S F OR CAS E P RE S E NTATION
I follow the mantra that was taught to me:
This is what I see.
This is what I recommend.
Patients need to own their problems. If they do not perceive a problem or
care about a risk, then they will not be open to fixing it. By the same token, if
you have bad news to deliver, the humane thing is to offer hope. You need to
be honest about the findings, but let them see the possibilities.
For me, the hardest news to deliver is the presence of advanced periodontal
disease in a young patient. More than once, I have had patients in their
thirties who have lost a tooth and come to ask about a single implant. When
we see the radiographs, the situation can be hopeless or nearly so. I hope that
you don’t see this in your part of the world. It is heartbreaking for the
message to be that the one tooth you have lost is the least of your troubles, or
to have to educate a patient on the reasons why their hard-earned budget for a
single implant is not the solution. When practicing authentic, ethical dentistry,
our job is to educate and motivate, but to do so with kindness and empathy.
I have a system or flow to case presentations that I use and would
recommend—called the Presentation 7. It is deliberately written in patient,
storytelling language to make sure that we stay in understandable mode. We
are not presenting at a study club or trying to impress our colleagues here.
This is about maintaining and building rapport, and keeping patients engaged
and understanding.

1. This is what I see

2. This is where we could go

3. Here are the ways we could get there

Here are my concerns/our limiting factors

 4.

5. Here are the risks, including doing nothing

6. Here are the next steps, the first things

7. Here are the costs involved

This is a flow. You don’t have to use these words exactly, but rather use it as
a “mantra” to structure the presentation.
What the Flow should take into account

1. Emotional intelligence.

2. Personality styles.

3. Different learning styles.

S TE P 1: THIS IS WHAT I S E E
This is where the storyboard comes into its own. At the end of the diagnosis
and observations phase, I have built up a series of slides with the key points
highlighted.
Example of a storyboard with a series of slides, highlighting key areas
from the diagnosis and observations analysis.
It is important to share the good news as well as the issues.
We need our patients to own their problems. It is their mouth; they have lived
the life and their dental history that has brought them to this point. My
intention here is to spell out, in visual, annotated pictures, where they are
now. This is the beginning of the codiagnosis process—it is codiscovery, if
you like. “Here is your tooth… you can see here the outside enamel and the
inside is dentine. A healthy tooth doesn’t look like that. Your tooth did not
come into your mouth like that. You have lost 30 percent of the tooth
structure, as you can see.”
Show them what health looks like. Often people are unaware that their teeth
have lost structure due to wear because it has happened gradually over time.
Remember the concept of context—patients may be unaware of what is
normal. Maybe they think that their teeth are supposed to wear down as we
get older.
In the following case, for example, this gentleman came to see me because he
thought he needed a crown on the upper right lateral incisor. He had no idea
that the reason this tooth felt bigger than his other teeth was because it had
been spared the wear due to its position. Only by showing him his pictures in
a step-by-step fashion and comparing his lower anteriors to teeth that hadn’t
worn, and explaining that on some teeth he had lost up to 30 percent of the
height of the teeth, did he begin to understand and ask what we should do
about this.

I used the boxes in Keynote to indicate how the width–length ratio of his
upper centrals had been affected.
It is very important to speak in a non-judgmental way, with no hint of “what
they should have done” or what they have done wrong. Brené Brown has
shown through her research that shame is not an effective tool for social
justice. In our world, attempting to shame our patients is not an effective
practice builder. We want to maintain that adult/adult relationship. If patients
are ashamed, we want them to feel safe and able to accept what is here and
now. All we can do is to move forward from here.
It is also, I believe, important not to cast any blame on previous
work or dentists. This is what feels like a cheap shot, but I would
encourage you not to take it. It is so easy to criticize and make
yourself out to be the hero of the hour, who can save the day, but I would be
very, very wary of playing that role. You have no idea under what
circumstances the previous dentistry was carried out. Take the higher ground.
The closest I would come would be something along the lines of, “It’s hard
for me to comment on previous dentistry, as obviously I don’t have all the
information from that time. All I can say is that looking at how things
stand today, this is how I would consider and approach things.” Or, “I
cannot comment on how long this condition has existed without seeing
previous radiographs. What I can say is that you have lost 50 percent of
the bone around this tooth. If you were a regular attender, I would be
surprised if this did not show up on a previous radiograph, but maybe
there was a reason it wasn’t observed or communicated to you.”
My advice would be to try to get the patient to move past the “blame” of
what has happened and to engage in what to do now. If there was a financial
outlay that they are upset about, I would always recommend that they return
to the previous practitioner for discussion. Your job is to diagnose where
they are now and to recommend what could come next.
Verbal skills that I have learned:
If we did X, my concern for you would be...
I understand that you came here asking for X. Here is why that would
not be my recommendation (visual explanation).
I am always thinking, if this was a member of my family, what would I
recommend?
S TE P 2: THIS IS WHE RE WE COUL D
GO
Depending on the case, this is where you can link back to the patient’s values
and what they said was important to them. Speak to that first. Show them
imaging if you have done that, and show them the design element. Give them
the possible pathways. If you have before and afters of similar cases that you
have treated, this is good place to put those in, as examples.
Example of a before and after—A case where we disguised one dark
tooth with porcelain
Example of imaging to give an illustration of where we could go
S TE P 3: HE RE ARE THE WAY S WE
COUL D GE T THE RE
For example:
We could take out these teeth. We could use implants, bridges, or dentures.
We could whiten or apply composite or porcelain veneers.
We could treat the four anterior teeth, or more than that.
We could straighten your teeth and whiten or straighten first and then do
restorations.
We could move your teeth into a better position so that the dentistry
required to make them look better can be less aggressive.
We could monitor your bite and give you a nightguard, or we could take
the next steps to protect your teeth from further wear and replace what’s
been lost.
This stage is the most intricate dance between communication and feedback
from the patient. Remember to read their body language and ask questions.
Make suggestions, and depending on their response, you will begin to clarify
what they are thinking. Remember that even if the clinical dentistry is agreed
upon, there is no case acceptance until the finances are also agreed.
S TE P 4: HE RE ARE MY
CONCE RNS / OUR L IMITING FACTORS
Now is the time to link back to the patient’s presenting complaint or outcome
and see if the story you have told so far makes sense to them. Take time to
have some silence so that the patient can reflect on what they see in the slides
and what you are saying. Ask questions to check in and be ready to listen and
reflect back to them to check your understanding.
Are there limiting factors from the diagnosis? Is there a skeletal issue,
airway issue, lack of remaining tooth structure, or no room to restore the
teeth? You may have legitimate concerns. Sometimes the patient may press
ahead with something they want that doesn’t make sense to you as the dentist.
Examples of what I would consider limiting factors

1. Underlying skeletal issues, such as vertical maxillary excess or

deficiency (referral for an orthognathic opinion would be an
 option).

2. Severe loss of bone in periodontal disease.

3. Constraints imposed by the patients, for example, they don’t want

implants to replace missing teeth but desperately do not want a
denture.

4. Implants placed in a less-than-desirable position, but the patient

does not want to consider removing them.

Now is the time to speak from the heart with: I understand what you are
saying, but my main concern for you would be... If we drilled away that
amount of tooth... However, if that is a risk that you hear me saying but
are willing to take, then that’s a different matter. Are you telling me that
you understand that you should move your teeth and that if you do not I
will have to drill away more, and that puts you at risk for further
dentistry in the future? Are you saying that you understand all of that but
really do not want X treatment and would rather do Y, even with those
risks?
It then becomes a personal judgment as to whether you as the practitioner feel
that Y is justified. Do not be afraid to say no! That is where I would come
back to, “I understand that you are getting married in six weeks. However,
I would hate for you to rush into dentistry that will have consequences for
the rest of your life. Let’s see if there is another way.”
Bring the conversation back to what the patient is trying to achieve and see if
there is a third solution.
I believe that we can be empathetic and give our true opinion as to what we
would do if this was our own mouth, or if we were advising a member of our
family. Linking back to our values will help us to keep delivering an
authentic message.
Some of our patients would rather keep teeth for as long as possible and
accept the risks that treatment may only last for a short time, and then they
will move on to the next stage. For other patients, predictability is the most
important. Maybe they travel or have a job that does not easily lend itself to
time off for dental appointments. These patients may prefer to have any
questionable teeth extracted and go with a more predictable outcome.
The language we use is important. By talking in terms of what is important to
“our patients,” we are giving the person that we are talking to important
social validation that either choice is acceptable and understandable. This is
much more effective than asking, “What’s more important to you, keeping
teeth or the predictability of treatment?” There is a time and a place for
“you” questions, but it is very effective to pepper in “Other people make
these decisions too” as part of your conversation.
S TE P 5: HE RE ARE THE RIS K S ,
INCL UDING DOING NOTHING
Individuals have differing tolerances to risk. No intervention in dentistry is
without risk. This is our opportunity to bring up the conversation and gauge
the risk tolerance of our patient before presenting them with detailed consent
forms.
While I understand that we need to provide written consent with general and
individualized risk acknowledgments, I believe that this should come once
the definitive treatment plan has been agreed upon.
Risk, predictability and prognosis are all linked, and unfortunately, we do not
have a crystal ball.
Part of our diagnosis and observations process is to note if there are signs of
instability. If there are wear facets, sites of bleeding on probing, open
margins on restorations, nonvital teeth without endodontic restoration, or
endodontically filled teeth without full coverage restorations, these
conditions will not reverse themselves, and the damage that has been done is
permanent, without intervention.
This is different from a suboptimal endodontic obturation in a tooth that has
been symptomless for 20 years and shows no sign of periapical pathology on
radiograph. My answer for these teeth would be the “textbook-correct thing
to do—to reroot treat that tooth. The alternative is for you to accept the risk
and to travel hopefully, particularly as we are not relying on that tooth for the
overall success of the treatment plan.” Travel hopefully may be reversed if
this is a key tooth for a precision-retained partial denture—in which case the
textbook right answer should be followed.
Treatment planning is not a world of absolutes. There are many shades of
gray, and ifs and buts. If we treat our patients as adults and educate and
motivate them to the best of our ability, we can rest assured that we have
done our job.
B UIL DING TRUS T
Case presentation should be a collaborative process. We bring to the table
our expert findings, our knowledge of evidence-based dentistry, and our own
clinical biases. Like it or not, the patient brings their previous experiences,
their level of trust in you as their care provider, plus their lives—their access
to finance, time, family, and work factors, and of course, differing levels of
dental anxiety.
In any business, but particularly in the healthcare professions, trust plays a
major role in why a patient chooses a given individual for their care. In
private dentistry, patients have choice. In elective dentistry, such as smile
design or implant dentistry, they also they also have choice, not only between
providers, but whether or not to proceed with any treatment at any time. All
the work that you and your team have put into building rapport and
relationships will play a part.
It can be tempting with a complex case to feel that we should present Option
1, Option 2, Option 3, and the pros and cons. Indeed, to achieve correct
informed consent, we are required to give patients the alternatives and the
pros and cons based on the latest scientific evidence. However, if we
barrage patients with a series of “ifs” and “buts,” they may suffer from
information overload. Decision paralysis occurs if there are too many
choices, particularly if these choices are poorly explained or understood.
DECISION POINT A storyboard presentation can also be recorded as a
video, using a platform like Loom, and sent to the patient so that they
can share your thoughts with family or friends. You can decide if this
would be a benefit, or to simply export it as a PDF and email it as images
only.
S TE P 6: HE RE ARE THE NE XT S TE P S ,
THE F IRS T THINGS
It is important to be very clear about the next steps and the priorities from a
health standpoint. Not every patient will be able to make a decision, and if
there is a lot of information to consider, a second consultation may be
required. It is helpful to have a couple of simple priorities that can help to
move a patient forward—these may be dealing with active decay or seeing
the hygienist as a priority, which could be scheduled while the patient is
deciding about the overall plan. There may be referrals to be made or special
tests for further information. Whatever the situation, it is important to be
clear about the first steps so that the patient knows what comes next.
S TE P 7: HE RE ARE THE COS TS
INVOLVE D
We are healthcare providers and we are also the business that stands to profit
if the patient goes ahead with treatment. This can be a difficult ethical arena,
and while money must not ever influence our clinical decision-making, it
would be naïve to believe that it plays no part in the process. As a dental
business, we need a percentage of patients to say yes to our treatment
propositions so that we can continue to invest in our education and pay our
wages and other bills.
Discussing finances
When it comes to discussing finances with patients, I am next to useless! I
have known this from the beginning of my career. My preference is to be
focused on delivering the right clinical care for the patient. I switch hats
behind the scenes to work with our financial advisors in setting the fees (and
I have no problem in setting a fair fee for the level of work that we provide)
and being sure that the financial aspects of the business are healthy.
However, I have never been comfortable with quoting fees directly, partly
because I am the person (the owner of the business) who could be negotiated
with to alter the fees if put under pressure, and I did not become a dentist to
negotiate on finance. Instead, I work with well-trained treatment coordinators
who are excellent communicators.
It is so important to charge a fair fee for the work that you do so you can
continue to invest in your education, pay your team well, look after yourself
and your family, and succeed in business so that you can keep serving your
patients.
Treatment coordinators (TCs) can play a powerful role in separating the
dentist from the discussions about money. The dentist can focus on the
clinical needs and best options for the patient, and the TC can present the
fees and be the patient’s advocate in terms of finding a solution that is right
for them. There are many dental financing options currently available for
patients in order to spread the cost of treatment, without putting the practice
into risk from bad debt. This can be the domain of a well-trained TC.
Increased training in communication skills, particularly listening skills, leads
to increased effectiveness.
It is important to remember that clinical dentistry has not been accepted until
the financial arrangements have been agreed and acted upon and the
appointments have been booked.
COACHING OUR PATIE NTS THROUGH
THE DE CIS ION-MAK ING P ROCE S S
Remember the different personality styles from Chapter 3? An awareness of
the patient’s personality style should allow you to adjust your style
throughout the entire case presentation process to be most effective with
theirs.

• Remember to use patient-friendly language. Metaphors can be helpful.

• Remember to keep quiet on occasion to allow your patient to process

the information.
 • Remember to check in with what they are thinking.

• Remember to read their body language.

• Remember to listen.

High “D” patients will be quick decision makers, but it pays to be well-
organized with your thinking so that if they want to go ahead, you do not
waste their time by hesitating over appointment schedules.
High “C” patients are unlikely to make a quick decision, and they may need
more information and wish to do more research themselves.
High “I” patients can nod and say “yes” but give false acceptance and leave
you wondering why they did not go ahead unless you learn to ask questions
and listen more closely.
High “S” patients need validation that they are making a good decision. This
is where testimonials from other patients who have proceeded with treatment
can be very powerful, as well as offering to include in the consulting process
family members or friends who can support them in their decision.
When we were treatment planning, we had decisions to make as to what the
priorities might be. When we are presenting these options to the patient, we
are guiding and coaching them and giving our best advice so that they can ask
the right questions to be able to make the fully informed decision that is right
for them.
The process may now become a negotiation where your patient begins to
figure out what is possible, taking everything, including finance and time, into
the equation.
Further training for you and your team on discussing finance, overcoming
objections, and making financial arrangements is invaluable. Price is often
brought up as the easiest objection for people to use, and sometimes our own
feelings about money can cloud our judgment. I would certainly recommend
that you have options available for patients to be able to spread the cost of
treatment, and it is worth working with a third-party provider to implement
this in your practice.
An objection about anything, including price, is a request for more
information, and the best way to deal with this is to ask more questions to
understand what the hesitation or barrier really is.
DECISION POINT It is vitally important to have a clear process for
following up with patients after the case presentation. The final, agreed
treatment plan needs to be written up with a consent process in place. You
may have separate consent forms for different treatments, and it makes sense
to include the summary of the risk analysis as part of an individualized
consent process. Decide who is going to follow up after the case presentation
appointment, who is going to finalize the financials, and who is going to
prepare the consents. Checklists can be very helpful for keeping track of
every step.
DECISION POINT Consider a tracking system that can be virtual or analog
for tracking every step of the process, from full assessment to the patient
starting treatment. We use a manual whiteboard in our office which follows a
Kanban system. Kanban is a method used traditionally in manufacturing but
can be used to track any process by means of a visual board. We have a large
whiteboard in our office with sticky notes with patients’ names on them and
columns that indicate the stages of the journey. In this way, we can see at a
glance if there are bottlenecks or potential hold-ups coming, or if a patient
has not proceeded along the board, then my team can see at a glance and ask
questions.
In summary, when we have a consistent protocol for gathering data, analyzing
it, designing the desired end goal, comprehensive treatment planning, and
presentation of options, we are giving the patient the opportunity to proceed
with more predictable treatment plans. This planning can be part and parcel
of modern practice. Every case and every patient will be different, but the
journey can be underpinned by reliable systems.
Assessment of completed cases is also a critical part of learning so that we
can continue to improve our skills and our end results. Patients who are
delighted with the results and their entire experience will refer others.
Having a library of completed cases also allows entry into further
educational processes, such as the British Academy of Cosmetic Dentistry’s
Accreditation Award or the American Academy of Cosmetic Dentistry’s
Accreditation Process (for more information, visit www.bacd.com and
www.aacd.com).
Further Reading
Cathy Jameson, Collect What You Produce, Jameson Management, Inc.,
2019.
Ashley Latter, Don’t Wait for the Tooth Fairy, www.ashleylatter.com
Atul Gawande, The Checklist Manifesto. How to Get Things Right,
Profile, 2011.
C HA PTER 17
C A SE STU D IES
As a student of all the people I have spoken about, I never knew if I had fully
understood the content that they shared until I had the opportunity to apply the
learning. This book would not be complete without some examples of the
smile analysis process in action. I have chosen three cases to share with you
to illustrate how the system can be applied in different situations.
For each case I have provided:

1. Pertinent findings from the preclinical and clinical exam

2. Before photographs and radiographs

3. Complete copies of the Diagnosis and Observations forms and the

Risk Assessment forms

4. Slides of notes from the storyboard

5. Details of smile design

6. The challenge list

7. A description of the case presentation discussion

8. The definitive treatment plan

 After-treatment photographs
9.

10. Reflection

CAS E S TUDY 1: PATIE NT A

Preclinical information
This lady is a business owner with a very busy life and is a high “D”
personality. She previously came to the practice asking about smile design
and veneers, and was put off because she had wanted the treatment carried
out quickly and we mentioned orthodontics to move her teeth. She did not
have time for that in her busy lifestyle.
A few years passed when she returned and decided the time was right, but
she really wanted veneers or bonding and wanted my opinion about what she
should do.
Before
My treatment coordinator met with her in our consultation room and gathered
the preclinical data, checked her medical history, had a conversation about
her expectations, and explained the process to her.
CL INICAL E XAMINATION
At the clinical examination, we took photographs and video, and gathered all
the relevant information, together with radiographs.
I questioned the patient about her motivation and what was driving her to
seek treatment now.
I sowed some seeds about my concerns but remained neutral as to whether I
felt she could have treatment without orthodontics. In my mind I was thinking,
“You really need to move that tooth!” but in reality, I was reserving
judgment because I knew that we would need to work hard to motivate her,
and I wanted to have everything ready in the storyboard so that I could give it
my best shot. If I had met her insistence that she didn’t want ortho with an
immediate opinion that she had to have it, I would have risked losing her
right away and she may have gone elsewhere to see if they would do it
differently. The only way I could have argued my case at an initial exam
would have been with words. Words cannot explain to a patient in the same
powerful way that visual explanations can. In terms of codiagnosis, I wanted
her to see the problem for what it was, so it was not me telling her she
couldn’t have what she wanted. Instead, I wanted her to understand for
herself that to get what she actually wanted—a beautiful smile—the right
thing to do was to move the teeth first.
I have also learned from experience that maybe there is another way. I have
learned that I can relax in the clinical examination, as I do not have to come
up with a solution there and then. When I have completed the analysis stage, I
know whether I was able to think of anything else or I will have consulted
with colleagues who may support my view or offer an alternative.
The patient left the clinical exam with me and I told her, “I’m going to sit
down with your photographs, my clinical notes and your radiographs, and
really study all of the options. When you come back, I’ll be able to be much
more specific about your options, the pros and cons and the costs, and we
can help you to decide what’s right for you.”
She left saying she was excited to see what I would come up with. “I have
faith in you—I know there’s a way for me to get the smile of my dreams
without spending years in orthodontics.”
Sometimes patients like to paint the world as they would like it to be! I have
learned to just smile and say that I will certainly do my best.
S TORY B OARD CRE ATION
While I was doing the clinical exam, my treatment coordinator opened the
storyboard template on her Mac laptop and saved Patient A’s name.
She could then download the initial photographs and video that she had
taken, and after the clinical exam, she would download the remainder of the
clinical photos into a “starter slide.”
My dental nurse took the remainder of the clinical photos with our digital
SLR camera and then immediately put them into the patient folder in our
server’s photography file. My treatment coordinator could then pick them up
either onto a hard drive to transfer them to her Mac or use Dropbox.
Points to note: We do not spend time at this stage editing the pictures or
getting them all perfectly positioned. They can be overlapping and on top of
each other, as the aim is to have all the photos available so that when I sit
down to do the analysis, they are all there.
In slide 3 above, my treatment coordinator also copied the video that was
taken, which I then use to make my dynamic evaluations, and more
specifically decide the incisal edge position.
 www.dentalbooks.org
E DITING A VIDE O IN K E Y NOTE
• When you are on the slide that has the video on it and you click directly on
the video so that the white markers are visible around the edges as in the
image above, a Movie menu appears on the right-hand side.
• In this menu, you will find a Volume slider. It is good practice to slide this
all the way to the left so that the sound does not play. None of us like to
hear our own voices played back to us, and it only serves as a distraction.
The video is about lip dynamics, not sound.
• The Trim slider also allows you to edit the beginning and end of the video
so that if there is a long pause before anything happens, you can take that
out.
• In the drop-down menu under Repeat, you can also choose Loop, which
means that when you play the presentation, the movie keeps repeating until
 you click to the next slide.
GUIDE D OB S E RVATION
Following the system laid out in Chapters 6, 7, and 8, I sat down at my
scheduled treatment-planning time and opened Patient A’s clinical notes in
two tabs in Google Chrome, MyiTero, and the storyboard in Keynote.
I copied and pasted her full-face smile photo into the smile analysis template,
and using two fingers on the trackpad, I zoomed in to check that the
interpupillary line was parallel to the horizon. I could move the horizontal
lines up and down to check the top of the eyebrows and the intercommisural
line. I also like to check the top of the ears, but in this case, her hairstyle
prevented this.
I also chose a photo to prepare the smile analysis, although her teeth were not
apart. This is because in the photo with her teeth apart, she was not giving
such a good smile with her top lip. She clearly has a high smile line, but in
the photo with her teeth slightly apart, she was not showing as much gum.
This is the reality of the technical photos, particularly when different people
are taking the photos. And, of course, patients are feeling self-conscious and
perhaps impatient, and we cannot spend 30 minutes getting the photos just
right in a busy day-to-day practice. We have to do our best and also learn to
work with what we have.
F IL L ING OUT THE DIAGNOS IS AND
OB S E RVATIONS F ORM
The following pages are the Diagnosis and Observations form exactly as I
would fill it out in my patient records, following the Macro, Mid and Micro
template.
Some abbreviations I use
 NAD—No abnormality detected
NTR—No treatment required
I use the FDI World Dental Federation notation system. The quadrants are
upper right 1, upper left 2, lower left 3, lower right 4, and the teeth are
numbered 1–8 in each quadrant, with 1 being the central incisor. Number
21 is therefore the upper left central incisor, and 34 is the lower left first
premolar.

Supporting data reviewed: Photos Video Radiographs Study models (circle

or highlight) MyiTero NIRI
Midface: Lower face: (1:1) DIAGNOSIS:
Upper lip: Normal Short Long
Lip mobility: (tooth length—display at rest + gingival position) 8 mm normal
CEJ palpable: Yes, recession
Maxilla to horizontal: Canted R canted L level
Buccal corridors: R narrow full - L narrow full
Length of upper right central: 11 mm (long)
PATIENT MAIN CONCERNS: She was looking for improvements in her
smile particularly on the left
GENERAL RISK FACTORS:
Relevant medical history inc. smoking: No RMH, nonsmoker
Is the patient a bruxist? No
Do they already have a nightguard? No
General perio classification: Localized gingivitis
Gingival biotype: Thin—tendency to recession
Soft tissue concerns: None, lower lip asymmetry noted, more lower posterior
teeth showing on the left
AIRWAY CONCERNS— None
MACROESTHETIC EVALUATION:
Refer to the smile analysis slide in your storyboard, the profile photos and
the study models or MyiTero/IOS scan.
Zoomed-in smile on storyboard
MIDLINE:
Facial to dental: Okay
Skeletal: 1
Molars/canines: 1 on right, 3 on left
E-plane/Andrews Line: Okay
Arnett’s True Vertical: Okay
Arch form: narrower upper left
Smile curve (alterations in tooth position for ideal): Irregular
M-position: Okay
E-position: Okay
Gingival positions: Irregular, marked recession on upper left central
Papillae positions: Good
RED proportion observations: RHS better than left where crowding
Width/length: Okay to CEJ
Phonetic observations: NAD
Crowding/spacing/rotations: Upper left central rotated
Compensations/overeruptions/alterations in occlusal levels: None
Crossbites: Lower left premolars
FUNCTION:
Guidance: Group function to left, canine to right
CO:CR: Coincident
Signs of instability: Some early wear and recession
TMJ (clicks/ROM/deviations/crepitus/pain): None, good range of motion
Muscles: NAD
ORTHO CLASSIFICATION: Crowding upper maxilla with narrow left
side
Options: Orthodontics to improve upper crowding and align upper anteriors
MISSING TEETH: Not relevant
Risks of leaving spaces:
Implant risk assessment: ITI
Bridge risk assessment:
Denture options:
Radiographic report: Reviewed OPT and anterior PAs
UPPER RIGHT POSTERIOR:
Perio risk: Low
Existing endo: None
Risk of future endo: 16 deep restoration
Restorations: 16 do amalgam, Okay
Caries +/-: NAD
Erosion/abrasion/attrition/abfraction: NAD
UPPER ANTERIOR:
Perio risk: Low
Existing endo: None
Risk of future endo: Low
Restorations: NAD
Caries +/-: NAD
Erosion/abrasion/attrition/abfraction: No wear but significant recession 21
UPPER LEFT POSTERIOR:
Perio risk: Low
Existing endo: None
Risk of future endo: 26 deep restoration
Restorations: 26 amalgam okay
Caries +/-: NAD
Erosion/abrasion/attrition/abfraction: NAD
LOWER LEFT POSTERIOR:
Perio risk: Low
Existing endo: 34
Risk of future endo: Low
Restorations: NAD
Caries +/-: NAD
Erosion/abrasion/attrition/abfraction: NAD
LOWER ANTERIOR:
Perio risk: Low
Existing endo: None
Risk of future endo: 3 crowns on lower anteriors
Restorations: As above, margins not esthetic
Caries +/-: NAD
Erosion/abrasion/attrition/abfraction: NAD
LOWER RIGHT POSTERIOR:
Perio risk: Low
Existing endo: None
Risk of future endo: Low
Restorations: 46 occlusal amalgam NAD
Caries +/-: NAD
Erosion/abrasion/attrition/abfraction: NAD
Are existing posts present: No
MICROESTHETIC EVALUATION:
COLOR –
Whitening? Yes with protection for root exposure anteriorly
Individual teeth—White/brown spots? None
RISK ASSESSMENT:
Biology: No
Structure: Yes
Function: No
Esthetics: Yes
Tooth color/tooth shape and/or position: Crowding upper arch and no
support for gingival levels around 21
Porcelain options and risks: High risk due to degree of crowding
Bonding options and risks: Possible after ortho as teeth are very triangular
Once I get to the end of this list, I have the main problems in my mind. There
are certain diagnoses, such as asymmetrical lower lip, that we will need to
accept—but I am comfortable that I have seen it. There are other issues like
function, which will be improved if I can persuade the patient to go for
orthodontics. This will be my challenge, as she has already insisted that she
would prefer not to.
I make a summary as a separate note in the patient’s record.
S MIL E DE S IGN
For this patient, the main esthetic concerns were so obvious, and she was so
definite with what she did and did not want, that I did not want to set any
false expectations by doing any smile imaging. I could have run an outcome
simulation on MyiTero, but I risked losing her engagement due to the dual
issues of recession and rotation.
Challenge list based on diagnosis and observations

1. Rotation of upper left central incisor

2. Triangular shape of anterior teeth and some wear to edges

Visible margins of lower anterior restorations

 3.

4. Recession on upper left central incisor

Treatment options to discuss orthodontic referral, periodontal
referral for recession on 21, porcelain veneers or bonding for
upper anteriors, replace lower restorations with all porcelain
crowns.
Note: This is not the treatment plan. There is no point in my
detailing every aspect of the possible options until I have discussed
these with the patient. I am comfortable now that I have analyzed
the case thoroughly, and I have decided how I will persuade her to
consider orthodontics.
Note: I did not do any imaging for this patient as I felt this would
give her false expectations about what could be achieved. I did not
need to motivate her to seek a better smile; I needed to motivate her
to do it in the right way and to accept the reality of her challenging
situation, particularly in relationship to her gums.

For cases like this, I find a good motivator for ortho rather than restorative is
using the RED (Recurring Esthetic Dental) guide. In the storyboard, I can
illustrate where I would need to cut a tooth in order to fit the proportions in
restoratively. I can then also explain the things I cannot change without an
interdisciplinary approach, such as the bulbosity on the cervical margin of
the 21 and the gingival level.
Verbal skills: My concern for you is that in order to improve things with
veneers, I would have to be very destructive to the upper left incisor. This
will mean drilling away a lot of healthy tooth and quite likely will mean
that the tooth will die and a root canal treatment will be needed. And even
if I can do all that, giving the illusion of straightness will only magnify the
difference in gum levels.
I asked more questions to find out what her barriers were, and they were all
related to time. She wanted a quick result. However, she also wanted the
best, and finally she agreed that she did not want me to drill her tooth so
aggressively. I managed to persuade her that an inter-disciplinary approach
involving soft tissue surgery and accelerated orthodontics would meet her
requirement for a faster treatment time but also provide a less invasive and
more optimal esthetic end result.
RIS K AS S E S S ME NT F ORM
The Risk Assessment form helps to guide my thinking about treatment plans
but also forms part of the education piece for the patient. In this case, ortho
and periodontal grafting was going to move her from a high-risk restorative
case to low risk with improved function and guidance.
Final treatment plan

1. Accelerated fixed ortho to derotate the upper left incisor and

improve the crossbite on the left (Orthodontist Dr. Sheri Daniels,
London)

2. Soft tissue grafting upper left central (Periodontist Michael Zybutz,

London)

3. Replacement of lower crowns (Luke Barnett Ceramics, Watford)

4. Whitening (in-house with protection for other areas of recession)

(Phillips Zoom)

Composite bonding upper 3–3 (Venus Diamond, Heraeus Kulzer)

 5.

6. Hygiene maintenance

7. Retention—Fixed and removable upper and lower

An individualized consent letter was written, based on the above.

P RE -TRE ATME NT AND P OS T-

TRE ATME NT P HOTOGRAP HS
RE F L E CTION
The eventual simplicity of this case being finished with whitening and
bonding was due to the patient agreeing to move herself from a high-risk
restorative case to low risk, through the use of orthodontics. The soft tissue
correction was still a high-risk procedure but was improved greatly and as
the surrounding gingival levels are more even, the slight difference that still
exists between the centrals is not obvious.
CAS E S TUDY 2: PATIE NT B

Preclinical information
This young lady is a 36-year-old entrepreneur. She had researched and
wanted a smile makeover with porcelain veneers as she felt her teeth were
not responding to whitening, and the edges were chipped.
My treatment coordinator met with her in our consultation room and gathered
the preclinical data, checked her medical history, and had a conversation
about her expectations and explained the process to her.
CL INICAL E XAMINATION
We took photographs and video and a MyiTero scan, charting, perio records,
and full exam.
I asked her if she was aware of the notched recession on her anterior teeth.
She said that she was and that she knew she had a bad habit of picking at
these areas but that her lip covered them. She knew she should stop doing
that—it was a bad habit.
DIGITAL TOUR OF THE MOUTH
After my clinical exam, I sat the patient up and showed her the iTero screen
to introduce some areas of concerns (remember “sow the seeds” from
Chapter 5). With the iTero 5D, I also have the ability to show an HD intra-
oral picture of the tooth, which has been captured in real time. You could
also do this kind of tour of the mouth with an intra-oral camera if you have
one or by putting clear arch photos up on a large screen.
For this patient, I pointed out the recession and the large restorations.
Verbal Skills: You can see here (e.g., upper left first molar) that most of
this tooth is filling. The risk is that these thin bits of remaining teeth can
fracture or break.
I asked about the missing lower premolar which was not a concern to the
patient.
If there is any sign of wear on the teeth, I like to show the patient this in
color-off mode. I can point out the areas of wear. Remember, I am not
offering any answers or solutions. I just want to point out concerns and see if
they have any awareness of these issues, and if they have ever been offered
solutions previously. In this case, she was completely unaware, but I had
sown a seed so she would come to the next appointment expecting to hear
about possible solutions to these issues, as well as her request for smile
design.
Guided Observation
Supporting data reviewed: Photos video radiographs study models
(circle or highlight). MyiTero NIRI
Mid Face: Lower Face: (1:1) DIAGNOSIS: Normal face proportions
Upper Lip: Normal Short Long
Lip Mobility: (tooth length—display at rest + gingival position) low
CEJ Palpable: Yes
Maxilla to horizontal: Canted R canted L level
Buccal corridors:
R narrow full
 L narrow full
Length of upper right central: 9.8 mm
PATIENT MAIN CONCERNS: Would like whiter, more even smile
GENERAL RISK FACTORS
Relevant medical history inc. smoking: None, non-smoker
Is the patient a bruxist? Yes, but she is unaware (tori/exostoses/scalloped
tongue) scalloped tongue
Do they already have a nightguard? No
General perio classification: Localized loss of attachment, habit, no disease
noted
Gingival biotype: Thin
Soft tissue concerns: No concerns, noted thin upper lip
Airway concerns: None
MACROESTHETIC EVALUATION:
MIDLINE:
Facial to dental: Okay
Skeletal: Class 1
Molars/Canines: Class 1
E-plane/Andrews line: Upper centrals slightly retroclined, large mandible.
Wear worse on anteriors, so possible restricted envelope of function
Arnett’s true vertical:
Arch form: Posterior molars are tilted in despite wide upper arch
Smile curve: (ALTERATIONS IN TOOTH POSITION FOR IDEAL) uneven
smile line
M-position: Okay
E-position: Okay
Gingival position: Marked recession on upper anteriors, pt has a habit.
Doesn’t show and low lip line. No sensitivity
Papillae positions: Okay
Red proportion observations: Good
Width/Length: Slightly short—9.8mm
Phonetic observations: NAD
Crowding/spacing/rotations: Upper centrals are retroclined
Compensations/Overeruptions/alterations in occlusal levels: Step up lower
anteriors
Crossbites: None although close on lower right first premolar
FUNCTION
Guidance: Canine guidance both sides
CO:CR: Hit and slide
Signs of instability: Significant wear on palatal of uppers—restricted
envelope of function
TMJ (Clicks/Rom/Deviations/Crepitus/Pain): Normal limits
Muscles: Normal limits, square jaw, large masseters
ORTHO CLASSIFICATION: Restricted anteriors
Options: upright anteriors and posterior segments
MISSING TEETH: lower right 5, does not concern the patient
Risks of leaving spaces: no real risk
Implant risk assesment—ITI: Narrow space
Bridge risk assesment: Narrow space
Denture options: Narrow space
DECISION POINT DIRECT OR INDIRECT
I like to plan for replacing amalgams as I believe that these are better
restorations from a biological standpoint. This does not mean that I
recommend that all amalgams be replaced, but I like to consider:
1. If I was to replace it, is it small enough that a direct composite would be
okay?
2. Is it so large that an indirect restoration would be beneficial (inlay/onlay
or crown)?
3. Or is it a situation where indirect would be ideal, but I could restore with
direct composite if finances were an issue?
The decision depends on remaining tooth structure, supported or unsupported
enamel, if the patient is a bruxist, and if the amalgam is shining through the
buccal wall. Be careful of first and second premolars in smile design cases.
It may be possible from a structural standpoint to do a direct restoration, but
if the buccal wall is stained dark, then it can be very difficult to satisfy the
esthetic demands without covering the buccal cusp down to the gingival
margin.
If I write “open margin” or “fracture” lines in my notes here, that is a trigger
point to discuss with the patient that these are higher up the priority list than
“margin OK” restorations.
UPPER RIGHT POSTERIOR:
Perio risk: Low
Existing endo: None
Risk of future endo: 17, 16, 15, 14 all large restorations
Restorations: Very large restorations, 16 gold crown, amalgams indirect,
margin OK on 17
Caries +/-: NAD
Erosion/abrasion/attrition/abfraction: NAD
UPPER ANTERIOR:
Perio risk: Low
Existing endo: None
Risk of future endo: Low
Restorations: none
Caries +/-: NAD
Erosion/abrasion/attrition/abfraction: Significant pathologic wear through to
dentine, tips of 3s and palatal 2–2
UPPER LEFT POSTERIOR:
Perio risk: Low
Existing endo: Strange view of 24 on OPT—Needs a PA to confirm
Risk of future endo: 24, 25, 26, 27
Restorations: 24, 25 either, 26 indirect slight open margins, 27 direct
Caries +/-: NAD
Erosion/abrasion/attrition/abfraction: NAD
LOWER LEFT POSTERIOR:
Perio risk: Low
Existing endo: None
Risk of future endo: 37
Restorations: 37 either
Caries +/-: NAD
Erosion/abrasion/attrition/abfraction: NAD
LOWER ANTERIOR:
Perio risk: Low
Existing endo: None
Risk of future endo: Low
Restorations: None
Caries +/-: NAD
Erosion/abrasion/attrition/abfraction: Significant pathologic wear through to
dentine lower incisors and tips of canines
LOWER RIGHT POSTERIOR:
Perio risk: Low
Existing endo: None
Risk of future endo: 47
Restorations: Large composite in 47
Caries +/-: NAD
Erosion/abrasion/attrition/abfraction: NAD
Are existing posts present: no
MICROESTHETIC EVALUATION
COLOR—
Whitening? Yes with protection of recession
Individual teeth—White/brown sports? No
RISK ASSESSMENT:
Biology: No
Structure: Yes
Function: Yes
Esthetics: Yes
Tooth color/Tooth shape and/or position: Restricted envelope of function,
needs facebow mounting
Porcelain options and risks: With careful planning smile design to replace
missing tooth structure as above
Bonding options and risks: Challenging as above
S MIL E DE S IGN
In the storyboard, the outlines demonstrate that the relative widths of the
anterior teeth are good. The issue is the wear and the step up, in the occlusal
plane/curve of Spee. This is evident in the difference in height between the
lower first premolars and the canines, and also the gingival levels of the
lower anterior teeth are higher than the posteriors, caused by dentoalveolar
compensation.
Challenge list

1. Wear of anterior teeth, constricted envelope of function

2. Large restorations in posterior teeth

3. Recession on upper anteriors

Treatment goals:

1. Health

2. Improve whiteness and evenness

Treatment options:

1. Consider ortho to improve occlusal levels and angulation of

anterior teeth.

2. Mounted study models for a wax-up 2–2, smile design ideally 5–5
and consider gold crown, composites lower 3–3 and night guard.
Would want to cover the palatal of upper 2–2 due to wear.
 3. Hygiene and monitoring wear and recession—time lapse. Could
consider soft tissue grafting in the future if needed.

4. Risks of endo in the future due to heavily restored posterior

dentition.

The storyboard was illustrated with screenshots of the MyiTero images,

including images using the NIRI capability to highlight calculus deposits and
reinforce the need to see the dental hygienist as part of the overall plan.

Risks of no treatment are that the wear and loss of tooth structure will
continue, leading to further compensation and loss of esthetics. As the
protective guidance of the anterior wear is lost, heavily filled posterior teeth
may also start to fracture as they become subject to increased lateral forces.
In this case, while ortho could have formed part of the treatment plan, I was
comfortable that with proper planning, I could achieve the result with
restorative treatment. She had damaged the palatal of her upper anteriors and
there were different plans that we could have followed, including a
combination of porcelain veneers and palatal composites. In this case, I
decided that full-coverage, minimal-prep porcelain would give me the
strength I required on the uppers, while bonding on the lowers and planning
of the occlusal scheme would restore and protect the exposed dentine.
Risk Assessment
In this case, there are some high-risk areas, like the patient’s gingival
recession, which are actually mitigated by other factors such as her low lip
line. Again, filling out this form takes minutes after having been through the
diagnosis and observations and serves as an educational tool to share with
the patient and to have recorded in the notes.
Final treatment plan
 1. Facebow registration for mounted study casts

2. Hygiene

3. Digital diagnostic wax-up

4. Dahl to increase room to restore lower anteriors by adding

composite to palatal of upper anteriors

5. Indirect restorations upper 5–5

6. Bonding lower 3–3 (Venus Diamond, Heraeus Kulzer)

7. Nightguard

The patient understands that she will need further indirect restorations on the
remaining heavily filled teeth and that there is a risk of requiring endodontics
due to the size of the restorations. She also understands that she has
moderate-to-high functional risks, and we will monitor her occlusion and
guidance.
The restorations were scanned with MyiTero and Emax restorations designed
digitally and constructed on printed models. Ceramics and digital design by
Rob Poland, Ken Poland Dental Studios, London, England.
Additive digital wax-up for temps using Exocad (a design and manufacture
software) in the laboratory with the imported .STL file from iTero. This was
adapted to my preparation margins to construct the final restorations as an
exact replica of the wax-up once I had verified it in the mouth—an advantage
of the digital system.
Digital wax-up

Restoration design
Emax porcelain restorations fitted to the printed model
RE F L E CTION
This patient attended, asking for veneers but with no understanding of the
particular risks for her mouth. This type of case needs very careful handling
in terms of expectation and managing the biomechanical forces. The
longevity of the restorations will be determined by how well we have
managed those forces, and Patient B will need to play her part by attending
regularly for maintenance reviews and wearing her nightguard. Margin
placement was somewhat of a dilemma for me as, ideally, I did not want to
finish the restorations on root surface, but you will see that on the upper left
lateral I did choose to cover the abfraction lesion. The fact that the margins
would be visible on some teeth was discussed with the patient in advance
and her lip protected these areas from view.
I sometimes say to patients with tooth surface loss due to wear, “Enamel is
the hardest surface in the body, and you have managed to wear it down. We
can repair your teeth, but the same forces that acted on your teeth will now
be acting on our restorations, which will never be as strong as your
natural teeth were in the first place. This means that we have to be careful
and find ways to manage that risk, as the last thing I would want is for you
to be disappointed that there is maintenance required after treatment.”
CAS E S TUDY 3: PATIE NT C
Preclinical information
This 48-year-old male nurse attended, asking to have his upper front teeth
removed. He was very unhappy with his appearance and had looked at
different options for his front teeth. He revealed that he had orthodontics for
four years as a child, and he had lost trust in dentists. He really did not want
to return to orthodontics. He was now looking for a solution to “fix” the four
front teeth. He had a budget in mind and had wondered if he could replace
those teeth with implants. He knew that his upper canines were prominent,
but this did not concern him. He knew that he had an open bite, and that did
not concern him either.
With a case like this, I am always keen to investigate why the patient may
refuse orthodontics, so I ask questions during the consult, but I am careful not
to judge or to disagree. I always return to, “Today, we’ll gather all of the
information and then I’ll think about the different options with the pros and
cons, and when you come back, I can be much more specific about the
different options, the risks and benefits, and the costs.”
Remember again, “afflict the comforted and comfort the afflicted.” I might be
thinking to myself, “You need to do ortho,” but it is important not to share that
just yet, but to concentrate on building rapport and trust, particularly with
someone who has declared a lack of trust in our profession. How can I
design the storyboard to be able to illustrate his options with maximum
educational impact?
Everything needs to be taken into account, including the patient’s age and
financial ability to consider complex treatment. All of us have our own line
or level of experience where we would and should either decline certain
treatments or refer to someone with more experience.
This patient was starting from the point of wanting his front teeth removed. I
stated that although that might be an option, it would not be my favorite
option as there is nothing quite like your own teeth. I would certainly take it
into account. I could already see that because of his high smile line, even if
he needed to lose a tooth for biological or structural reasons, he was a high
esthetic risk for any tooth replacement. I knew that once I had been through
the guided observation process, I would have all the facts to be able to
brainstorm the possible solutions for him.
Above all, I gave him hope. “There will be an answer. I just need to study
and think, and we can discuss it further.” He left the initial appointment
excited to see what options we would come up with.
CL INICAL E XAMINATION
Full clinical exam including photographs, video, and MyiTero scan.
Guided Observation
Supporting data reviewed: photos video radiographs study models
(circle or highlight). MyiTero NIRI
Midface: Lower face: Longer lower face DIAGNOSIS: anterior open bite
Upper Lip: Normal Short Long
Lip Mobility: (tooth length—display at rest + gingival position) 9 mm
slightly hypermobile
CEJ Palpable: Yes
Maxilla to horizontal: Canted R canted L level
Buccal corridors: R narrow full
L narrow full
Length of upper right central: 10.6 mm
PATIENT MAIN CONCERNS: Hates his front four teeth, would like them
extracted and maybe implants placed
GENERAL RISK FACTORS
Relevant medical history inc. smoking: Smokes 3 per day, alcohol 21 units
per week
Is the patient a bruxist? No
Do they already have a nightguard? No
General perio classification: Localized gingivitis, good bone levels,
structural recession
Soft tissue concerns High smile line, anterior tongue thrust
Airway concerns: None
MACROESTHETIC EVALUATION:
PATIENT MAIN CONCERNS: Upper 4 anterior teeth
MIDLINE:
Facial to dental: Okay—dental midline is canted
Skeletal: skeletal anterior open bite and longer lower facial height, Class 3
Molars/Canines: Class 3
E-plane/Andrews line: Class 3
Arnett’s true vertical: Class 3
Arch form: Narrow upper arch
Smile curve: (alterations in tooth position for idea) reverse smile curve,
AOB
M-position: Okay
E-position: Okay
Gingival position: Upper laterals are palatally positioned so gum is low on
them. Lower gum in upper premolar, buccal corridors
Papillae positions: As above
Red proportion observations: Narrow in between canines, canines rotated
buccally
Phonetic observations: NAD
Crowding/spacing/rotations: Upper and lower anteriors crowded
Compensations/Overeruptions/alterations in occlusal levels: as above for
AOB
Crossbites: Posteriors in crossbite
FUNCTION:
Guidance: AOB—see MyiTero
CO:CR: Coincident
Signs of instability: Recession on molars
TMJ (Clicks/rom/deviations/crepitus/pain): NAD
Muscles: NAD
ORTHO CLASSIFICATION: Anterior open bite, Class 3 profile, narrow
maxilla

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Options: referral for specialist/orthognathic opinion or use Invisalign to
widen upper arch and relieve anterior crowding without correcting AOB.
See xrr below—Need to check status of upper roots before any ortho. 16
recession—risk with ortho it gets worse—Invisalign good as gradual
movement and aim to tip buccally not move. 16 has significant recession—if
moving this tooth, it is important to tip it and avoid further buccal movement
—small risk of increased recession—to advise the patient.
MISSING TEETH: 17 missing.
Risks of leaving spaces: Occlusion is held posteriorly so little to no risk
Radiographic report: Some shortening of upper anterior roots on the peri-
apical, may be an angulation issue but needs to be confirmed with additional
view and history
UPPER RIGHT POSTERIOR:
Perio risk: Low
Existing endo: None
Risk of future endo: 16, 18
Restorations: Large amalgams, margins OK
Caries +/-: NAD
Erosion/abrasion: 16 buccal
UPPER ANTERIOR:
Perio risk: Low
Roots appear short on the radiograph—to discuss with patient if any history
of trauma, and take a PA of centrals or an OPT to check. Likely to be fore-
shortening due to angle of roots compared to biting on the X-ray holder.
Vitality test before treatment.
Existing endo: None
Risk of future endo: As above if resorption
Restorations: NAD
Caries +/-: NAD
Erosion/abrasion: NAD
UPPER LEFT POSTERIOR:
Perio risk: Low
Existing endo: None
Risk of future endo: Low
Restorations: 26 do amalgam looks okay
Caries +/-: NAD
Erosion/abrasion: NAD
LOWER LEFT POSTERIOR:
Perio risk: Low
Existing endo: None
Risk of future endo: 35, 36, 37
Restorations: Large restorations
Caries +/-: NAD
Erosion/abrasion: NAD
LOWER ANTERIOR:
Perio risk: Low
Existing endo: None
Risk of future endo: Low
Restorations: NAD
Caries +/-: NAD
Erosion/abrasion: NAD
LOWER RIGHT POSTERIOR:
Perio risk: Low
Existing endo: None
Risk of future endo: 46, 47
Restorations: 46 amalgam slight distal overhang
Caries +/-: NAD
Erosion/abrasion: NAD
MICROESTHETIC EVALUATION
COLOR—
Whitening? Yes
Individual teeth—White/brown sports? Some brown lines on upper anteriors
Are existing posts present: No
Vitality risks of existing teeth: 2–2 short roots on radiograph needs to be
confirmed
RISK ASSESSMENT:
Biology: No
Structure: Yes
Function: Yes
Esthetics: Yes
Tooth color/Tooth shape and/or position: High risk due to crowding and
patient request
Porcelain options and risks: Ortho would be better, very destructive to prep
teeth due to crowding
Bonding options and risks: Could build out laterals but will be very narrow
and thick, risk of caries if not kept clean
Are existing posts present: No
Vitality risks of existing teeth: 2-2 short roots on radiograph needs confirmed
S MIL E DE S IGN
As demonstrated in Chapter 7, I utilized a smile design tool (DSDApp by
Coachman) to give me several different options to present to the patient.
From the smile analysis slide in the storyboard, I was able to see how the
relative widths of the teeth related to the intercanine width.
Laying the gingival curve highlights the difference in gingival levels which
will occur when teeth are sitting at different angles.
DECISION POINT In smile design, the gingival levels are very important.
Patients may not notice them when their teeth are crooked, but it is important
to highlight what is possible, as differences will be much more obvious when
the teeth are straight. How would you deal with gingival levels in a case like
this?
Moving teeth will improve gingival levels. Biologic width needs to be
taken into account if any soft tissue recontouring is to be considered.
In the storyboard, copying and pasting tooth outlines in the intercanine
space helps to identify how much tooth structure would need to be
reduced. This is not a motivational image, but I often use it first to help
me identify the options, and also to explain to the patient why moving
teeth would be a preferred option.
Risk Assessment
NOTE: Some of the boxes were hard to fill in for this patient—guidance in
AOB cases is on the posterior teeth, although the teeth we are considering
are not in occlusion. This is a good factor for the anterior teeth but will be
putting additional strain on the posterior teeth.
In his case, his high esthetic risks are modified by his reasonable
expectation. I did not consider it unreasonable to expect an improvement in
his anterior esthetics.

1. Position of upper 2–2

2. Position of canines, narrow maxilla

3. Large, heavily filled posterior teeth with future risks of endo

 Severe recession around 16
4.
1. Radiograph history and question patient to check upper root
length
2. If okay—options demonstrated on DSDApp—ortho and
whitening—2–2 porcelain with high risk of devitalizing upper
anteriors leading to RCT and future risks of loss, and narrow teeth
if canine width is fixed. Lateral gums would need recontouring.
3. Discuss large posterior restorations (he has his own general
dentist).
4. Discuss significance of AOB and recession on 16 and options
for perio referral, significance if 16 is lost in the future.

CAS E P RE S E NTATION
The storyboard was used to go through all of the slides and
recommendations. The patient was adamant that after his history of four years
in orthodontics, he did not want to revisit this. He repeated that it was his
four front teeth that were his concern. He also had a limited budget which did
not cater for prerestorative orthodontics.
I had been convinced that once he saw the images, he would either go for
moving the teeth, or for option 3 which was the most conservative.
He was blown away by the presentation and understood my
recommendations but preferred option 2 in the imaging.
Referral to previous radiographs confirmed the roots of the anterior teeth
were stable, and the teeth all tested positive to vitality tests. The patient was
informed of the radiographic findings.
E THICS
To prepare the four anterior teeth in a case like this is clearly not minimal
invasive dentistry.
Each of you will come across cases where you have to make a call between
what you think is the right treatment and what the patient wants. Sometimes it
is right to say “no” and certainly we must always aim to “do no harm” and to
be able to clinically justify our treatment and prove that the patient fully
consented in full awareness of the risks and benefits.
Deciding to prep his four front teeth was not a decision I took lightly. I took
his age into account. I recently saw a similar patient in his 20s and my advice
was clear—orthodontics was the right thing to do. In this case, the patient
was approaching 50, had a history of extensive ortho and an underlying
skeletal defect that was not his presenting complaint. Coupled with that, I felt
that my particular competencies and training meant that I understood how to
prepare the teeth, using guides to be able to maintain as much healthy tooth
structure as possible. I looked the patient in the eye and explained the risk of
endodontics now and in the future. If you, as the dentist, were not confident in
your clinical skills, then you could certainly recommend a second opinion, or
refer the patient to a restorative specialist at this stage.
If I had a frank conversation with the patient and I am sure that they are
making a considered judgment, and the patient tells me, “I understand that
this treatment involves removing healthy tooth tissue and that this puts me
at higher risk of either needing root canal treatment or of losing those
teeth over my lifetime, and that this would be a great challenge because of
my esthetic risk factors. I understand all that but I would prefer that
option over any other.” I make sure there is an individualized consent form
that the patient signs and that my dental nurse has witnessed the conversations
—and that there is time given for the patient to reflect between the
presentation and preparing the teeth.
I take these decisions very seriously and try to imagine should I ever end up
having to justify my clinical decision-making, I would feel confident that I
could do so backed up with evidence.
In this particular case, I felt that the boost to the patient’s self-esteem
outweighed the risks to the teeth. You may disagree with me, but I hope that
you can understand my logic. I do not believe that I serve my community of
patients well by being all or nothing. Sometimes an acceptable compromise
is worth agreeing to.
Definitive treatment plan

1. Hygiene care

2. Whitening with the exception of 16 with recession

3. Indirect restorations 2–2 with a diagnostic wax-up and prep guides

(Rob Poland, Ken Poland Dental Studio, London)

4. Further review of posterior restorations and recession

Preparations were carried out according to arch form and scanned with the
iTero scanner.
Palatal view showing how I placed full coverage restorations on the lateral
incisors but managed to preserve the palatal enamel on the centrals. The
laterals were going to be thick palatally, and the patient was aware of that.
We were able to test drive any impact on phonetics in the temporary phase.
RE F L E CTION
There is a color difference between the upper canines and the restorations;
the color match was taken from the lower incisors. This is more obvious in
photographs than in real life, and the patient is committed to home whitening
to lift the color of the canines. The gingival levels of the central incisor are
also not completely level. When finishing a case, it is worth reflecting on
details that you would change if you could, as this is how you learn and
grow.
However, resist the temptation to be too hard on yourself and take in and
enjoy the transformation with the patient.
A PPEN D IX
D I A GN OSI S A N D
OB SE RVAT I ON S
Dentist:
Patient:
Date:
Supporting data reviewed: Photos video radiographs study models
(circle or highlight) MyiTero NIRI
Global Diagnosis:
Midface: Lower face: (1:1) DIAGNOSIS:
Upper Lip: Normal Short Long
Lip Mobility: (tooth length—display at rest + gingival position)
CEJ Palpable:
Maxilla to horizontal: Canted R canted L level
Buccal corridors: R narrow full
L narrow full
Length of upper right central:
PATIENT MAIN CONCERNS:
GENERAL RISK FACTORS
Relevant medical history inc. smoking:
Is the patient a bruxist? Yes No
(tori/exostoses/scalloped tongue)
Do they already have a nightguard? Yes No
General perio classification:
Gingival biotype:
Soft tissue concerns:
Airway concerns:
MACROESTHETIC EVALUATION:
MIDLINE:
Facial to dental:
Skeletal:
Molars/canines:
E-plane/Andrews Line:
Arnett’s True Vertical:
Arch form:
Smile curve (alterations in tooth position for ideal):
M-position:
E-position:
Gingival positions:
Papillae positions:
RED proportion observations:
Width/length:
Phonetic observations:
Crowding/spacing/rotations:
Compensations/overeruptions/alterations in occlusal levels:
Crossbites:
FUNCTION:
Guidance:
CO:CR:
Signs of instability:
TMJ (clicks/ROM/deviations/crepitus/pain):
Muscles:
ORTHO CLASSIFICATION:
Options:
MISSING TEETH:
Risks of leaving spaces:
Implant risk assessment:
Bridge risk assessment:
Denture options:
Radiographic report:
UPPER RIGHT POSTERIOR:
Perio risk:
Existing endo:
Risk of future endo:
Restorations:
Caries +/-:
Erosion/abrasion/attrition/abfraction:
UPPER ANTERIOR:
Perio risk:
Existing endo:
Risk of future endo:
Restorations:
Caries +/-:
Erosion/abrasion/attrition/abfraction:
UPPER LEFT POSTERIOR:
Perio risk:
Existing endo:
Risk of future endo:
Restorations:
Caries +/-:
Erosion/abrasion/attrition/abfraction:
LOWER LEFT POSTERIOR:
Perio risk:
Existing endo:
Risk of future endo:
Restorations:
Caries +/-:
Erosion/abrasion/attrition/abfraction:
LOWER ANTERIOR:
Perio risk:
Existing endo:
Risk of future endo:
Restorations:
Caries +/-:
Erosion/abrasion/attrition/abfraction:
LOWER RIGHT POSTERIOR:
Perio risk:
Existing endo:
Risk of future endo:
Restorations:
Caries +/-:
Erosion/abrasion/attrition/abfraction:
Are existing posts present:
MICROESTHETIC EVALUATION:
COLOR -
Whitening?
Individual teeth—White/brown spots?
RISK ASSESSMENT:
Biology
Structure
Function
Esthetics
Tooth color/tooth shape and/or position:
Porcelain options and risks:
Bonding options and risks:
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To the Reader
Dear Reader,
Thank you for joining me on this journey. I appreciate that there is a massive
amount of information included in these pages. It was never my intention to
give you a quick “cookbook” approach to smile analysis as I believe that
you, my reader, our profession and our patients deserve more.
Though it may have taken you many hours and periods of reflection to absorb
the information contained in these pages, I have tried to give you the lessons
that thirty years in practice have taught me. It is my intention to provide you
with my thought process and system as a guide and an example you can build
on and modify and integrate with your own, unique style.
This book would not exist without the many mentors and educators who have
shared their knowledge and inspired me over the years, and the enormous
goodwill of the patients of Cherrybank Dental Spa who have trusted us with
their care and joined us as we advanced the state-of-the art in enhancing
healthy, beautiful smiles.
I wish you well on your mission to analyze smiles with empathy, compassion
and systematic judgment.
Thank you for taking this journey with me,
With best wishes,
Elaine Halley
Perth, Scotland
A C KN O W LED GM EN TS
My journey in dentistry to the point in time where I felt I had a book to write
has been highlighted by many great minds, independent thinkers and generous
mentors.
I would like to give thanks for the people who have shaped my career:
Clinically, I would like to acknowledge everything that I learned from Mike
Wise, Pete Dawson, Larry Rosenthal, and the Aesthetic Advantage team,
particularly Tom Dudney and Ken Hamlett, who really helped me with my
early understanding of form and function. Newton Fahl and Pascal Magne,
who were so generous with their teaching, Christian Coachman and the entire
DSD family, Ralph Georg for the DSDApp and the Planning Centre in
Madrid, whose thought leadership and pursuit of excellence is constantly
pushing boundaries. I include in that the wonderfully talented Jameel Gardee
and Adam Morgan—our DSD UK teaching team. Bill Robbins and Jim Otten,
whom I have shared the virtual study club world with and who have
continued to challenge my thinking and encourage me to share my knowledge
to help others. Linda Greenwall, who very early in my career showed me that
a woman could stand up and educate, and be passionate about dentistry and
patient care.
Cathy and John Jameson and Jameson Management set me on a pathway for
understanding the systems behind the business of dentistry.
My team at Cherrybank Dental Spa, particularly Jillian Melloy, who has been
my cheerleader since the very early days of my dental and teaching career.
Jackie Smith and Janice Beckett, who have worked for me tirelessly for over
20 years. Dental nurses Rosswen Davies, Gillian Fearnley, Sarah Rodgers,
and Jennifer McKenzie, and treatment coordinator Sam Ferrier are the
photographers and patient communicators who have contributed to the patient
journeys of all the people whose smiles are shown in this book. A
combination of wisdom from Flo Couper, and learning and implementation
from Gayle Reekie and Abbie Frankland, and Abby Sutherland made sure all
of our patients were periodontally informed and healthy. Caroline Ralston
and Julie McIntyre complete the Cherrybank Team, and I thank them for their
contributions. My two brothers, Cameron Philip and Steven Philip, who have
taken care of business so that I could write (and dream) about smiles.
Similarly, my “peer review” friendships in dentistry—especially David
Bloom and Chris Orr and our BACD family, and Rob Wain and Ian Kerr for
continually challenging my perspective in dentistry and broadening my
horizons. Sinead McEnhill, Fazeela Khan Osbourne, Eimear Keenan, and
Uchenna Okeye for being the amazing clinicians and educators that you are
and providing me with friendship and moral support beyond words. Carol
Fish, for being my trusted friend and study partner through dental school and
for your years of friendship afterward.
A special thank you to my associates Chris McCrudden and Jodie Fulton for
believing in the Cherrybank way and upholding our values with patient care.
They have both contributed to the care for patients in this book. My
interdisciplinary team of Guy McLellan for surgical perspectives, Michael
Zybutz for periodontal skills, and Ian Hutchison when I need the alternative
orthodontic opinion or two!
To all the dental technicians that I have learned from and worked with, but
especially Rob Poland and Luke Barnett. We have learned together and
problem-solved together, and created beautiful, life-changing smiles together,
and there is no doubt that without your continual investment and progression,
I would not have been able to progress my thinking and care.
Mark Skimming for giving me the opportunity to serve as the clinical director
for the Pain-Free Dentistry Group. Through the onboarding and mentoring of
brilliant young associates, I was able to establish the need and formulate the
structure of learning that is required to move from single-tooth dentistry to
understanding how to plan comprehensively.
For allowing this book to become a reality, I would like to thank (again) my
brother Cameron and his wife Krissie for their unfailing support—from
Krissie for trusting me with her smile as my patient at Aesthetic Advantage in
New York in 2002, to both of you supporting me through the storms of being
a practice owner, educator and mother, while also encouraging me to keep an
eye on future opportunity.
Mark Ferber for giving me the encouragement, opportunity, discipline, and
late evenings of debate and constructive criticism! I could not have done it
without you. The Channel 3 community and Tommaso Albonetti, without
whom I would not have had the opportunity to put pen to paper. Thank you
for giving me a voice.
I would particularly like to thank Andrea Shepperson, who took the time to
read this book and send me comments from New Zealand. Your global
perspective on dentistry gave me the confidence to keep to my point! Celine
Higton, Sarah Fitzharris, and Kathy Frazar all added their feedback, and I
really appreciate the time and perspectives that they gave me.
Andrew Jameson and Richard Ella for your outstanding portrait photography
skills.
Steve Philip, Jennifer McKenzie, Janice Beckett, Robyn Allan, and Jillian
Melloy for being models to help with clinical explanations.
The unwavering support of my mother, Carol Philip—from my childhood to
my first days in practice, to checking my grammar and punctuation.
And to all the wonderful patients of Cherrybank Dental Spa, Perth, who have
trusted our team with their smiles and without whom this book could never
have been created, including Steve Philip, Sam Ferrier, Robyn Allan,
Amanda McGrillis, Stacy Munro, Sally Newton, Michael Smith, Julia
Merkin, and the many, many more.
Finally, my three children, Hamish, Heather, and Kirsty. Thank you for your
patience while I was writing, your enthusiasm to be models for the book, and
your words of perspective and encouragement at every stage. My three rocks!
THE A U THO R

Dr. Elaine Halley is originally from St. Andrews in Fife in Scotland and
has been practicing dentistry in her Perth, Scotland, practice for 26 years.
She graduated from the University of Edinburgh in 1992 and achieved
membership of the Royal College of General Dental Practitioners in 1995.
She traveled extensively for her education and completed the Masters
Level Certificate of Aesthetic Advantage at the Rosenthal Institute in New
York. She has completed further study in the US at the Dawson Institute,
studied under Newton Fahl in Brazil, and took many courses at IDEA in
San Francisco including with Pascal and Michel Magne.
Dr. Halley ran the UK division of Jameson Management, a US-based
practice management company, until 2007 and has experience with
consulting and analyzing dental practices as businesses.
She is a member of the American Academy of Cosmetic Dentistry and is a
director of the UK’s first Seattle Study Club, Pathfinder in Scotland.
She is a member and past president of the British Academy of Cosmetic
Dentistry and was the first accredited member in Scotland. She is also a
member of the International College of Dentists.
Dr. Halley has always been committed to post-graduate education and has
a master of science degree in Restorative and Aesthetic Dentistry with
distinction from the University of Manchester. She is a Digital Smile
Design Master and Key Opinion Leader for DSD by Christian Coachman.
She has always believed that everything around dentistry should be as
comfortable as possible for patients, so her focus has been on designing a
dental experience with customer care and comfort as a priority, combined
with the best use of technology and evidence-based healthcare provision --
an oral health/total health model of care.
She is an opinion Leader for several leading dental companies including
Ivoclar Vivadent, Optident, DMG, and Align technology, and she lectures
throughout the UK and Europe. She is one of Scotland’s most experienced
Invisalign practitioners and teaches other dentists how to work with the
system for tooth straightening through Aligner Consulting. She teaches
Digital Smile Design for Tipton Training and is a tutor and module leader
in Patient Assessment and Risk Management for the City of London Dental
School.
Dr. Halley is a board member for the UK Division of the global Digital
Dental Society and is a co-founder member of the European Academy of
Digital Dentistry.
Dr. Halley has an award-winning private practice, Cherrybank Dental Spa
in Perth, Scotland, that she opened in 1995 and is an accredited DSD
Clinic. Cherrybank is part of the Slow Dentistry Global network. She
opened a second practice in Edinburgh in 2010.
She is clinical director for the Pain Free Dental Group, a group of
practices across Scotland where her role includes mentoring other dentists
to improve their clinical and patient communication skills.
In 2018 Dr. Halley was awarded Outstanding Contribution to Dentistry at
the Dentistry Scotland Awards.