The Journey To

The Journey to
Excellence in Esthetic
Dentistry
Editors
YAIR Y. WHITEMAN
DAVID J. WAGNER
DENTAL CLINICS OF
NORTH AMERICA
www.dental.theclinics.com
October 2020 Volume 64 Number 4

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Contributors
Contributors
EDITORS
YAIR Y. WHITEMAN, DMD

Associate Clinical Professor, Director of Advanced Restorative and Esthetic Dentistry,
Division of Constitutive and Regenerative Science, UCLA School of Dentistry, Los
Angeles, California, USA
DAVID J. WAGNER, DDS

Private Practice, West Hollywood, California, USA; Clinical Lecturer, Advanced
Restorative and Esthetic Dentistry, Division of Constitutive and Regenerative Science,
UCLA School of Dentistry, Los Angeles, California
AUTHORS
PHIL BRISEBOIS, BA
Digital Specialist, UCLA Center for Esthetic Dentistry Lecturer, Founder NOVO Dental
Studios & GRAVIDEE
SIVAN FINKEL, DMD

Advanced Program for International Dentists in Esthetic Dentistry, New York University
College of Dentistry, The Dental Parlour, New York, New York
LAWRENCE FUNG, DDS

UCLA Center for Esthetic Dentistry Lecturer, Culver City, California
MARC HAYASHI, DMD, MBA

Health Sciences Assistant Clinical Professor, Section of Restorative Dentistry, UCLA
School of Dentistry, Los Angeles, California
JULIE LOGAN
Writing and Branding Consultant, Los Angeles, California
ALIREZA MOSHAVERINIA, DDS, MS, PhD, FACP

Assistant Professor, Diplomate, American Board of Prosthodontics, Division of Advanced
Prosthodontics, UCLA School of Dentistry, Los Angeles, California
PETER PIZZI, CDT, MDT

Advanced Program for International Dentists in Esthetic Dentistry, New York University
College of Dentistry, New York, New York; Pizzi Dental Studio, Staten Island, New York
KATHRYN PRESTON, DDS, MS

Assistant Clinical Professor, Section of Orthodontics, UCLA School of Dentistry, Los
Angeles, California
TODD R. SCHOENBAUM, DDS, MS

Clinical Professor, UCLA, Los Angeles, California
Contributors
PHONG TRAN CAO, DDS

Lecturer, University of California, Los Angeles, Los Angeles, California; Cosmetic Dentist
and Private Practice, 5 Star Dental, Las Vegas, Nevada
DAVID WAGNER, DDS

Private Practice, West Hollywood, California, USA; Clinical Lecturer, Advanced
Restorative and Esthetic Dentistry, Division of Constitutive and Regenerative Science,
UCLA School of Dentistry, Los Angeles, California
YAIR Y. WHITEMAN, DMD

Associate Clinical Professor, Director of Advanced Restorative and Esthetic Dentistry,
Division of Constitutive and Regenerative Science, UCLA School of Dentistry, Los
Angeles, California
The Journey to Excellence in Esthetic Dentistry
Contents
Preface: The Journey to Excellence in Esthetic Dentistry ix

Yair Y. Whiteman and David J. Wagner
Science, Materials, and Technology Update
Science in the Practice of Clinical Dentistry 609

Todd R. Schoenbaum
This article informs dental clinicians on the essential workings of scientific
research and statistical analyses. It provides clinicians with the essential
knowledge necessary to understand and review scientific work.
Review of the Modern Dental Ceramic Restorative Materials for Esthetic Dentistry in
the Minimally Invasive Age 621
Alireza Moshaverinia
Material selection is one of the most important decisions to be made by
clinicians. Proper material selection can affect the long-term function,
longevity, and esthetics of restorations. There are a large number of
restorative materials available, which has increased the complexity of
the decision-making process. Improper material selection can lead to
failures in the outcome. This article is designed to provide the practi-
tioner with up-to-date practical information on ceramic restorative mate-
rials and techniques in a clear, evidence-based, and unbiased manner. It
also provides decision-making guides to help the practitioner determine
the best ceramic material for various clinical scenarios.
Adhesive Dentistry: Understanding the Science and Achieving Clinical Success 633
Marc Hayashi
Successful adhesive dentistry begins with correct placement and poly-
merization of the bonding agent. Although numerous agents exist, all abide
by certain key principles, including the newest group, the universal adhe-
sives. Fundamental steps also exist in the application process that require
the operator to understand the chemistry of the adhesive being used. Mo-
dalities exist that can help preserve the durability of the bond achieved,
thus slowing down the degradation process. However, no material or
agent can overcome poor technique. Thus, it is of the utmost importance
that the practitioner respects the technique sensitivity of adhesives, and
follows the manufacturer’s instructions.
Implementing Digital Dentistry into Your Esthetic Dental Practice 645

Lawrence Fung and Phil Brisebois
The use of digital dentistry is on the increase as costs to acquire digital
technology have gone down dramatically and allowed for more practi-
tioners to integrate digital equipment with reduced investment. One of
vi Contents
the most significant benefits of digital technology in dentistry is the

ability to streamline processes that can be cumbersome via the analog
way. In digital dentistry, it is important to understand the advantages
and disadvantages of each device or system available.
The Use of Botulinum Toxin and Dermal Fillers to Enhance Patients’ Perceived
Attractiveness: Implications for the Future of Aesthetic Dentistry 659
Phong Tran Cao
Physical appearance and attractiveness consciously and subconsciously,
affect patients’ quality of life. Traditionally, dentists were tasked with
improving a patient’s smile, a central aspect of facial aesthetics and phys-
ical appearance. More recently, as the scope of practice of the aesthetic
dentist has broadened to potentially include other components of facial
cosmesis that go hand-in-hand with a patient’s smile, new options have
emerged with which modern aesthetic dentists should familiarize them-
selves. As laws surrounding their use in dental offices continue to evolve,
Botox and dermal fillers represent natural next steps in aesthetic dentistry.
Team Collaboration and Communication
A Beginning Guide for Dental Photography: A Simplified Introduction for Esthetic

Dentistry 669
David J. Wagner
Photography is one of the most important skills dentists need to master in
order to perform esthetic dentistry at a high level. Today, digital single-lens
reflex cameras are commonplace. Young dentists have grown up with
Internet, smartphones, and online platforms exposing them, and their pa-
tients, to cases that other dentists have shared, increasing the awareness
and popularity of esthetic-focused treatment. This article provides readers
with a simplified and attainable approach to begin the dental photography
journey, as well as increase skill level, depending on practice style and
desired investment.
Dentist-Ceramist Communication: Protocols for an Effective Esthetic Team 697

Sivan Finkel and Peter Pizzi
No matter how skilled and well trained esthetic dentists or technicians may
be, they cannot deliver results without a proper partnership. Close
ceramist-clinician communication is a critical component of successful
esthetic dentistry. In order to design an esthetic vision, convey this vision
to the patient, and then execute the vision successfully, there must be
effective communication between the ceramist, the clinician, and (most
importantly) the patient. This article highlights some of the authors’ philos-
ophies, as well as an overview of the key communication protocols that
have proved effective for this team.
A Communication Guide for Orthodontic-Restorative Collaborations: An

Orthodontic Perspective on the Importance of Working in a Team 709
Kathryn Preston
As both restorative dentists and specialists have their respective realms of
expertise, it is important to develop a team of qualified providers to
Contents vii
improve treatment outcomes for patients. In many cases, this involves

collaboration between a restorative dentist and orthodontist. Effective
communication is critical, with the dentist’s understanding of basic ortho-
dontic terminology and case planning considerations. Recognizing the
context in which to apply normative occlusal and cephalometric values
often necessitates comprehensive specialty-level experience. All pro-
viders should recognize when to involve the indicated team members
when complex multidisciplinary treatment needs are present. The team
approach offers an opportunity to optimize excellent patient care.
A Communication Guide for Orthodontic-Restorative Collaborations: Digital Smile

Design Outline Tool 719
Yair Y. Whiteman
Ideally, Orthodontic-Restorative cases are planned alongside from the
beginning, however, in some instances the restorative dentist encounters
the patient for esthetic evaluation near the end of orthodontic phase. This
is a high-stakes evaluation because the decision to remove brackets im-
plies that refinement of tooth positioning cannot occur unless the patient
re-enters orthodontic treatment. One challenge in multidisciplinary treat-
ment is accommodating effective communication between providers
and employing Digital Smile Design outline tool as a visual aid can help
optimizing treatment outcome. This article discusses the importance and
steps utilizing digital outline tool to provide quick and effective communi-
cation on treatment progress and recommendations.
Business Professional Focus
Branding Dynamics for the Esthetic Dentist: Building Your Brand to Build Your
Practice 731
David J. Wagner and Julie Logan
The objective of this article is to introduce the concept of branding to den-
tists interested in implementing elective esthetic treatment into their prac-
tice. For many, this will serve as an introduction to begin; for others, it can
provide a road map for revising and reinforcing a branding program
already in place.
viii The Journey to Excellence in Esthetic Dentistry
DENTAL CLINICS OF NORTH AMERICA
FORTHCOMING ISSUES RECENT ISSUES

January 2021 July 2020
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April 2021
Geriatric Dental Medicine April 2020
Joseph M. Calabrese and Michelle Surgical and Medical Management of
Henshaw, Editors Common Oral Problems
Harry Dym, Editor
July 2021
Radiographic Interpretation for the Dentist January 2020
Mel Mupparapu, Editor Oral Diseases for the General Dentist
Arvind Babu Rajendra Santosh and
Orrett E. Ogle, Editors
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The Journey to Excellence in Esthetic Dentistry
Preface
The Journey to Excellence in
Esthetic Dentistry
Yair Y. Whiteman, DMD David J. Wagner, DDS

Editors
Our ability to provide patients with the most up-to-date treatment options, materials,
treatment modalities, and evidence-based decision making requires a culture of
continuous learning, collaborative teamwork, and exceptional focus. In his influential
work, Outliers, Malcolm Gladwell claims that an average of 10,000 hours is required
for a person to become an expert in a certain field. In dentistry, a considerable amount
of time outside of “normal work hours” is necessary in order to develop skills to
become an expert. This is not only where dentistry becomes a vocation, but also
how we can differentiate ourselves and how we can reach and maintain satisfying
and fulfilling careers.
Though dental school strives to provide students with as much in-depth knowledge
and experience as possible, due to lack of time, only a foundational level of education
can be achieved. As a result of continuous advancements in material science, tech-
niques, dental research, and integration of digital technology, there has been a tremen-
dous increase in teaching requirements and need for curriculum transformation in
recent years. Consequently, dental schools may only have the bandwidth to concen-
trate on procedural-teaching and single-tooth dentistry. Therefore, upon graduation,
when a dentist aims to practice at the highest level, they must continuously elevate
their skills not only to match the latest standards of care but also to improve their ability
to provide exceptional dental care beyond what is normally expected.
In this series of articles, we focus on a journey to excellence in esthetic restorative
dentistry and aim to provide a roadmap for clinicians who wish to develop clinical skills
and elevate the scope and status of their dental practices. We emphasize not only that
at the core of this area of dental care is one’s ability to technically perform treatment
but also it is equally as important to attract patients, build relationships, and commu-
nicate the value of treatment. Finally, the series of articles is designed to include
Dent Clin N Am 64 (2020) ix–xi

https://doi.org/10.1016/j.cden.2020.07.004 dental.theclinics.com
0011-8532/20/ª 2020 Published by Elsevier Inc.
x Preface
checklists and practical reference guides that can be used while working clinically or
when developing the business and team of one’s practice.
To achieve a higher level of competence, dentists must pursue continuing education
that is taught by ethically responsible experts rooted in sound, unbiased information.
Dentists should seek out upper-echelon dental academy meetings and surround
themselves with like-minded people, building lasting professional relationships with
mentorship dynamics. Evidence-based scientific data must be critically evaluated
and assessed when making decisions. To start, Dr Todd R. Schoenbaum provides
a detailed guide for reading and evaluating scientific literature.
Materials and bonding techniques must be thoroughly understood in order to
execute a minimally invasive modern style of dentistry. An update of current materials
and bonding techniques is reviewed by Dr Alireza Moshaverinia and Dr Marc Hayashi.
In today’s dental landscape, digital technology is increasingly becoming a viable and
alternative method to traditional analog workflows. Dr Lawrence Fung and digital lab
innovator Mr Phil Brisebois discuss digital technology and its place and integration in
the dental practice. Adjunctive services, such as injectables, have been a complemen-
tary component of the esthetic dental landscape for some time. There is a major po-
sition for their place within the scope of treatment, and patient’s outcomes can be
enhanced, creating an even greater value and awareness for the life-changing treat-
ment that esthetic dentists can provide, as outlined by Dr Phong Tran Cao.
Team collaboration and communication are imperative to a dentist’s success when
performing restorative esthetic treatment. Photography is a tool used to help achieve
seamless communication among the dental team as well as with patients. A begin-
ner’s guide to dental photography along with a clinical reference manual is provided
by Dr David J. Wagner. It is known that dental esthetic treatment results hinge on
the skill set of both restorative dentist and ceramist. Developing a world-class
dentist-ceramist partnership is discussed by Dr Sivan Finkel and master ceramist
Mr Peter Pizzi.
The role that specialists play is invaluable when properly executing minimally inva-
sive esthetic treatment. The goal should always be to preserve as much natural tooth
structure in order to accomplish the best outcome for the patient. An understanding of
what is possible with various specialty points of view is therefore necessary for restor-
ative dentists. Proper communication with all specialist types is imperative.
Specifically, orthodontists play a significant role within the scope of minimally invasive
treatment. Getting teeth in the proper position results in the need to reduce less tooth
structure to obtain beautiful, lasting outcomes. The paired articles by orthodontist Dr
Kathryn Preston and prosthodontist Dr Yair Y. Whiteman help to introduce these con-
cepts and display a high-level communication style to allow seamless treatment inte-
gration among patient, restorative, and specialist.
Last, it is within the private practice sector that a dentist tends to find his or her pro-
fessional life butterflied most, wearing multiple hats as a health care provider, a small
business owner, a manager of people and the lead decision maker influencing the suc-
cess of a dental practice enterprise. As we become clinicians choosing to elevate our
practices, skills, patient experience, and ultimately help to change the lives of our pa-
tients by providing the highest level of dentistry that is possible, we need to be able to
communicate to patients what this means. Branding is a mechanism that allows this
communication to occur on many levels. To develop a brand for a dental practice in
parallel with an elevated set of clinical skills can catapult a dental practice and patient
experience to new heights and help to create a legacy of excellence in a world of
average. Branding for the esthetic dentist is outlined by Dr David J. Wagner and Ms
Julie Logan, a branding specialist based in Los Angeles, California.
Preface xi
We hope you find this series of articles helpful at whatever point you are in the
journey to esthetic excellence. We too are on this lifelong journey and continue to
seek advancement, always aiming to improve, acquire new skills and perspective,
build professional relationships, and learn something new every day.
Yair Y. Whiteman, DMD

Division of Constitutive and
Regenerative Science
UCLA School of Dentistry
10833 Le-Conte Avenue
Room 33-064A CHS
Los Angeles, CA 90095-1668, USA
David J. Wagner, DDS
8733 Beverly Boulevard
Suite 202
West Hollywood, CA 90048, USA
E-mail addresses:
[email protected] (Y.Y. Whiteman)
[email protected] (D.J. Wagner)
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Science in the Practice of
Clinical Dentistry
Todd R. Schoenbaum, DDS, MS
KEYWORDS
Biostatistics Clinical dentistry Science
KEY POINTS
Comprehend study design and its impact on research quality and meaning.
Learn essential biostatistical tests and analyses.
Understand what is meant by statistical significance and its relation to clinical
significance.
THE RATIONALE AND CHALLENGES OF IMPLEMENTING SCIENTIFIC DATA INTO

CLINICAL PRACTICE
Extensive amounts of time and energy are spent by clinicians learning how to be the
most proficient operators they can be, learning how to execute treatment at increas-
ingly exceptional levels. They know that their skills, materials, techniques, diagnostic
abilities, and treatment planning abilities ultimately determine how successful they are
in addressing the needs and desires of their patients.
Clinical decision making is a complex skill. It requires the synthesis of hundreds of
questions for every decision: material selection, preparation design, implant locations,
and so forth. Some of these complex decisions are made out of habit or tradition,
where clinicians rely (not necessarily incorrectly) on their mentors, previous suc-
cesses, and training. Ultimately, clinicians must continue to evaluate and adapt and
learn and move forward in producing improved results. Clinicians must strive to be
perpetual students, to continually endeavor to improve their skills and knowledge.
These improvements might be in longevity, aesthetics, ease of use, patient comfort,
patient health, duration of treatment, economics, or consistency.
When making any clinical decision, there are 4 areas to take into consideration:
1. Patient desires (ie, finances, time constraints, aesthetics)
2. Clinical evaluation (ie, bone volume, American Society of Anesthesiologists classi-
fication, functional loads)
3. Unique clinical experience (eg, “We have been very successful immediately loading
implants in our practice”)
UCLA, 10833 Le Conte Avenue, CHS, Room B3-034, Los Angeles, CA 90095, USA
E-mail address: [email protected]
Dent Clin N Am 64 (2020) 609–619

0011-8532/20/ª 2020 Elsevier Inc. All rights reserved.
610 Schoenbaum
4. Scientific evidence (ie, most systematic reviews show little increase in risk for im-
mediate load implant protocols when carefully selected and skillfully executed)
None of these 4 areas should be neglected, although at times clinicians may find
that the strength of one outweighs another. Their patients will be best served, and their
outcomes improved, when clinicians successfully incorporate as much information as
possible from each area. Scientific studies are not the be-all and end-all of clinical de-
cision making. It represents only a piece. Clinicians’ anecdotal experiences should
carry weight in the decision-making process. Conflicts arise between what clinicians
have seen to be true, in their hands, and the scientific literature. The potential reasons
for this may include differences in patient populations, differences in surgical
approach, differences in implant systems, and differences in the skill of technicians.
Individual clinicians develop standard operating procedures based on the unique sit-
uation but efforts should be made to increase the understanding of when alternative
materials and techniques should be implemented for a given clinical scenario. Exper-
tise is built on accurate answers to hundreds of questions from all 4 areas in every clin-
ical decision that clinicians make.
However, this article is about the science part of this process. The other 3 areas are
not addressed here but should in no way be neglected. Properly interpreted and un-
derstood, scientific evidence can significantly improve results. Scientific studies give
insight into the expected success rates of a new material, complications that can be
expected with a particular treatment protocol, or which patients might be at increased
risk for failures.
There are a few requirements, though: the science must be sound, the analysis
appropriate, the question answered relevant, and the interpretation cautious. The
job of clinicians is not to determine whether the science was sound or whether the sta-
tistical analysis was appropriate. That is the job of biostatisticians, editors, and re-
viewers. The job of clinicians is to determine whether the study question being
answered is relevant to the current bigger clinical question. Clinicians must also deter-
mine whether the interpretation of the study is correct. It is all too common in the sci-
entific literature to see conclusion statements woefully undersupported or even
countered by the data in the study.
A Hypothetical Vignette
Imagine that a new 1-piece implant has come to market with US Food and Drug
Administration (FDA) approval. Clinicians are interested in switching over to it for
most of their implants and the patients are asking for it, but will it work? This is not
a binary question, and perhaps there will be indications where it will and will not prove
sufficiently successful. There is no objective threshold for success. What one clinician
might classify as successful might be intolerable to another. At any rate, clinicians are
considering surgically implanting this new device into a vast number of their patients
and results matter.
The clinicians ask a manufacturer representative to come by the office. They are
shown a bar graph from an osseointegration study published in a reputable journal,
and the new implant’s bar is the tallest. It has superior bone to implant contact
compared with the control, and in another study, this one testing dry static axial
load to failure, the new implant’s number is the biggest and there is a P value of
.02. Then there is a quote from a supposedly famous dentist: she loves the new
implant and so do her patients.
So far, everything looks promising and the clinicians decide to switch over to the
new implant. For 12 months, many of the implants placed in the practice are the
new implant; hundreds of them. The patients are happy, and the referrals are flowing
in, but then the failures begin to show up. Slowly at first, then en masse. Peri-
implantitis, prostheses repeatedly debonding, abutments fracturing. It seems that
osseointegration and dry static axial load to failure are not the only factors that the cli-
nicians should have considered before aggressively incorporating this material.
Looking back, the clinicians wonder how this implant got through the FDA clearance
process. Without going into the granular details of the process, suffice to say that
dental devices are generally FDA approved without need for extensive testing of safety
and efficacy. In general, it is done by claiming (to the FDA) that the new device or ma-
terial is largely similar to previously approved devices. So what did the clinicians miss
in their cursory evaluation of this implant and what should they have done differently?
Assuming the 2 studies they flipped through were properly performed and analyzed,
the osseointegration and dry static axial load of the implant are as good as or superior
to the current implants. However, those are only 2 of the hundreds of questions clini-
cians should be asking about whether or not this implant is viable. This implant is 1
piece, so why are none of the other implants clinicians use of this design? What are
the clinical challenges of this design? Are the results of a dry static axial load test really
correlated with how implants are treated in the oral environment? Is there a better way
clinicians should test load to failure? Was the famous dentist raving about this implant
vested in the manufacturer?
I am proposing that, in this scenario and hundreds of others like it, clinicians will be
better able to identify and avoid potential problems if they have an understanding of
the literature. Science cannot avoid all problems in clinical dentistry, but I hope that
this article helps provide a start on a journey of better understanding of the scientific
literature that clinicians rely on (directly or indirectly) to make clinical judgements. A
proficient understanding of the science and literature will not occur immediately. It
takes time and effort. As a starting point, I suggest that clinicians make a habit of
finding a reputable, scientifically based, clinically oriented journal in their area of focus
and read through it on a regular basis. This habit will increase familiarity and comfort
with how studies are performed, analyzed, and interpreted. The learning curve may be
steep at first. Ignore studies that are of no interest. Read through the others with the
understanding that it is not necessary to grasp every aspect of what is presented. With
time, a greater level of comfort and confidence will develop and I believe the reader will
become significantly more empowered to make strong, science-backed decisions.
TYPES OF STUDIES AND THEIR VALUE IN CLINICAL PRACTICE
Most clinicians have seen something like the hierarchy of evidence pyramid (Fig. 1). A
few things about this: it is not universally agreed on and various disciplines in medicine
and dentistry have variations they lean on (more than 80 such hierarchies have been
published). Epidemiology uses a vry different hierarchy than orthopedic surgery for
example. Nor does the pyramid mean that any conclusion from an upper level is al-
ways more correct than a conclusion from a lower level. Table 1 provides a brief
explanation of the various types of studies and their use in clinical dentistry.
The hierarchy is not a strict ranking of what study is right or wrong when conflicting
information arises. There are poorly done (and published) systematic reviews, and
there are well-informed experts. Experts are often right (that is why they are experts),
but the potential for bias is high. Objective and forthright experts are easily identified
and develop a reputation for minimizing and acknowledging their biases. For busy cli-
nicians, these unbiased experts are immensely valuable resources. In contrast, sys-
tematic reviews and randomized controlled trials (RCTs) can be wrong, or poorly
612 Schoenbaum
Fig. 1. A hierarchy of evidence for clinical dental research. This hierarchy is best understood
as a risk for bias pyramid, not a hierarchy of truth. The higher levels of evidence are more
likely to be correct, but they are not implicitly superior. Sys, systematic.
done, or grossly overinterpreted, although they are less likely to be wrong because of
biases. The hierarchy is best understood to represent the potential for biases affecting
the resulting recommendations, so perhaps a reliability pyramid is a better term for
them. Every study has inherent biases. The best studies recognize this, apply analyt-
ical and study design techniques to mitigate them, and acknowledge how they may
have affected the results and conclusions.
In brief, a systematic review (preferably with a meta-analysis) attempts to answer a
question (eg, do screw-retained implant crowns survive longer than cemented implant
crowns?) by aggregating, synthesizing, and analyzing all relevant published studies.
Clinicians might consider it an expert-level book report. It is an attempt to analyze
the existing data in a meaningful way. This approach only works if there are sufficient
studies on a given topic, and its resultant quality depends on the quality of the included
studies. The systematic review is a report on the current preponderance of evidence,
which is the metric by which clinical decisions are best made.
Anecdotally, it seems there has been a strong trend in clinical dentistry to publish
and cite (formally or casually) systematic reviews. Although I appreciate the enthu-
siasm for increased levels of evidence, clinicians need to think about systematic re-
views for a moment.
Systematic reviews should be performed by a group of experts knowledgeable in the
field. Such undertakings require deep understanding of the problem at hand, which
questions need to be asked, which studies should be included, and how to properly
interpret the results. Such tasks are not best performed in the early stages of a career.
Not all systematic reviews are created equal, and in clinical dentistry this is espe-
cially true. Table 1 shows that the position of systematic reviews in the hierarchy de-
pends on the types (and quality) of the studies analyzed. Systematic reviews built on
less rigorous studies are not at the top of the pyramid.
Table 1
Levels of evidence for clinical treatment disciplines
Study Design What It Is Relevance to Clinical Dentistry

Systematic reviews An expert synthesis of the best This is the highest level of
of homogenous available interventions on a evidence. However, rarely seen
RCTs particular topic in clinical disciplines because of
the sparsity of strong RCTs
Strong RCTs A random, controlled, blinded Rare in any surgical discipline
trial. The only way to (especially clinical dentistry).
establish cause and effect Best available new evidence
Systematic review An expert synthesis of the best Good for summarizing risk factors
of cohort studies available observational associated with an outcome
studies
Individual cohort A high-level observational In general, a tool used less in
studies study. No treatment is clinical dentistry and more in the
performed on patients as public health disciplines and
part of the study epidemiology
Systematic review An expert synthesis of the best Not common in clinical dentistry
of case control available research for risk
studies factors for rare outcomes
Case control A cross-sectional study used to An efficient way to identify risks
studies identify risk factors for rare for diseases not often seen
outcomes
Case series A series of cases showing Useful in seeing what might be
proof of concept. Not proof possible by experts. Useful for
of expected results or exploring new techniques or
expected complications materials. Interpret cautiously
Expert opinion A well-regarded individual’s or Efficient and practical method for
group’s opinion on a topic. finding information. High risk
Reliability and accuracy potential for bias
depend on the veracity and
knowledge of the expert
However, in clinical dentistry (and in surgical medical fields), clinicians have a prob-
lem: the best novel evidence is a sufficiently powered RCT (Fig. 2) with narrow varia-
tion in the results. High-quality RCTs are expensive to execute and require strong
management, oversight, and analysis. Randomizing patients into control or placebo
groups in clinical treatment produces ethical and practical challenges (is anyone inter-
ested in a placebo surgery?). Blinding of patients, operators, and evaluators is nearly
impossible for obvious reasons. In addition, even when such challenges are
addressed, recruitment of sufficient numbers of participants commonly proves prob-
lematic. As a result, there are not enough RCTs of any quality in clinical dentistry,
Fig. 2. Randomized clinical trial design.

614 Schoenbaum
let alone high-quality RCTs. Much of what is commonly published in the dental litera-
ture as RCTs are often better classified as clinical trials because of a lack of true
randomization, controls, and blinding. A clinical trial is essentially a large, more
rigorous case series with quantified analysis.
There are various methodological approaches to creating a systematic review.
Among the most well regarded is the Cochrane Review. The rigor of the Cochrane
approach synthesizes the appropriate studies into concise and reliable results. Only
high-quality studies are included in such reviews. However, clinical dental research
is not well funded, and clinicians do not see many high-quality clinical studies for
any given question. As a result, a highly rigorous Cochrane Review for a given clinical
dental technique or device often produces conclusions such as, “The quality of the ev-
idence is assessed as very low due to high and unclear risk of bias of primary studies
and there is some evidence of reporting bias so clinicians should treat these findings
with caution.”1 Although honest, this is not very useful when clinicians are looking for
scientific guidance to treat their patients. The high rigor of the Cochrane Reviews often
leaves practitioners in clinical dentistry without much guidance.
As such, many systematic reviews published in clinical dentistry do not adhere to
the Cochrane guidelines and use other, less restrictive frameworks in order to find
something useful to say about the evidence. This approach produces more clinically
relevant information but with a higher risk for errors and bias. Imagine a systematic re-
view with strong conclusion and recommendation statements finding that immediate
loading of implants is highly successful. On the surface, this seems to be a high-level
recommendation about what success rates can be expected with this procedure.
However, what if the systematic review was built on 4 small case series, 2 of which
were from 1 author, and all of which were performed by experts? It is easy to see
how such conclusions might be biased toward results that will not prove generalizable.
Cohort studies are nonintervention studies; they are observational exclusively. This
term is commonly misused in published titles in dentistry. They are not useful for deter-
mining what techniques or materials perform better. They are used to see how risk fac-
tors affect an outcome. For example, Raes and colleagues2 studied 2 groups of
implant patients over time: smokers and nonsmokers. The primary outcome being
evaluated was papilla regeneration, for which the smoking group was at significantly
greater risk to not regenerate papilla.
Case control studies are also strictly observational. They are designed to find asso-
ciated risk factors for a rare outcome. The resulting odds ratio indicates the odds of a
patient with the risk factor developing the disease outcome. For example, Becker and
colleagues3 studied the effect of osteoporosis on the odds of having an implant failure.
This exploratory study was unable to find any association between osteoporosis and
implant failure. This finding does not mean that there is no real association. There may
be, but perhaps it is too small to see with this sample size, or perhaps there is too
much variation. These issues are discussed later. The results of observational studies
are correlation only and do not prove causation, but they may hint at it.
The case series and case study mostly commonly reside near the bottom of every
hierarchy of evidence, but why then are they so frequently published in many high-
level clinical dental journals? As a procedural discipline, clinical dentistry relies heavily
on advancement in techniques and protocols to improve outcomes. Such develop-
ments are difficult or impossible to test in RCTs and observational studies. Case series
and case studies come in various levels of rigor and reliability. At the most rigorous
end, the case series is designed with a primary outcome measurement (eg, number
of prosthetic complications with angled screw channels). The next (n) number of par-
ticipants (n) is determined in advance, along with strict inclusion/exclusion criteria. The
next (n) number of patients to present to the clinics, willing to participate, and meeting
the inclusion criteria are included in the study. The outcome (complications) is tracked
for each and the results analyzed. There is no control or alternative group with which
they will be compared. Where appropriate, the results can be cautiously compared
with values obtained from other studies (historical control). If performed and reported
honestly, the rigorous case series can provide ideas about short-term or intraoperative
complications and results.
The case study (sometimes called a clinical report) is similar to the case series
but much less rigorous. The case study is simply a qualitative presentation of 1
to several similar cases (sometimes mistakenly published with “case series” in
the title to appear more rigorous). The included cases are selected solely by the in-
vestigators (beware of selection bias). There are no comparisons to be made and
there is no accounting for how these patients were selected and others not. In gen-
eral, a case study (or weak case series) is best regarded as the best of what is
possible by the author. The results may not be generalizable to other clinicians
or patient populations, nor may they be predictable. It could be imagined that a
clinician performed the same procedure hundreds of times with mediocre results,
but in a few instances the outcomes were outstanding. Only those few outstanding
cases make the article, and no analysis is performed to see what the normal results
were and how divergent the outcomes may have been. The case study is a proof-
of-concept study, a sample of what might be possible. For example, Schoenbaum
and colleagues4 showed resolution of peri-implant gingival recession by the use of
an interim restoration. This approach is proof only of what is possible and may not
indicate what is common.
INTRODUCTION TO BIOSTATISTICS
In the remainder of this article, the intention is not to turn readers into biostatisticians,
nor would they even be interested. It is the job of the journals, and their review teams,
to ensure that the proper study design and analyses were performed. The better the
journal, the more rigorous they are about this process. Nor does this article explain
how a trial should be set up or which tests should or should not be performed. How-
ever, it may help clinicians become better consumers (and critics) of the published
dental literature.
Bias
In particular, this article focuses on publication bias. By the time an article is published,
a bias in selection has been made at several different levels: demographics of patients
seeking this treatment, clinicians so proficient they intend to publish their results,
cases worthy of publication, results the author wants to publish, and results the editor
wants in the journal. Each of these biases contributes to published results that gener-
ally do not indicate what might happen on average. For example, it could easily be
imagined that investigators and editors would have little interest in publishing a study
looking for (and failing to detect) a correlation between selective serotonin reuptake
inhibitors (SSRIs) and implant failure. It is not very interesting to report that here is
yet another factor that has no effect on failure. Imagine 30 such studies were per-
formed. If the threshold for significance is P<.05, it should be expected that, through
nothing but chance alone, at least 1 of those studies would find a “significant” corre-
lation between SSRIs and implant failure. This study is the one that will be published.
The data from the other 29 will not. This situation is analogous to the multiple testing
error in statistics, but on a metascale secondary to publication bias.5
616 Schoenbaum
Statistical Significance or Clinical Significance

When skimming an article, clinicians often look for the results table and look for the
variables that have an asterisk or boldface indicating P<.05. They conclude that this
variable is important and the others are not. The late Paulo Vigolo6 published an
excellent 10-year RCT examining whether splinting adjacent implant restorations
in the posterior maxilla maintains better bone levels than nonsplinted restorations
(the controls). At the 10-year follow-up of 114 implant restorations, he found a sta-
tistically significant difference in bone levels between splinted and nonsplinted
groups. The splinted restoration design preserved “significantly” more bone
(P 5 .0042) than the nonsplinted group. If the discussion was stopped there, the un-
derstanding of this study would lead to the conclusion that restorations should be
splinted in an effort to preserve peri-implant bone. A closer analysis reveals that,
although the effect is present, it might hardly be considered a strong enough effect
to suggest splinting for this reason. The effect at 10 years was that splinted restora-
tions preserved 0.1 mm more bone. As Dr Vigolo wisely noted in this article: “A sig-
nificant difference in bone loss was seen between the two groups. However, the
difference of 0.1 mm [at 10 years] was not considered clinically meaningful.”6 Statis-
tical significance does not equal clinical significance. Statistical significance (ie,
P<.05) indicates that an effect is likely present, but clinical significance indicates
whether it is relevant.
Forest Plots
One of the most reliable and efficient ways to find strong scientific evidence for clinical
questions is a well-done systematic review with a meta-analysis. The output of the
meta-analysis is called a forest plot, which is a summary graphic of results of all
studies included in the review. The ability to quickly interpret a forest plot is essential
to quickly getting an overall look at the data for the question at hand. When a compar-
ison is being made between 2 groups (eg, cement-retained crowns and screw-
retained crowns; Fig. 3), the vertical bar in the middle represents the line of no
difference between groups. The purple squares represent the weight allotted to the
study (usually from sample size). The horizontal lines (usually) represent the 95%
Fig. 3. Forest plot comparison of studies evaluating survival rates of implants. The size of the
purple square reflects its weight in the analysis; green diamond is the overall results of the
meta-analysis. CI, confidence interval. (From Lemos CA, de Souza Batista VE, de Faria Al-
meida DA, et al. Evaluation of cement-retained versus screw-retained implant-supported
restorations for marginal bone loss: A systematic review and meta-analysis. J Prosth Dent.
2016;115:424; with permission.)
confidence interval (CI) of that study. Shorter horizontal bars indicate greater precision
or consistency in the results. The green diamond at the bottom is the overall effect
estimated based on the included studies. The example from Lemos and colleagues7
(see Fig. 3) indicates that cemented restorations show a significant (and clinically sig-
nificant) reduction in peri-implant bone loss. However, as with many clinical dental
meta-analyses, the CIs for each study are huge and most studies have small sample
sizes.7 Most of the results of this particular analysis are skewed by the result from 1
study8, which had many more participants than any other. Interpretation of such
data should be cautious.
Interpreting Graphs
When reviewing graphs in the literature (and especially in product marketing), special
attention should be given to the units and the scale of the graphs. Is the scale in 1-mm
increments or 0.1 mm? Does the scale start at 0 or some number to emphasize effect?
Fig. 4 shows the same hypothetical data presented with 2 different scales. One im-
plies a huge difference between groups, whereas the other minimizes this impression.
There is no right or wrong way to display the data, except that it should be done with
an honest intent to show the results.
Confidence Intervals
CIs represent a key method to show the precision of a measurement. If continuous
data are used (ie, numeric value measurements), the mean is only part of what clini-
cians should want to know. The precision of the values that provide that mean is
also important. It is an oversimplification, but the 95% CI is best understood to
mean that there is a 95% chance that the true mean for the group lies within this range.
Samples that have more consistent results have a narrower CI for the group. For
example, if there are 2 types of implants both with a mean implant stability quotient
(ISQ) at an insertion of 72, they might be imagined to be comparable. However,
what if group A had all values between 68 and 76, whereas group B had values spread
between 55 and 80? Group A clearly has much greater consistency and predictability
for ISQ compared with group B. This dataset could be presented as:
Fig. 4. A hypothetical example comparing 4 groups of bone graft materials. The data are
the same in both groups. Alteration of the y-axis scale produces very different impressions
about the differences between groups.
618 Schoenbaum
Mean ISQ (95% CI)

Group A 5 72 (70–74)
Group B 5 72 (61–75)
Power and Sample Size

Unfortunately, clinically relevant dental research is woefully underfunded. This situa-
tion is not likely to change anytime soon. Therefore, clinicians must often to try to un-
derstand what to expect clinically from limited or highly variable data. It is an
unfortunate reality for the profession.
The sample sizes are often too small. There is no preset number of samples that makes
a study useful (eg, n 5 10 or n 5 100). The size of the sample needed depends on the dif-
ference that is expected to be seen between groups, the variability within groups, and the
precision desired. A nondental example: imagine investigators want to determine the true
difference in mean mass between golden retrievers and Labradors. There is probably a
difference, but previous data have shown that it is not much, maybe 1 kg. A large number
of dogs (maybe 1000) will be needed from each breed to find a statistically significant dif-
ference. If instead investigators want to find whether there is a difference in weights be-
tween house cats and bull mastiffs, they would need very few from each group to find a
statistically significant difference (maybe n 5 5).
If investigators intend to find a difference between groups, they need a sufficient
number of samples for each group, and that number depends on the expected size
of the difference. To see small differences, large sample sizes are needed, whereas
large differences require much smaller samples sizes. This idea is an important part
of power calculations. Power is the chance that a difference can be seen between
groups (based on an estimate of the means, variability, and sample size). The biosta-
tistical norm is to use 80% as the power threshold, meaning that there will be an 80%
chance to see a difference, and a 20% chance of not being able to see the difference
even when there is a difference. Power analyses are generally used to determine the
number of samples needed in each group. If there are too few samples, the study is
underpowered. There is an increased likelihood that no statistically significant differ-
ence will be seen between the groups, even though there really is a difference.
Overinterpretation
Clinicians must synthesize the results of multiple questions and concerns for every de-
cision they make. One part of that process is the scientific data with which they are
familiar. The more informed clinicians are in a discipline, the better the decisions will
be. As clinicians begin their journey of incorporating science into their practices,
they must keep in mind that each study is only a piece of the overall puzzle. A single
study is not conclusive evidence. It is but 1 piece, of a mountain of data, answering
only 1 question. Each decision requires answers to multiple questions, and each ques-
tion has dozens (it is hoped) of studies attempting to provide answers. There will be
conflicting data. There will be questions that have superior results for group A, and
other questions that will have superior results for group B. Part of being (or becoming)
the best that clinicians can be is understanding those differences and making the
appropriate choices given conflicting information. Do not look at a single study and as-
sume its results represent the definitive answer to that single question, and certainly
not to all the questions that clinicians must answer.
I would also like to briefly explain the difference between efficacy and effectiveness.
When studies are performed by experts, in highly controlled environments, with care-
fully selected and informed patients, the results are in the category of efficacy. When
clinicians treat patients in busy clinical practices, with patients that are not as carefully
selected, informed, or controlled, this is in the category of effectiveness. The compli-

cations, and success rates, of these 2 environments are very different. Do not assume
that the results obtained in a published study de facto represent what clinicians see in
clinical practice. Efficacy represents the best of what might be possible given every
factor is tuned to the highest levels.
SUMMARY
Exceptional clinicians rely on the best available evidence. The data in clinical dentistry
are sometimes insufficient and flawed. However, some data are better than no data.
The better prepared clinicians are to understand the science and see the benefits
and limitations, the better prepared they are for improving the quality of care. Those
who are striving toward excellence must insist on scientific data, and should them-
selves be working to contribute.
DISCLOSURE
The author has nothing to disclose.
REFERENCES
1. Esposito M, Grusovin MG, Maghaireh H, et al. Interventions for replacing missing

teeth: different times for loading dental implants. Cochrane Database Syst Rev
2013;(3):CD003878.
2. Raes S, Rocci A, Raes F, et al. A prospective cohort study on the impact of smok-
ing on soft tissue alterations around single implants. Clin Oral Implants Res 2015;
26(9):1086–90.
3. Becker W, Hujoel PP, Becker BE, et al. Osteoporosis and implant failure: an explor-
atory case-control study. J Periodontol 2000;71:625–31.
4. Schoenbaum TR, Solnit GS, Alawie S, et al. Treatment of peri-implant recession
with a screw-retained, interim implant restoration: A clinical report. J Prosthet
Dent 2019;121:212–6.
5. Ioannidis JP. Why most discovered true associations are inflated. J Epidemiol
2008;19:640–8.
6. Vigolo P, Mutinelli S, Zaccaria M, et al. Clinical evaluation of marginal bone level change
around multiple adjacent implants restored with splinted and nonsplinted restorations:
a 10-year randomized controlled trial. Int J Oral Maxillofac Implants 2015;30:411–8.
7. Lemos CA, de Souza Batista VE, de Faria Almeida DA, et al. Evaluation of cement-
retained versus screw-retained implant-supported restorations for marginal bone
loss: A systematic review and meta-analysis. J Prosthet Dent 2016;115:419–27.
8. Fugazzotto PA, Vlassis J, Butler B. ITI implant use in private practice: clinical re-
sults with 5,526 implants followed up to 721 months in function. Int J Oral Maxil-
lofac Implants 2004;19(3):408–12.
FURTHER READINGS
Burns PB, Rohrich RJ, Chung KC. The levels of evidence and their role in evidence-
based medicine. Plast Reconstr Surg 2011;128:305.
Del Fabbro G, Bzovsky S, Thoma A, et al. Hierarchy of evidence in surgical research. In:
Thoma A, editor. Evidence-based surgery. Cham (Switzerland): Springer; 2019.
p. 37–49.
Motulsky H. Essential biostatistics: a nonmathematical approach. New York: Oxford
University Press; 2015.
Review of the Modern
Dental Ceramic Restorative
M a t e r i a l s f o r E s t h e t i c D e n t i s t r y in
t h e Mi n i m a l l y I n v a s i v e A g e
Alireza Moshaverinia, DDS, MS, PhD
KEYWORDS
Ceramics Dental materials Dental ceramics
KEY POINTS
Material selection is among the most important decisions to be made by clinicians; proper
material selection can affect the long-term function, longevity, and esthetics of
restorations.
The large number of restorative material have provided great number of choices for restor-
ative dentists, but has increased the complexity of the decision-making process.
The overwhelming number of restorative dental materials mean that improper material se-
lection can potentially lead to failures in the outcome.
This article provides the practitioner with up-to-date practical information on ceramic
restorative materials and techniques and decision-making guides to help determine the
best ceramic material for various clinical scenarios.
INTRODUCTION
In modern restorative dentistry, we are overwhelmed with a plethora of different

ceramic restorative materials available in dental market, which makes the process
of material selection very confusing for a restorative dentist. Increased patient con-
cerns about esthetics have led to widespread use of dental ceramic materials. Restor-
ative dentists are bombarded with so much information from dental manufacturers
and their representatives that it sometimes makes the selection criteria for different
clinical scenarios were complicated. It is very well-known that achieving successful
clinical outcomes are attributed with 2 important factors: (1) knowledge of dental ma-
terial and selection of the correct dental material and (2) the hand skills of the practi-
tioner, including proper handling of the dental material and proper communication with

Division of Advanced Prosthodontics, UCLA School of Dentistry, 10833 Leconte Avenue, B3-023
CHS, Los Angeles, CA 90095-1668, USA
Dent Clin N Am 64 (2020) 621–631

622 Moshaverinia
the laboratory technician. With this combination we are able to deliver proper restora-
tions to our patients in a routine bases.
Here, it has been attempted to simplify this confusion in the selection of ceramic
dental materials. A systematic approach and a decision-making guide will be provided
to help the restorative dentist choose the best material in each clinical situation.
WHAT ARE DENTAL CERAMICS?
A ceramic is a product made from a nonmetallic inorganic material that is processed

by firing at high temperature to achieve desirable mechanical and optical properties.
The development of ceramic dental restorative materials as a metal-free category of
restoratives has been a milestone in treatment options that changed the clinical work-
flow of dentists.1,2 The technical improvements in development of ceramic materials
have enabled scientists to marry the impeccable advantages of ceramics such as
excellent esthetic appearance and optical properties with superior biocompatibility,
improved mechanical properties, and low plaque retention.3,4 To be used in everyday
dentistry, ceramics need to meet specific criteria: (1) appropriate toughness—the ma-
terial needs to be tough and withstand crack propagation, (2) suitable mechanical
strength to withstand occlusal forces, (3) favorable optical and desirable esthetic
properties, and (4) predictable in vivo performance offering long-lasting and durable
restorations.
Generally, we expect dental ceramics to be translucent at incisal edges, opacious at
cervical edges, provide adequate strength, and enable conservation of tooth struc-
ture. Owing to excellent esthetic and prosthetic properties, ceramics could be used
as a framework material in all types of tooth restorations, including single crowns, in-
lays or onlays, and laminate veneers.5,6 The presence of different phases in the
ceramic composition along with manufacturing processes have provided the dentists
with an array of restorative materials to choose. Broadly speaking, dental ceramics
could be classified into the following broad categories to help clinicians select the
best material based on their patients need: glassy ceramics, resin matrix ceramics,
and polycrystalline ceramics.7,8 In light of this, a brief overview of this classification
will be given in the following sections to shed more light on the properties and func-
tionality of dental ceramic materials.
Glass Matrix Ceramics

These nonmetallic inorganic multiphase ceramics are usually composed of a residual
glass phase with finely dispersed crystalline phases.8,9 The glassy ceramics are usu-
ally fabricated by precise crystallization of the glass nucleated evenly throughout the
glass phase or by embedding 1 or more crystals in the structure.10,11 The crystallin
phase can occupy 0.5% to 99.0% of the composition, but usually contains 30% to
70% of the final composition.11 The type, size, and volume fraction of the crystallin
phase along with its distribution in the glass matrix are among the important factors
controlling the mechanical and aesthetic properties, such as the toughness and trans-
lucency of the final material. Moreover, the presence of crystallin phase improves the
mechanical strength of the final material by inhibiting crack propagation and growth.12
The glassy phase also contributes to the improved mechanical properties by filling the
grain boundaries. The advantage of glass matrix ceramics over traditional ceramics
include ease of synthesis processes, less shrinkage, improved translucency owing
to the decreased internal light scattering.13,14 The glass matrix ceramics are generally
divided into 2 subcategories: natural materials such as Feldspathic ceramics and syn-
thetic materials such as lithium disilicate.
Modern Dental Ceramic Restorative Materials 623
Feldspathic ceramics
The feldspar-based ceramics are known as the traditional dental ceramics based on a
ternary system composed of natural feldspars (potassium/sodium aluminosilicate),
Kaolin (Al2O3.SiO2.2H2O), quartz (SiO2), and some metal oxides as additives.10 During
the fabrication process, the melting feldspar provides a glassy matrix for distribution of
a disordered network of silica tetrahedra. The improved strength of potassium con-
taining feldspars known as leucite (K2Al2Si6O16) turn them into a suitable option for
veneering material on metal and ceramic substrates or as reinforced resin-bonded
glass-ceramic cores. This class of glass ceramic dental restorative material can be
produced in different tooth shades with a range of opacity and translucency by adding
different metal oxide pigments. In routine dentistry, the opaque feldspar ceramics are
used as a first layer shielding the underlying metal followed by a layer of enamel ce-
ramics to develop the natural color of the tooth. Despite the advantageous properties,
feldspathic porcelains are limited to low load-bearing anterior applications owing to
lesser flexural strength and increased brittleness. The perceived color of natural teeth
is the result of the reflectance from the dentin modified by the absorption, scattering,
and thickness of the enamel.1 One of the primary factors that influences the appear-
ance of layered ceramic restorations is the layering effect. Translucent porcelain may
have a greater effect on the color of the veneered restoration than the opaque sub-
strate. There is a significant correlation between the thickness ratio of core and veneer
ceramics and the color of the restoration. Even when adequate ceramic thickness ex-
ists, clinical shade matches are difficult to achieve, because there is a wide range of
translucency among the core materials of all-ceramic systems at clinically relevant
core thicknesses. Clinicians claim that porcelain of high opacity should be used to
decrease the perceived color difference of porcelain veneers after bonding to dark
or discolored tooth substances. Different manufacturers have introduced porcelain
systems with increased opacity and claim superior color stability over different back-
grounds. Layered feldspathic veneers are indicated when restoring tetracycline tooth
or discolored preparations owing to the fact that layered porcelain powders gives
more flexibility with respect to choice of opacity and translucent areas. Further,
layered feldspathic veneers are indicated when undertaking more conservative cases
in younger population with large pulps owing to the fact that less tooth structure needs
to be removed. Many dentists choose feldspathic veneers because they can be made
thinner than pressed ceramic with more than 1 color of porcelain throughout the
veneer. Vitablocs (Vita Zahnfabrik, Bad Säckingen, Germany) are among the most
used feldspar-based computer-aided drafting/computer-aided manufacturing ce-
ramics with an average flexural strength of 154 MPa.
Lithium disilicate
The synthetic glass ceramics have emerged as an alternative to become independent
of the natural resources and their inherent variations with higher volume fraction of
crystallin phase distributed in a glassy matrix. Currently, lithium disilicate glass ce-
ramics are among the popular restorative dental materials that are available as
heat-pressable ingot and a partially crystallized machinable block.15 Lithium disilicate
glass-ceramics are one of the well-known synthetic glass-ceramics based on SiO2–
Li2O system composed of randomly oriented fine platelet-like or rod-like entangled
lithium disilicate crystals at higher concentrations of up to 70% and a lower concen-
tration of lithium orthophosphate (Li3PO4) crystals heterogeneously dispersed in the
glass matrix.10,13 The higher concentration of crystallin phase and the tighter interlock-
ing matrix of this synthetic glass ceramic poses significantly higher strength of approx-
imately 350 MPa and fracture toughness of 2.5 MPa m1/2 compared with the naturally
624 Moshaverinia
occurring feldspathic porcelain.13,16 Secondary to the improved mechanical proper-

ties, this restorative material can have a wide range of applications including resin-
bonded veneers, crowns, and 3-unit bridges up to the second premolar. IPS e.max
(Ivoclar Vivadent, Schaan, Liechtenstein), a lithium disilicate ceramic, was developed
in part by Prof. Wolfram Holland at Ivoclar Vivadent. After the development of clinical
applications, the material was released to the dental community about 12 years ago.
This ceramic material is well-researched, and many authors have described its phys-
ical properties. The effect that flaws in IPS e.max lithium disilicate or luting agent
spaces have on fracture potential and tensile strength have been tested, as well as
the effects of physiologic aging in a water environment, abrasiveness, wear, and sur-
face roughness. It has met, or exceeded, almost all of the clinical requirements consid-
ered ideal for a dental ceramic used in clinical practice.
Celtra Duo (Dentsply Sirona, York, PA) is one of the newly available lithium silicate-
based ceramics available in the market. It is a zirconia-reinforced lithium silicate with
the amount of Zr inclusion is around 10% zirconium oxide. The manufacturer claims
that the smaller ceramic crystal size and ultrafine microstructure material lead to
increased mechanical strength. Celtra Duo lithium silicate-based ceramics are avail-
able in pressable or milled formats and can be used crowns and bonded partial
crowns (inlays, onlays, and veneers).17
The other lithium silicate-based ceramics is GC Initial LiSi Press (GC America, Alsip,
IL), which is a high-strength and high-density lithium disilicate-based ceramic. This
new lithium silicate ceramic offers equal distribution of microcrystals, leading to excel-
lent mechanical and optical properties. The recommended indications for this press-
able ceramics are crowns, inlays, onlays, veneers and 3-unit fixed partial dentures up
to the second premolar.18
Resin Matrix Ceramics

A generalized definition of a resin matrix ceramic is a hybrid material composed of an
organic matrix highly filled with inorganic particles such as ceramics, glasses, and
glass ceramics.19 The polymer matric provides a supportive network reinforcing the
inorganic network of the hybrid material. The American Dental Association Code on
Dental Procedures and Nomenclature used to exclude the resin matrix material
from being classified as ceramic materials; however, its 2013 version defined the
term ceramic as “pressed, fired, polished, or milled materials containing predomi-
nantly inorganic refractory compounds - including porcelains, glasses, ceramics,
and glass-ceramics.”20 Therefore, the resin matrix hybrids fall into dental ceramics
category because they contain more than 50% inorganic particles. This class of dental
materials are a suitable choice for computer-aided drafting/computer-aided
manufacturing, providing superior properties compared with the traditional ceramics
and glass ceramics such as better mimicking the elasticity of dentin and ease of milling
and adjusting.8
Polycrystalline Ceramics
This class of dental restoratives are nonmetallic inorganic all ceramic materials without
any glassy phase.8 The fine grain crystals tightly arranged into regular arrays by
directly sintering the crystals in the absence of any intervening material that promotes
the strength of the material by reducing crack propagation.9 Despite improved me-
chanical properties, the polycrystalline ceramics have limited translucency. One
approach to enhance the translucency is to reduce the light scattering through
decreasing number of grain boundaries by increasing the grain size.1 However,
increasing the crystallin grain size can result in reduction of mechanical properties.
In addition, etching the polycrystalline ceramics with hydrofluoric acid seems to be

very difficult owing to absence of the glass phase. Aluminum oxide (Alumina) and Zir-
conia are among the popular polycrystalline ceramics that will be discussed briefly in
the following subsections.
Alumina
Alumina (Al2O3) is a natural metal oxide with a broad range of industrial applications
such as abrasive materials secondary to its high hardness. Besides higher hardness,
the superior wear and corrosion resistance along with biocompatibility have turned
this material into a popular candidate in dentistry.21 The very fine grain size of
medical-grade alumina ceramics hinders static fatigue and deflects cracks while un-
der load. All these properties have turned Alumina into a desirable substrate for a
wide range of medical applications, including dental restoratives and orthopedic ap-
plications. However, the Alumina ceramics are prone to bulk fractures owing to higher
elasticity.22 Procera AllCeram from Nobel Biocare (Zürich, Switzerland) (the first fully
dense polycrystalline ceramic) and In-Ceram AL, a product of VITA Zahnfabrik, are
representatives of this type of ceramic.
Zirconia
Zirconia (zirconium dioxide) is a polycrystalline ceramic with excellent toughness,
strength, and fatigue resistance. Depending on the temperature, this polymorphic
ceramic can be formed in 3 different crystallographic phases as cubic forming at tem-
peratures of more than 2300 C, tetragonal occurring at temperatures between 1100 C
and 2300 C, and monoclinic phase occurring at room temperatures to 1100 C.23,24
Zirconia has an elasticity similar to stainless steel, but superior biocompatibility. In
addition, the decreased plaque retention results in healthier gums after application
of zirconia.25 Zirconia restorations continue to be successful (from the standpoint of
fit, retention, wear, and fracture resistance), and yet controversial in some clinical
leader and academic circles, for use in simple single unit and more complex restora-
tions. There are perhaps 50 different zirconia ceramics on the market and, often, the
laboratory technician or clinician have no idea what the manufacturing standards were
for a given zirconia block or disk used to fabricate restorations coming from different
sources. The physical strength and ability to resist fatigue fracture depends on the
manufacturing standard that is applied by a specific manufacturer. Yttria-stabilized
zirconia (with flexural strength of >900 MPa) is indicated for clinical situations including
anterior and posterior crowns, implant abutments/crowns, 3-unit inlay and onlay
bridges, cantilever bridges with a minimum of 2 abutment teeth and a maximum of
1 pontic of no more than 1 premolar width, and multiunit long-span (up to 14 units)
Fig. 1. Ceramic dental materials selection tree showing the important parameters to
consider before ceramic material selection in different clinical scenarios.
626 Moshaverinia
Fig. 2. (Left) Preoperative view of patient’s frontal intraoral view. Patient specifically re-
questing change of the restorations of her anterior maxillary sextant without losing any
of her tooth structure. (Right) Intraoral frontal view of the definitive feldspathic ceramic res-
torations. Please note that lithium disilicate ceramics could also be used in this clinical case.
(Courtesy of Mr. Domenico Cascione, BS, CDT, MDT, Santa Monica, California.)
(DC-Zircon). Some of the available zirconia dental ceramics such as Lava Plus High
Translucency Zirconia (3M ESPE, St Paul, MN) are indicated for clinical circumstances
with limited interocclusal space, in addition to situations when the tooth-preserving
preparation is needed where minimum of 0.5 mm occlusal wall thickness is available.2
The flexural strength of widely used zirconia dental ceramics range from 1.0 to 1.4 GPa
(Glidewell [Newport Beach, CA] BruxZir Solid Zirconia, 1–1.4 GPa; Ivoclar Vivadent
Zenostar T, 1.2 GPa; Katana Zirconia [Kuraray Noritake Dental Inc., Okayama, Japan]).
Owing to their high opacity, several studies have tried to enhance the translucency
of the zirconia materials by modification of their microstructure, including decreasing
the alumina content, increasing the density, decreasing the grain size, adding cubic
phase zirconia, and decreasing the amount of impurities and structural defects.2
The size of the crystalline grain is the microstructural feature that is more closely
related to the adjustment of the translucency of polycrystalline ceramics. The creation
of ceramic materials with high translucency has been done in the past by means of
increasing the grain size during sintering. Larger grains lead to a smaller number of
grain boundaries, thereby decreasing light scattering. For Y-TZP, it has been shown
Fig. 3. (Left) Preoperative lateral view of tooth #21. The patient requested a minimally inva-
sive approach to preserve his tooth structure (no full coverage crowns). (Right) Definitive
bonded lithium disilicate ceramic restoration. Please note that feldspathic porcelain is con-
traindicated in this clinical situation. Alternative ceramic material options are mention on
the right side corner.
Fig. 4. (Left) Preoperative lateral view of tooth #14. (Right) Definitive zirconia ceramic resto-
ration. Alternative ceramic material options are mention on the right side corner.
that larger grains are detrimental for both the mechanical properties and the stability of
the tetragonal phase. Therefore, the translucency of zirconia cannot be achieved by
means of increasing its grain size. The increased translucency made the zirconia
ceramic materials slightly more esthetic, but it was challenging for laboratory techni-
cian to achieve esthetic outcomes consistently.
An alternative method to fabricate high translucent Y-TZP is achieved by decreasing
the grain size significantly. Nevertheless, the grain size needs to be decreased until
reaching a critical value that results in mitigation of the so-called birefringence phe-
nomenon.4 Birefringence occurs in Y-TZP owing to the large amount of tetragonal
crystal phase (>90%), which is a crystal that has different refractive indexes according
to its crystallographic orientation in the microstructure. Such anisotropic behavior
related to the variation in the refractive index causes significant light scattering.
Another way to overcome these scattering effects is the use of cubic zirconia, which
offers optical isotropic behavior, increasing the translucency.2 These newer, highly
translucent zirconia materials are certainly more translucent than the original mono-
lithic zirconia dental ceramic materials. However, increased translucency (owing to in-
crease in cubic structure content) causes a decrease in the flexural strength. The
flexural strength of highly translucent zirconia ranges from 500 to 800 MPa (Glidewell
BruxZir Anterior and Ivoclar Weiland Zenostar MT, and Katana [Noritake] STML,
750 MPa and UTML 560 MPa). It has been reported that the translucency of zirconia
is variable depending on the processing method, manufacturer formulation, and lab-
oratory sintering times and temperatures.
Fig. 5. Preoperative view of patient’s #8 and #9. (Right) Definitive lithium disilicate ceramic
restorations. Please note that feldspathic porcelain could also be used in this clinical case.
628 Moshaverinia
Fig. 6. (Left) Preoperative view of patient’s #8 and #9. (Right) Definitive lithium disilicate
ceramic restorations. Ceramic material was selected based on substrate percentage of
enamel and dentin.
CASE SELECTION AND CLINICAL CONSIDERATIONS (MATERIAL SELECTION)
In this article, we have reviewed some of the widely used dental ceramic materials in
the market and discussing their mechanical, optical, and handling properties. Here, a
material selection (Fig. 1) tree is provided to help the clinician and restorative dentist to
choose the appropriate type of restorative material in different clinical scenarios.
To select the suitable type of ceramic dental material, there are important parame-
ters to be considered:
1. Position: The clinician should consider the fact that the restoration will be used in as
an anterior or posterior restoration. For anterior restorations (Fig. 2) a more trans-
lucent ceramic material with lower mechanical strength lead to favorable esthetic
outcomes. However, for posterior restoration where translucency is not of impor-
tance a stronger ceramic material such as alumina, zirconia, or bonded lithium dis-
ilicate are indicated (Figs. 3 and 4).
2. Design: The clinician should consider the design of the ceramic restoration: single
unit versus splinted. Definitely for multiple splinted unit restorations, a stronger
ceramic material is recommended.
3. Strength: A biomechanical risk assessment is necessary to analyze the amounts of
expected occlusal forces. For a low to medium biomechanical stresses, feldspathic
Fig. 7. (Left) Preoperative view of patient’s maxillary frontal intraoral view. (Right) Defini-
tive lithium disilicate ceramic restorations. Please note that feldspathic porcelain could
also be used in this clinical case; however, masking the discolored teeth and percentage
of dentin are not favorable factors for feldspathic porcelain application.
Fig. 8. (Left) Preoperative view of patient’s mandibular frontal intraoral view. The patient
reports a history of nocturnal bruxism, but still wanted veneers. (Right) Definitive lithium
disilicate ceramic restorations. Please note that feldspathic porcelain might not be desirable
alternative ceramic restorative material owing to discolored substrate teeth, low percentage
of enamel of substrate, and unfavorable biomechanical assessment.
or lithium disilicate ceramics are recommended. However, for more medium to high
amounts of occlusal stresses, stronger ceramics such as alumina or zirconia are
indicated (see Fig. 4).
4. Substrate: The tooth or material substrate is one of the most important selection
criteria for ceramic restorative materials. There are 3 factors to take into account:
percentage of enamel left, percentage of dentin left, and presence or absence of
discoloration. The presence of enamel and dentin favors a ceramic material that
can be reliably bonded to tooth structure, such as feldspathic porcelain or lithium
disilicate ceramics. In the anterior sextant, the presence of more than 50% enamel
substrate left (in the absence of any discoloration) favors the use of feldspathic por-
celain owing to their high translucency and optical properties (Fig. 5). However,
when the amount of enamel left is less than 50% or in the presence of discoloration,
lithium disilicates are the material of choice (Figs. 6–8). In the posterior sextants
feldspathic porcelains are contraindicated owing to their low mechanical proper-
ties. For lithium disilicate ceramic restoration, the clinician should always consider
bonding to tooth structure of underlying substrate material. However, for alumina or
zirconia restorations bonding is needed only if the retention is compromised
(<3 mm height or a >20 convergence angel).
5. Translucency: To achieve successful esthetic outcomes, it is important to consider
translucency versus opacity of the ceramic restorative material. Generally, in the
esthetic zone, a high translucent material is desired, whereas for posterior region
high opacity is more favorable (Fig. 9).
Fig. 9. Comparison of the mechanical and optical of discussed dental ceramics in the current
review.
630 Moshaverinia
REFERENCES
1. da Silva LH, de Lima E, Miranda RBP, et al. Dental ceramics: a review of new ma-
terials and processing methods. Braz Oral Res 2017;31:133–46.
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Contemporary dental ceramic materials, a review: chemical composition, phys-
ical and mechanical properties, indications for use. Open Access Maced J
Med Sci 2018;6:1742–55.
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ical and experimental considerations. Dent Mater 2011;27:83–96.
4. Bajraktarova-Valjakova, Korunoska-Stevkovska, Kapusevska, et al. Contempo-
rary Dental Ceramic Materials: Chemical Composition, Physical and Mechanical
Properties. Open Access Macedonian Journal of Medical Sciences 2018;6(9):
1742–55.
5. Nikolopoulou F, Loukidis M, Proffesor A. Critical Review and evaluation of com-
posite/ceramic onlays versus crowns. 2014. https://doi.org/10.4172/2157-7633.
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6. Edelhoff D, Brix O. All-ceramic restorations in different indications: a case series.
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7. Kelly JR, Benetti P. Ceramic materials in dentistry: historical evolution and current
practice. Aust Dent J 2011;56:84–96.
8. Gracis S, Thompson V, Ferencz J, et al. A new classification system for All-
ceramic and ceramic-like restorative materials. Int J Prosthodont 2016;28:
227–35.
9. Shenoy A, Shenoy N. Dental ceramics: an update. J Conserv Dent 2010;13:195.
10. Saint-Jean SJ. Dental Glasses and Glass-ceramics. Adv. Ceram. Dent., Elsevier
Inc.; 2014, p. 255–277. https://doi.org/10.1016/B978-0-12-394619-5.00012-2.
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10.1007/978-3-319-56059-5_9.
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Material Types in Dentistry. Silicon 2011;3:109–15.
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biomimetic structure. Nano Lett 2018;18:7146–54.
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Mater Res A 2017;105:619–39.
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types of dental glass-ceramics and ceramics for CAD-CAM technologies. Mate-
rials (Basel) 2010;3:3700–13.
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CAD/CAM restorative materials. Dent Mater 2016;32(11):e275–83.
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cate glass-ceramics. Dent Mater 2019;35(5):713–29.
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doi.org/10.1016/B978-0-08-102166-8.00030-X.
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www.ada.org/en/publications/cdt. Accessed March 13, 2020.
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mechanical properties, biocompatibility and applications. Dalton Trans 2016;45:
19194–215.
Adhesive Dentistry
Understanding the Science and Achieving
Clinical Success
Marc Hayashi, DMD, MBA
KEYWORDS
Adhesive Dentin bonding agent Acid-etch Bond durability Dentin sealing
Postoperative sensitivity Moist bonding Solvent evaporation
KEY POINTS
Understanding bonding agent classification helps to quickly clarify the benefits and draw-
backs of adhesive groups, and explains the unique properties of universal adhesives.
Enamel and dentin are very different substrates that require different approaches with ad-
hesive application.
Key steps in adhesive application include acid-etching, moist bonding, and solvent
removal.
Bond degradation occurs over time, but it can be lessened with the application of various
agents to the cavity preparation.
INTRODUCTION
One of the most overlooked steps in adhesive dentistry is the application of the
bonding agent. A proper understanding of the science behind these materials is of
paramount importance in achieving consistent and predictable clinical outcomes. Un-
fortunately, this step in adhesive dentistry can be hard to teach objectively, and few
dental schools or continuing education courses provide the opportunity to test param-
eters like bond strength on natural teeth. Practitioners thus become reliant on clinical
outcomes and recollection of what they have learned in school. Furthermore, practi-
tioners have numerous options to choose from, with each adhesive seemingly supe-
rior to others and each having varying application protocols.
It is worth noting that adhesives have undergone tremendous improvement over the
years since their initial introduction in 1955 with Buonocore’s1 research on resin
bonding to etched enamel surfaces, and later the introduction of bonding filling mate-
rial to etched dentin by Fusayama and colleagues.2 Advancements have favored
simplicity, with subsequent reductions in the number of application steps down to
UCLA School of Dentistry, 10833 Le Conte Ave, Box 951668, Los Angeles, CA 90095, USA
Dent Clin N Am 64 (2020) 633–643

634 Hayashi
the single bottle materials widely used today. However, one must remember that
simplicity does not always translate to improvement, and proper understanding of
the material used is critical to achieving clinical success.
Adhesive Classification
The first step to improving clinical outcomes is knowing which bonding agent is being
used. But to know that, one must understand that essentially all bonding agents are
composed of 3 major components in some form, including an acid-etchant, primer,
and adhesive. These components are separated or combined in various manners to
create the adhesives available today. These combinations create the classification
systems that help quickly distinguish one adhesive from another. Perhaps the easiest
classification is by inclusion or separation of the acid-etch component. Bonding
agents with a separate phosphoric acid etch step are termed “etch-and-rinse,”
whereas those with the acid-etch included in the adhesive are termed “self-etch.”
Within these categories themselves, the number of application steps varies. The man-
ufacturer’s instructions included with the adhesive will state the required application
protocol, providing the practitioner with the information needed to assign a classifica-
tion. A summary of the classification breakdown is seen in Table 1.
Classification Characteristics
Now that it has been determined which adhesive system is being used, one can begin
to understand the pros and cons of each. For simplicity, each bonding agent will be
referred to by its generation number going forward. At this juncture, it is also important
to understand that the fifth and seventh generation bonding agents will tend to have
similar characteristics, whereas the fourth and sixth generation bonding agents will
have their own similar characteristics. The reason for this distinction is the presence
of a neutral adhesive layer, which is provided by a separate step involving the adhesive
alone.3 This means that the acidic priming resin, characteristic of the fifth and seventh
generation group, will be separated from the composite placed on top. This separation
is key, allowing for the creation of a hydrophobic adhesive layer that is also more resis-
tant to hydrolysis over time. This also allows fourth and sixth generation adhesives to
be compatible with dual-cure and self-cure composites.3 A summary of the character-
istics of these bonding agent groups is listed in Table 2.
Given the benefits of the fourth and sixth generation adhesives, we would expect
this to translate to clinical success. Interestingly, a systematic review by Peumans
and colleagues4 evaluated the effectiveness of contemporary adhesives placed in
noncarious cervical lesion clinical trials between 1950 and 2013. It was found that
Table 1
Adhesive classification by total-etch/self-etch, number of steps, and generation
Classification Steps Generation Examples

Etch-and-rinse Etch, rinse, prime, 4th OptiBond FL (Kerr); Scotchbond
bond (4 steps) Multi-Purpose (3M)
Etch-and-rinse Etch, rinse, prime 5th OptiBond Solo Plus (Kerr); Tenure
1 bond (3 steps) Quik with Fluoride (DenMat)
Self-etch Etch 1 prime, 6th Clearfil SE Bond (Kuraray)
bond (2 steps)
Self-etch Etch 1 prime 7th Prompt L-Pop (3M)
1 bond (1 step)
Adhesive Dentistry 635
Table 2
Characteristics of bonding agent groups
Group Pros Cons

4th and 6th Neutral adhesive/hydrophobic Technique sensitivity during
generation layer separates acidic/hydrophilic placement, especially with
primer from composite 4th generation
Compatible with dual-cure and
self-cure composites
More hydrolysis resistant bond
5th and 7th Less technique sensitivity with More acidic and hydrophilic
generation application Some require dual-cure
Reduced number of steps activator with self-cure/
(7th generation) dual-cure composites or
luting cements
the glass ionomers and two-step self-etch mild adhesives (2SEa-6th generation) dis-
played the most favorable and durable clinical bonding performance.4 The 3-step
etch-and-rinse adhesives (3E&Ra-4th generation) also performed favorably in this
study, providing further evidence to support the use of these adhesives.
This study also highlighted an interesting finding in clinical effectiveness within the
self-etch adhesives. If the pH of the adhesive was less than 1.5, it was termed strong,
whereas a pH of greater than 1.5 was termed mild. When a strong pH adhesive was
used, it was associated with a higher annual failure rate for self-etch adhesives.
This conclusion is important, as it has implications in the discussion of the next group
of adhesives, the universal bonding agents.
Universal Bonding Agents

Universal adhesives have gained in popularity due to their simplicity of use, versatility,
and clinical effectiveness. The definition of a universal adhesive, however, is still
vague, as the term “universal” seems to imply it can be used in all different ways at
all times (self-etch, total-etch, self-cure, dual-cure, light-cure, bonds to tooth, bonds
to composites, metals, ceramics, and zirconia), all while coming in one bottle. If that
were the definition, it could be argued that no such adhesive currently exists. Nonethe-
less, it appears that these universal adhesives are here to stay and are deserving of a
classification all their own.
One of the key benefits of universal adhesives is their ability to be used for both in-
direct and direct restorations. This means they can be used with direct composites, as
well as bonding a veneer or crown. This versatility reduces the number of materials
needed in the practice without compromising the quality of the restoration. What
makes this versatility possible in many of the universal adhesives is the inclusion of
the adhesive monomer 10 methacryloyloxydecyl-dihydrogen-phosphate (10-MDP
for short). This monomer is the same one that has been used for many years in Kurar-
ay’s Panavia adhesive resin cement (Osaka, Japan). With its addition, the adhesive
can bond to methacrylate-based restoratives and cements, as well as to tooth, metal
and zirconia.5 10-MDP is also a highly hydrophobic monomer, making it less prone to
water sorption and hydrolytic breakdown.3 In addition, it can bond chemically to the
tooth via its interaction with calcium in the hydroxyapatite of the tooth, forming stable
MDP-Ca salts, which, along with nano-layering, explain the high stability of this bond
and resistance to degradation.6
636 Hayashi
As stated previously, the pH of the adhesive seems to play an important role in clin-
ical effectiveness, with a milder pH being beneficial. Although a mild pH self-etch ad-
hesive is desired on dentin,7 it is a concern on enamel, as the ability to adequately etch
the substrate is in question. To improve this bond, the popular selective-etch tech-
nique is recommended.7,8 This is where the enamel margin is etched with phosphoric
acid, rinsed, dried, and then followed by placement of the universal adhesive. When
used in this manner, a positive effect on the bond durability is noted.9
Another concern with pH of the adhesives is the effect of its compatibility with dual-
cure and self-cure composites and resin cements.8 In general, a stronger acidity/lower
pH means less compatibility. Without proper polymerization at the adhesive interface,
we have no bond. To overcome this, the use of dual-cure activators or amine-free ce-
ments must be used.8 Thus, it is critical to read the manufacturer’s instructions
regarding the adhesive being used, as different adhesives have differing formulations.
It should also be noted here that it is advised to not mix and match adhesives and resin
cements when possible. With different chemistries present, adequate polymerization
may not be occurring, thus negatively impacting the bond and clinical outcome.
ADHESIVE APPLICATION TECHNIQUE

Tooth Preparation
Before discussing the application technique of bonding agents, we need to go back a
step further. Although seemingly insignificant, the bur used in the tooth and cavity
preparation process is important. With the enamel being etched by phosphoric
acid, we focus on the dentin. Although both carbide and diamond burs are used in
the cavity preparation process, carbide burs are recommended on the dentin due to
the thinner smear layer and higher bond strengths they create when using a self-
etching adhesive.10,11 When using an etch-and-rinse technique on dentin, no differ-
ence in bond strength was noted with respect to bur type used, although the bond
strengths were all lower than the self-etch adhesive.11
Another factor to consider is the cavity preparation depth. Although enamel is rela-
tively homogeneous throughout, dentin properties and composition vary considerably
depending on the distance from the pulp. It has been shown that deeper dentin (closer
to the pulp) exhibits lower bond strengths than superficial dentin (closer to the denti-
noenamel junction), regardless of the adhesive system used.12 This finding demon-
strates the importance of intertubular dentin, which increases in total area toward
the enamel. As the intertubular dentin increases, the dentinal tubule volume de-
creases, promoting greater development of the hybrid layer as coined by Nakabayashi
and colleagues,13 which appears to be more important for bond strength than resin
tag development.12 Furthermore, the deeper the dentin, the more permeable the sub-
strate due to greater tubule diameter and number.14 This increase in permeability can
negatively influence the bond strength achieved at the adhesive interface,15 especially
for the etch-and-rinse adhesives in which the phosphoric acid removes the peritubular
dentin and completely opens the tubules.16 Thus, one proposed method of counter-
acting this fluid movement is through the use of local anesthetics with vasoconstric-
tors along with mild self-etching adhesives, which function to both decrease the
pulpal pressure in the tooth and leave the smear plugs in the tubules largely intact,
respectively.17
Adhesive Application
Regardless of the adhesive used, following the manufacturer’s instructions is essen-
tial. Each will have slightly different protocols and recommended application times
that are tailored to the specific chemistry of that adhesive. Nonetheless, a few key
principles apply to all adhesives during the application process.
Acid-Etch Application
As mentioned previously, there is a general concern regarding the ability of self-
etching adhesives being strong enough to adequately condition the enamel to the level
of that achieved with 35% to 37% phosphoric acid, especially with uncut enamel.
Thus, etching the enamel through the selective-etch technique is often advocated
with self-etch adhesives,7 as higher bond strengths have been reported when
compared with enamel treated with the self-etch adhesives alone.18 An application
time of 15 seconds appears necessary to adequately condition the enamel surface,
with longer etch times increasing surface roughness but producing no significant in-
crease in bond strength.18
In the dentin, 15 seconds also appears adequate to achieving adequate bond
strength, as longer etching times have been shown to reduce bond strength.19 How-
ever, as is often the case in the clinical setting, we often run into nonideal dentin sub-
strate. One such variation is that of sclerotic and older dentin, which has been shown
to be more acid-resistant and require longer etching times in the range of 20 to 30 sec-
onds.20,21 Longer etching times however negatively affects any normal surrounding
dentin, making subsequent adhesive infiltration more challenging.21
Moist Bonding
Contrary to enamel, in which we often look for the “frosty” appearance after rinsing
and drying of the phosphoric acid, dentin is a very different substrate that behaves
differently. After etching and rinsing, effort should be made to avoid overdrying the
dentin. This is because of the collapse of the collagen matrix and decreased infiltration
by the adhesive that results, producing decreased bond strengths, leakage, and
sensitivity.22 Dentin should thus remain moist during the application process. This is
the reason for the often stated shiny or hydrated appearance to the surface that should
be present after etching and rinsing.
Various methods can be used to achieve this appearance, including gentle air-
drying, blot drying, or suction tip.23,24 With the use of self-etch adhesives, the guess-
work is largely removed, as no rinsing is involved. Interestingly, a study by Unlu and
colleagues25 compared self-etch and etch-and-rinse adhesives amongst dental pro-
viders with varied experience levels. They found that bond strengths achieved were
higher with the self-etch method across all levels and that operator experience does
influence the values obtained.
Solvent Removal
Proper evaporation of the solvent is perhaps one of the most overlooked steps in ad-
hesive application. The solvent is water, ethanol, acetone, or some combination in the
bonding agent. Water/ethanol-based solvents have been demonstrated to perform
better than acetone-based solvents, largely due to the thinner adhesive layer gener-
ated.26 Nonetheless, failure to evaporate the solvent has been shown to lead to
poor bond strengths and nanoleakage as a result of dilution, incomplete polymeriza-
tion, and phase separation of the adhesive. Consequently, longer air-drying times may
be beneficial.27 In addition, active agitation of the adhesive can help aid removal of the
solvent through enhanced movement of monomer inward and solvent outward, thus
improving the bond strength achieved and clinical performance.28,29 To aid this
step, the use of rigid microbrushes is recommended over flexible or long fiber-
based ones in which adequate application pressure cannot be achieved.29
638 Hayashi
It is important that this principal of air thinning with solvents not be directly applied to
the adhesive portion of the bonding agent. For instance, in fourth and sixth generation
adhesives, in which the adhesive is applied in a separate step, caution should be exer-
cised with excessive or prolonged air thinning, as this may significantly reduce the
dentin bond strength. As a result, thinning the adhesive with a microbrush may be a
superior alternative to air thinning.30
Bond Durability
It is known that the resin-dentin bonds decrease over time, and that this phenomenon
is due to the degradation of the resin and collagen fibrils responsible for bond forma-
tion.31 Matrix metalloproteinases (MMPs) have largely been implicated as the primary
enzymes contributing to this degradation, which become activated during dentin
bonding procedures.32 Thus, to extend the life of this bond and improve its durability,
several techniques are advocated. One such technique is to simply apply multiple
coats of the adhesive.29 Although there does not appear to be uniform agreement
on the number of coats needed, doing so has been demonstrated to decrease the
degradation rate with self-etch adhesives and improve the overall performance.33
Another technique with much interest is the use of an MMP inhibitor, with the most
widely known agent being Chlorhexidine. Common agents using chlorhexidine include
Cavity Cleanser (BISCO, Inc, Schaumberg, IL) and Consepsis (Ultradent, Inc, South
Jordan, UT). Even at low concentrations, chlorhexidine has been shown to be effective
in preventing degradation at the adhesive interface after acid-etching.29 An applica-
tion time of 15 to 30 seconds appears to be all that is necessary for effectiveness.34
Use of chlorhexidine with self-etch adhesives on the other hand is not as conclusive.
Although its placement on the dentin substrate before self-etch placement has shown
some promise,35 further research is necessary to validate this method.
Benzalkonium chloride is another agent that has demonstrated MMP inhibition
properties.36 This agent is included in the acid etchants of BISCO Inc and is included
in the cavity disinfectant Tubulicid Red (Dental Therapeutics, Saltsjo-Boo, Sweden),
and has been shown to strongly bind to demineralized dentin even after rinsing.36
When compared with untreated teeth showing decreases in bond strength after 6
and 12 months, the use of benzalkonium chloride demonstrated stable bond strengths
over the same period.37 In addition, glutaraldehyde containing desensitizers such as
Gluma (Kulzer, Hanau, Germany) have been implicated as MMP inhibitors in matrix-
bound dentin, contributing to prevention of collagen degradation.38 However, it’s
impact on bond strength of overlying resin remains unclear, with conflicting evidence
available.39,40 It should also be noted that this agent is marketed primarily for desen-
sitizing reasons, and has cytotoxicity concerns.41,42 Thus, its use on acid-etched
dentin remains unclear at present and warrants additional investigation.
Light Curing
Once the adhesive is placed, light curing is generally required among most bonding
agents to maximize the bond strength achieved. This critical step can easily be over-
looked, as it often receives less attention than most other topics. Nevertheless, proper
knowledge and technique with curing lights is of paramount importance in the dental
practice, as it allows the provider to provide much of today’s dental procedures, from
sealants and composites to bonded indirect restorations. It is no surprise then that its
correct use is critical to the successful execution of adhesive dentistry.
It should be kept in mind, however, that high-power light-emitting diode curing lights
available today are able to generate significant increases in temperature.43 This is
especially important when curing the bonding agent in deep preparations where little
dentin remains over the pulp, as pulpal damage can occur.44 Although increasing the
distance from the curing light to the dentin may decrease the temperature, compro-
mised polymerization may result, especially in areas difficulty for the light to reach.43
One method that shows promise to reduce the temperature rise with prolonged light
curing is directing a stream of air at the tooth during light exposure.45 In addition, un-
dercuts may be present in the cavity preparation, producing shadows and areas of
poor light exposure. This may require the operator to move the curing light around
over a longer period of time to ensure polymerization of all areas.43
In any case, it is important that this critical step be carried out correctly to ensure
adequate polymerization of the light cured adhesive and resins. In addition to tech-
nique, simple steps that can be taken to optimize the output from the curing light
include periodic monitoring with a radiometer and routine examination of the light
tip for damage and debris.43 Clear barrier sleeves and wraps can also be used as a
method of protection for the light tip during treatment to minimize contamination
without significantly compromising the curing of resin or the light spectrum emitted.46
IMMEDIATE VERSUS DELAYED DENTIN SEALING
Immediate dentin sealing (IDS) is the application of an adhesive to freshly cut dentin
after preparation for an indirect restoration, such as an onlay or crown, and before
the final impression.3 This allows for pre-polymerization of the adhesive and stress-
free dentin bond development, as well as protection from bacterial leakage and sensi-
tivity during the provisional phase.47 This differs from delayed dentin sealing (DDS) in
which the adhesive is placed right before seating of the restoration but is left unpoly-
merized. A study by Magne and colleagues47 demonstrated that the bond strength
achieved through the IDS protocol resulted in a significant increase in bond strength
over the DDS technique and reduces concern regarding incomplete seating. The
IDS technique also calls for the use of a filled adhesive, such as the fourth generation
OptiBond FL (Kerr, Orange, CA). Such an adhesive develops a uniform layer that is,
thick enough to resist subsequent re-exposure of dentin during cleaning and prepara-
tion procedures that occur before final indirect restoration seating.48
Although this technique appears effective, it can be technique sensitive, as resin
based provisionals can stick to the adhesive during fabrication, making retrieval diffi-
cult.47,48 A thick layer of petroleum jelly or another separating medium is thus neces-
sary to prevent this bond from occurring.47 In addition, polyether-based impression
material cannot be used with this technique, as faulty impressions have been shown
to occur over 50% of the time due to impression material adhering to the adhesive sur-
face. This phenomenon did not occur with air blocking and pumicing of the adhesive
with a vinyl polysiloxane material.49
POSTOPERATIVE SENSITIVITY
Postoperative sensitivity is a longstanding and common clinical problem that dentists

encounter with adhesive dentistry.50 Many efforts have been made to reduce its inci-
dence as outlined previously. From an adhesive standpoint, self-etch adhesives have
a purported benefit of less postoperative sensitivity given their incomplete removal of
the smear layer, with tubules remaining partially plugged.7 Nonetheless, the difference
in postoperative sensitivity between etch-and-rinse and self-etch adhesives appears
to be minimal,51,52 with operator technique being more influential than the type of ad-
hesive used.51
Another commonly held belief is the use of a glass-ionomer lining material under the
resin composite restoration to minimize the incidence of postoperative sensitivity.
640 Hayashi
Fig. 1. Understanding your adhesive.
However, a study by Burrow examined this technique, and found no difference in post-
operative sensitivity between restorations placed with or without a glass-ionomer liner,
regardless of the bonding agent used (total-etch or self-etch).53 Furthermore, Blum
and Wilson54 demonstrated that the available evidence does not support the routine
placement of liners, unless it is intended to have a therapeutic effect.
UNDERSTANDING YOUR ADHESIVE
With the preceding information in hand, we can now apply the principles to our adhe-
sives used in daily practice. Fig. 1 provides a decision tree to help understand which
adhesive is being used, and the steps that are generally required in its application. It is
critical to remember that all products may have slight differences in application times
based on their chemistries, and that following the instructions for use is of the utmost
importance.
SUMMARY
Adhesive dentistry has undoubtedly experienced tremendous improvements since

Buonocore’s1 initial introduction of enamel etching in the 1950s. Although the im-
provements have been significant and largely intended to reduce technique sensitivity
and the number of steps, certain key principles remain the same. Given certain limita-
tions with several adhesives, as outlined previously, the practitioner may even want to
consider using a couple of different adhesives for various situations. Regardless of the
approach, it should be reemphasized that careful application technique and attention
to detail during adhesive placement, along with following the manufacturer’s instruc-
tions, are key considerations in the pursuit of delivering quality and long-lasting adhe-
sive dental care.
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versus self-etch adhesive systems on the post-operative sensitivity in medium-
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Implementing Digital
D e n t i s t r y i n t o Yo u r E s t h e t i c
Dental Practice
a, b
Lawrence Fung, DDS *, Phil Brisebois, BA
KEYWORDS
Digital dentistry Intra oral scanners Smile design CAD/CAM milling
3D printing
KEY POINTS
The use of digital dentistry is on the increase as costs to acquire digital technology have
gone down dramatically and allowed for more practitioners to integrate digital equipment
with reduced investment.
One of the most significant benefits of digital technology in dentistry is the ability to
streamline processes that can be cumbersome via the analog way.
In digital dentistry, it is important to understand the advantages and disadvantages of
each device or system available.
INTRODUCTION
When we look around, it is amazing yet eerie to see how surrounded we are by tech-
nology. The word technology comes from 2 Greek words, translated into techne and
logos. Techne means art, skill, craft, or the way, manner, or means by which a thing is
gained. Logos means word, the utterance by which inward thought is expressed, a
saying, or an expression. Literally, then, technology means words or discourse about
the way things are gained. In today’s more relevant definition of technology, it can be
broken down into 4 working subsets: technology, an object, knowledge, and last, a
process. For the purposes of this article, the authors expand on all of these subsets
for digital dentistry. Digital dentistry and its implementation into practice is more
than just the piece of equipment. It is important to understand more than how to
use the device, the nuances of the technology, the processes involved, and how
the technology fits into your existing practice system.
a
UCLA Center for Esthetic Dentistry Lecturer, 6101 West Centinela Avenue, Suite 375, Culver
City, CA 90230, USA; b UCLA Center for Esthetic Dentistry Lecturer, Founder NOVO Dental
Studios & GRAVIDEE, 465 N Roxbury, Suite 703, Beverly Hills, CA 90210, USA
* Corresponding author.
Dent Clin N Am 64 (2020) 645–657

646 Fung & Brisebois
As with anything new to an existing system, there are pros and cons of modifying a
single process within the current work flow; digital applications are just additional tools
in your toolbox, like a hammer and a screwdriver.
In digital dentistry, it is important to understand the advantages and disadvantages
of each device or system available. From a well-rounded understanding, you will be
able to see how and if it fits within your practice. Just like any other instrument, digital
technology also has its limitations; in some situations digital technology works very
well, whereas in other circumstances, digital technology may be contraindicated, simi-
larly to using a screwdriver instead of a hammer. Herein, the authors discuss digital
technology in dentistry, its advantages, shortcomings, and it potential to elevate
how to practice contemporary dentistry with a vision to the future.
The use of digital dentistry is on the increase as costs to acquire digital technology
(digital radiology, for example) have decreased dramatically and allowed for more
practitioners to integrate digital equipment with reduced investment. For the purposes
of this article, the authors focus on the acquisition of patient data by exploring digital
intraoral scanners and digital radiography and they touch briefly on digital photog-
raphy. They also look at the applications one can have with the digital data, and their
potential outputs-associated 3-dimensional (3D) printing and milled restorations.
One of the most significant benefits of digital technology in dentistry is the ability to
streamline processes that can be cumbersome via the analog way. The biggest incen-
tive about creating more efficiency in a dental practice is the ability to provide consis-
tent high-quality dentistry while decreasing costs for the patient. In any business, the
net operating income, namely, the amount of money left over after expenses, is some-
thing that cannot be ignored, and therefore, reducing the chair time needed per pro-
cedure will bring about more revenue generated on a daily basis, and digital dentistry
can speed up certain processes, allowing for a more efficiently run practice. In the au-
thors’ practice, for example, new patient data acquisition time was reduced dramat-
ically with the use of digital technology, especially when considering the time
needed for preliminary physical impressions, to pour up the models, to mount the
case as well as to store the cases.
In the authors’ practice, the new patient record includes a full set of photographs,
intraoral scan, and a full-mouth radiograph set. A scan will allow the practitioner to
evaluate the dentition and discuss with the patient immediately on a 3D model versus
having to wait to pour up a case, mount on an articulator, and then bring the patient
back to discuss the findings. Because data are stored digitally, the practitioner can
reference the acquired data at any time, thus enabling the practitioner to go back
into these digital files to reexamine the patient to ensure nothing was overlooked.
Another advantage of digital dentistry is how the practice can expand their bound-
aries when assembling the dental team. In an esthetic dental practice, having an
exceptionally capable ceramist in the team and using digital technology enable the
practitioner to work remotely and send patients’ cases to practically any ceramist
throughout the globe. In addition, with the quality of digital photography and its accu-
racy at capturing color, shade match can be done remotely as well. With the use of
calibrated gray cards and polarized lens photography, accurate color information
can be transmitted to the ceramist; this can eliminate the need for a custom shade
appointment that would have normally had to be done in person by the ceramist.
Another noteworthy advantage of transitioning and embracing digital capabilities is
demonstrating to existing as well as new patients how updated your approach is. Not
only do patients appreciate seeing that their caregiver is up-to-date but also many
admire clinicians who are leaders in technology, and they become your biggest advo-
cates. By the same token, as patients become increasingly aware of advances in
Implementing Digital Dentistry 647
dentistry, if you do not have the updated technology in your office, they may question
your professional abilities. One great example is with the significant advertising being
done by those clear aligner therapy startups, such as Smile Direct Club, and how their
stores feature intraoral scanners. As more and more of the public are aware of these
scanning technologies, the more they expect it to be the norm.
DRAWBACKS OF DIGITAL TECHNOLOGY IN DENTISTRY?

Startup Costs
The costs are still relatively high when considering acquiring digital dental equipment.
Many of the systems operate on a subscription-based licensing platform. For
example, some Digital Smile Design Apps require a yearly subscription. Likewise,
some intraoral scanners have a monthly or annual fee, and cloud-based data storage
for backups often comes with a fee. Training is usually provided by the equipment
distributor, but any advanced instructional use of technology is not. Because of the
limited resources provided by many digital companies, the learning curve can be quite
steep initially.
Lack of Standardized Work Flows
It is the authors’ experience that digital dentistry currently lacks well-defined universal
work flows that can be seamlessly integrated into any practice. Interoperability is an
issue, and different data acquisition devices from different companies will export
different file types. Although the universally accepted digital scan file is stereolithogra-
phy (STL), some of the scanners will prefer to export in their own native scan files, such
as a polygon file format (PLY) or in the case of 3shape, it will export as a Digital Imaging
and Communications in Medicine format (DCM), which will need to be converted to
STL.
Limited Access to Digital Partners
One of the biggest challenges of digital is finding other members of the dental team
that use digital technology, because many of the higher-end small-scale laboratories
are still not fully digital because of the lack of digital case submission volume. The cost
for the small laboratories to acquire printing technology in-house and digital design
software may not be economically feasible if most of their current client list is not
digital.
Intraoral Scanners and Scanning
The following are some of the current popular scanners. In the graph, the pros and
cons of each system are displayed. Speed and cost can vary, and there is no consis-
tent correlation between those mentioned above and output quality. Some require
additional equipment to operate them (like a laptop for 3Shape). Although some scan-
ners may be more accurate, the size of the intraoral camera may be an obstacle for
some circumstances, like capturing distobuccal cusp of maxillary second molars or
a limited size oral cavity (ie, pediatric dentists and orthodontists). A learning curve
and adjustment for scanning, and scanning sequence and digital workflow present
other challenges when integrating digital impressions.1 Also, determining deep mar-
ginal finish lines of prepared teeth2 can be exceedingly more challenging and require
an additional skill set to be learned.
The Digital Dentistry as part of the restorative process can be broken down into 3
step: Data-acquisition, design, and manufacturing. In this section, the different op-
tions and systems for digital impressions are discussed. Although there are several
different digital impression systems on the market today, there are only 3 categories
these systems can be categorized into: (1) scan only (stand alone); (2) scan, design,
and output to a third-party mill; and (3) all-in-one ecosystem.
Stand-alone systems
There are several stand-alone systems on the market today; however, the following 5
would be considered the most relevant scanners. They include Cerec Primescan,
Carestream CS, iMedit 500, iTero, and Trios. Each of these scanners makes a very
high-quality digital impression, and all have specific features and benefits designed
to enhance the user experience.
It is important to note that although each of these scanners will make an impression
in color, that this color image is not always transferred to the laboratory for fabrication.
In order to achieve the highest-quality restorative outcome, it is extremely important to
understand the technology and software that your laboratory is using to process your
digital impressions. For example, although itero, Carestream, Cerec, and Medit all
make digital impressions in color, the STL that is provided to the laboratory for fabri-
cation is a black and gray scale image, making it more challenging and most times
impossible to mark the margin, especially with veneer and equigingival preparations.
Scan, design, and output to a third-party mill

The next category of products is used for scanning the patient, but also has the ability
to add chair-side design software. Although purchased separately, Trios by 3Shape
allows seamless integration, and with additional modules can be purchased directly
from 3Shape and added to the Chairside Dental Desktop software. These modules
include Implant Studio, Smile Design, Restorative Design, Ortho Simulator, Caries
Detection, and the CAM software required to output design to an in-house mill. Other
intraoral scanners can also be integrated as part of chair-side systems, but unlike
3Shape, use a second party design software called exocad ChairsideCAD.
All-in-One ecosystem
The systems available in this category are Planmeca Emerald and Sirona Cerec. These
systems allow a dentist and team to make a digital impression of a patient in their of-
fice, use the internal design software to design a restoration for the patient, and mill
that restoration using an integrated in-office mill. These systems have proven to be
very successful for some users but require a very specific workflow to be clinically suc-
cessful. Both systems are simple in their setup: included is an intraoral scanner with
built-in design software and a mill with built in CAM software,“call it plug and play.”
The challenge lies in the processing of the material and patient timing. The 2 most
commonly used materials in dentistry are Emax and zirconia, and both require post-
processing and sintering times that range from 45 minutes to 10 hours. A true benefit
can be seen using this technology to mill composite and polymethyl methacrylate for
inlays/onlays and also temporaries. In addition, both the Planmeca Emerald and
Sirona Cerec are also available as a stand-alone system, whereby digital impressions
can be made and sent to the laboratory for fabrication.
When investing in technology, it is important to consider one’s potential future use. If
the goal is to eventually have the ability to be self-sufficient and produce most resto-
rations in-office, it is important to consider the workflow and available options for each
specific scanner system when planning a purchase. The integration and workflow are
not as seamless as many manufacturers promote, and each system has their own
nuances.
Just like the system setup for the dental operatory, the dental laboratory has a va-
riety of different hardware and software that can be used to design and fabricate indi-
rect fixed restorations, digital dentures, implant planning, surgical guides, and
restorations, as well as other dental devices. Nowadays, most if not all dental pros-
thetics can be fabricated using CAD/CAM technology.
Although all systems are open and produce an STL file, the file format is in gray scale
and does not demonstrate colors and therefore cannot differentiate between tooth
and tissue colors. It is the responsibility of the scanner manufacturer to produce a
color-ready file or alternatively a file that can export the finish-line position ready to
be used by the laboratory for margin evaluation and restoration design. The inability
to view the file in color may create a real challenge for the restorative dentist when
evaluating a digital impression for finish-line reproducibility.
Regardless of the scanner’s ability to import and export into laboratory software in
color, they all work well to make digital impressions for crown and bridge, implants
workflow, dental appliances, smile design, and treatment planning. The key with all
of the systems still boils down to the quality of dentistry. None of the scanners have
the ability to see through tissue, and therefore, it is essential that tissue be retracted
properly from the margin, as well as preventing fluids from hindering a qualifying
impression. Equally important, the digital impression must be evaluated on screen
before being sent to the laboratory for fabrication (Fig. 1).
Fig. 2 demonstrates a workflow for the initial new patient visit. Once the data are
acquired from the patient, the information is uploaded into the patient management
software or onto a HIPPA-compliant storage program. With the use of digitally
collected patient dental conditions, they can be viewed with the patient for clear
communication and dental education.
The work flow chart in Fig. 3 is for indirect restorations and or dental appliances,
such as an occlusal guard. The process is not really different from the analog way;
instead of making an impression with polyvinyl siloxane impression material, you
would just capture the prepared data or dentition digitally. The biggest caveat of digital
dentistry is the ability to have the preparation or impression sent to the laboratory
immediately, saving pickup travel time, with zero risk for cross-contamination. Another
big advantage of digital is the ability to review the preparation or impression to ensure
there are no inaccuracies present that may warrant a new impression. A big advantage
of digital for indirect preparations, especially onlay preparations, is the ability to see
interocclusal reduction in real time to help reduce underreduction. Reviewing prepa-
rations in real time in occlusion will also help aid the practitioner from overreducing
preparations as well, allowing for the esthetic dentist to be as minimally invasive as
possible.
It is important to understand dental technology is changing at the fastest rate yet,
and it is imperative to keep up-to-date. Luckily, there are more resources available on-
line than ever, including continuing education courses and forums that can easily be
Fig. 1. (A) Scan made in color; (B) scan exported as a black and white STL into 3D software.
Fig. 2. Workflow for the initial new patient visit.
found on social media platforms that allow for crowdsourcing to help solve any digital
dentistry problems the clinician may have.
DIGITAL WORKING PROTOTYPE
Fig. 4 is the result of performing a digital smile design from an intraoral mockup to a
final product. Doing a digital wax-up is a great way for patients to preview and try
out their final product without any kind of tooth preparation.
The initial presentation of the patient was the top image. The chief complaint was
that the patient did not like the diastema between #8 and #9 and that the laterals
felt too narrow. The patient also had some bonding done before but was tired of the
need to keep replacing the composites and wanted something more long term.
With digital smile design, we were able to show the patient a visual representation
of the proposed changes. Once the patient approved the digital smile design, an
intraoral mockup was done to verify fit, esthetics, and phonetics of the new proposed
restorations. Once the patient signed off on the intraoral mockup, the scan was sent to
Fig. 3. Workflow for indirect restorations and or dental appliances, such as an occlusal
guard.
Fig. 4. Digitally modified smile.
the orthodontist, and they used it as a guide to close the diastema between #8 and #9
and create some restorative spacing on the mesial and distal of #7 and #10 to allow for
minimal reduction for the proposed feldspathic veneers.
A summary of the whole procedure as seen in Fig. 5 is from start to final product.
The case was done digitally and remotely with a laboratory, and shade matching
was only done chair-side with photography; no try-in was needed. The patient did
not have to travel to the laboratory, saving time and allowing for the practice and pa-
tient to use any ceramist in the world.
Fig. 5. Initial and postrestorations and orthodontics. (Courtesy of Lawrence Fung, DDS,
Culver City, CA.)
Fig. 6. Initial presentation. (Courtesy of Lawrence Fung, DDS, Culver City, CA.)
The chief complaint is the narrow laterals that were restored with conservative com-
posite restorations and the diastema between the 2 centrals (Fig. 6). The patient not
only wanted to close the diastema between the centrals but also wanted more
fuller-looking lateral incisors. The patient wanted the least minimally invasive proced-
ure done.
In this case, once the digital wax-up was provided by the digital designer, using a
SprintRay Pro (Los Angeles, California), the models for putty matrix fabrication and
evaluation were printed in-house (Fig. 7). The SprintRay Pro (Figs. 8 and 9) is a digital
light projector (DLP) printer that can print 2 inches in height per hour, so in this case,
the print took about 45 minutes. For 3D printing, there are DLP and SLA (STL). The
latter is significantly older but more accurate yet slower than the former. DLP, howev-
er, is starting to catch up in micron accuracy. A big benefit of DLP is the machines are
much less expensive than the SLA machines.3 The SprintRay Pro, which was used to
print the smile design models, is a DLP.
The patient, after reviewing the smile preview, was able to have an intraoral
mockup done to visualize immediately the proposed changes. Although the patient
is wearing this mockup, the mockup can be adjusted intraorally, and the new con-
tours can be scanned to help aid the digital designer when finessing the digital
wax-up (Fig. 10). The digital wax-up will serve as a blueprint for the new final resto-
rations and temporaries. The materials used for the intraoral mockup was Telio CS
from Ivoclar. The putty matrix used to duplicate the wax-up to the dentition was
Flexitime from Kulzer.
Fig. 11 shows 2 shades, one for the closest match and a second to offer as a com-
parison. The shade guide the author likes to use is VITA Classical. One of the biggest
advantages of digital dentistry is increased efficiency in the workflow.
Fig. 7. Printed model. (Courtesy of Lawrence Fung, DDS, Culver City, CA.)
Fig. 8. SprintRay Pro 3D printer. (Courtesy of SprintRay, Los Angeles, CA.)
In Fig. 12, the shade identification is marked so the ceramist can verify the shade
classification. Always include comparison shades as a way for the ceramist to cali-
brate color.
The filter removes unwanted reflections from the teeth that are caused by a flash.
These highlights can send false information to the ceramist. In the cross-polarized
photograph, you can see the hypersaturation of color and contrast much better
(Fig. 13). These filters are great, especially where any decalcification may be present,
and aids the ceramist when fabricating the custom restorations. The product the
author uses is polar_eyes from PhotoMed.
Fig. 9. SprintRay die and model resin. (Courtesy of SprintRay, Los Angeles, CA.)
Fig. 10. Try-in of the digital smile preview. (Courtesy of Lawrence Fung, DDS, Culver City,
CA.)
Once patient data are collected by the doctor and sent to the laboratory for fabri-
cation, the design workflow becomes the same. When a dentist sends an impres-
sion to the laboratory, whether it is digital or conventional, the same process for
designing and manufacturing will occur. A digital impression should be kept in a
full digital workflow throughout the production process in order to eliminate
inaccuracies.
Using digital technology allows the technician to evaluate the restoration prepro-
duction while looking at all aspects of the case, including interocclusal spacing, emer-
gence profile, margin position, and virtual articulator movements to evaluate
restorations in function. The programs can then help the technician evaluate material
requirements and help to determine if adequate space has been provided to produce
the prescribed restoration. The system can also suggest different materials to produce
a more subtle solution if preparations are less than ideal. The system and its precise
calibration with manufacturer material specifications will also ensure consistent resto-
rations will be fabricated.
With implants, digital technology allows for an easy transfer of information for
transmucosal profile by simple scanning of the restorative site. Fig. 14 is an
example of a surgical plan with an immediate custom healing abutment that was
designed from the preplanned implant coordinates, allowing the surgeon, restoring
doctor, and laboratory to plan the most ideal position of the implant based on the
desired prosthetic outcome. It also allows for the development of soft tissue from
the time of implant placement. The custom healing abutment will begin to support
Fig. 11. Shade selection.

Fig. 12. Shade tabs chosen. (Courtesy of Lawrence Fung, DDS, Culver City, CA.)
Fig. 13. Shade taken with cross-polarizing lens. (Courtesy of Lawrence Fung, DDS, Culver
City, CA.)
Fig. 14. Surgical plan with an immediate custom healing abutment that was designed from
the preplanned implant coordinates.
Fig. 15. It is effective to digitally record a predeveloped emergence profile and use that in-
formation to design the most ideal custom abutment and restoration.
and form the tissue profile that will aid in the development of papilla and is easily
modified by simply adding composite if the transmucosal design requires
modification.
In Fig. 15, it can be seen how effective it is to digitally record a predeveloped emer-
gence profile and use that information to design the most ideal custom abutment and
restoration.
In summary, digital dentistry could be a great addition to any practice. It does, how-
ever, have its drawbacks that need to be thoroughly understood. The digital process
and workflows could be superior to conventional techniques in some respects, but the
practitioner must be motivated to create systems in place to maximize the benefit of
digital technology in the practice.
Incorporating a digital workflow into a dental environment is a daunting task.
Whether in a clinical or laboratory environment, workflow options are endless, and
the variety of technology is vast. The benefits of using technology are clear: increased
levels of communication, predictability, and improved patient care.
DISCLOSURE
L. Fung, DDS is a paid consultant for SprintRay 3D printing technologies. P. Brisebois

has nothing to disclose.
REFERENCES
1. Zaruba M, Mehl A. Chairside systems: a current review. Int J Comput Dent 2017;
20(2):119–213. Available at: https://www.quintessence-partner.com/chairside-
systems-current-review.
2. Mangano F, Gandolfi A, Luongo G, et al. Intraoral scanners in dentistry: a review of
the current literature. BMC Oral Health 2017;17(1):149.
3. All3DP. SLA vs DLP: the differences – simply explained. Available at: https://all3dp.
com/2/dlp-vs-sla-3d-printing-technologies-shootout/. Accessed October 12, 2019.
FURTHER READINGS
Ender A, Mehl A. Influence of scanning strategies on the accuracy of digital intraoral

scanning systems. Int J Comput Dent 2013;16:11–21.
Gurrea DDS. Evaluation of dental shade guide variability using cross-polarized
photography. Int J Periodontics Restorative Dent 2016;36:e76–81.
Hegenbarth EA. Esthetics and Shade Communication: A Practical Approach. Eur J
Esthet Dent 2006;1(4):p340–60.
Reshad M, Cascione D, Magne P. Diagnostic mock-ups as an objective tool for pre-
dictable outcomes with porcelain laminate veneers in esthetically demanding pa-
tients: a clinical report. J Prosthet Dent 2008;99:333–9.
Robertson AJ, Toumba KJ. Cross-polarized photography in the study of enamel de-
fects in dental paediatrics. J Audiov Media Med 1999;22(2):63–70.
Sancho-Puchades M, Fehmer V, Hämmerle C, et al. Advanced smile diagnostics us-
ing CAD/CAM mock-ups. Int J Esthet Dent 2015;10:374–91.
Seelbach P, Brueckel C, Wöstmann B. Accuracy of digital and conventional impres-
sion techniques and workflow. Clin Oral Investig 2013;17:1759–64.
SLA vs DLP: the differences- simply explained. By Ricardo Pires. 2019. Available at:
https://all3dp.com/2/dlp-vs-sla-3d-printing-technologies-shootout/.
T h e U s e o f B o t u l i n u m Tox i n
and D ermal F illers to
E n h a n c e Pa t i e n t s ’ P e rc e i v e d
Attractiveness
Implications for the Future of Aesthetic
Dentistry
a,b,
Phong Tran Cao, DDS *
KEYWORDS
Aesthetic dentistry Cosmetic dentistry Aesthetic medicine Botox
Dermal fillers
KEY POINTS
Physical beauty has long held an important place in society, because of biologic and psy-
chological predispositions to treat those one deems attractive in more positive ways.
Facial features change over time and often represent the first and most obvious evidence
of physical aging.
Veneers and crowns, along with invasive surgical procedures, have previously been the
only tools available to alter a patient’s facial appearance and combat signs of aging.
Today, aesthetic dentists have other means at their disposal, including Botox and dermal
fillers, to greatly improve the appearance of their patients. These injectable products serve
a complementary role to standard equipment in the dentist’s armamentarium.
The field of aesthetic dentistry evolves with each passing day. New practices, prod-
ucts, devices, and perspectives continue to emerge, and dentists are leading the
charge to change lives through a tailored approach that combines these elements
to suit the unique needs of each individual patient. Although some may consider
“changing lives” hyperbolic coming from a dentist’s mouth, there is ample evidence
indicating that a person’s appearance can heavily impact his or her life experiences,
and that a healthy, beautiful smile alone may achieve this.1 Bearing this in mind,
a
University of California, Los Angeles, Los Angeles, CA, USA; b Cosmetic Dentist and Private
Practice, 5 Star Dental, 700 East Silverado Ranch Boulevard, Suite 100, Las Vegas, NV 89183, USA
* Cosmetic Dentist and Private Practice, 5 Star Dental, 700 East Silverado Ranch Boulevard, Suite
100, Las Vegas, NV 89183.
Dent Clin N Am 64 (2020) 659–668

660 Tran Cao
aesthetic dentists who dedicate themselves to improving patients’ smiles now have a
unique opportunity to expand beyond the lower third of the face when addressing
facial appearances. This opportunity comes in the form of such products as botulinum
toxin (BTN) and fillers (eg, hyaluronic acid). Once limited to cosmetic surgeons’ prac-
tices, these products also can aid dentists in addressing the aesthetic goals of their
clients.
When considering the future of aesthetic dentistry and how best to help patients
navigate their journey to a more attractive physical appearance, it is vital to understand
the underlying reasons for humans’ preoccupation with appearance and what is
considered generally attractive. It is also necessary to question whether dentists are
optimally using all tools and approaches at their disposal to support patients, and
whether new and emerging treatments beyond the typical veneers and facial surgeries
might offer a viable path forward. Dentists have a duty to improve not just their pa-
tients’ smiles, but also their quality of life. Understanding and assisting aesthetic
dental patients in their pursuit of a more attractive appearance is central to this role.
WHY ARE HUMANS SO PREOCCUPIED WITH PERCEIVED ATTRACTIVENESS?
The global beauty market is a billion-dollar business that is only expected to grow. The
reason for this continued growth has ancient and modern roots.
Artists, such as Leonardo DaVinci, studied faces to discern ideal proportions, and
the Roman poet Ovid wrote the first known manual of beauty advice for women. These
creatives were studying attractiveness from a unique perspective and even today re-
searchers continue to explore the concept of perceived attractiveness.
If history did not offer enough evidence to persuade one that humans are preoccu-
pied with attractiveness, it should be noted that evolutionary theories, such as those
regarding the survival of the fittest, also emphasize physical appearance. In fact, there
is evidence that people look for symmetry or absence of gross asymmetry as a mea-
sure of health and fitness in a mate.2
Furthermore, evolutionary psychology tells us that males are attracted to traits
associated with estrogen, such as bigger eyes and fuller lips or a smaller chin and
more diminutive nose. And research finds that males also favor high cheekbones in
women to indicate childbearing maturity. It is not only males who evaluate perceived
attractiveness with an evolutionarily modified lens. Females look for traits synonymous
with the presence of testosterone, such as square chins, broad musculature, and
heavy brows.3,4
Aside from the general selection of a mate based on innate measures of perceived
attractiveness, humans also make important decisions based on appearance. These
decisions, research indicates, may mean that humans are predisposed to equate
someone’s personality or trustworthiness with one’s perception of their facial
aesthetic.
More visually pleasing or attractive faces may lead to different outcomes for those
who have them and there is evidence that humans may consider attractive people
morally superior, give them better grades in school, and even offer them a lighter pun-
ishment for crimes committed.5,6
Those considered attractive often experience greater employment success and find
themselves being higher paid. Moreover, those who find themselves to be beautiful
also judge themselves more favorably.5,6
Conversely, those with facial asymmetry or other atypical facial features may find
themselves enduring a different set of social experiences. Those with facial asymme-
try or facial features outside of the norm may be deemed untrustworthy, lazy, or less
Fillers to Enhance Patients’ Perceived Attractiveness 661
intelligent. Research indicates that these are not simply an indication of one’s “prefer-
ences” from moment to moment. Studies indicate that the brain is essentially hard-
wired to perceive attractiveness in this light.7
Furthermore, there is evidence that humans view attractive faces differently, even
from birth, and that this reaction is biologic and rapid. In fact, research indicates that in-
fants respond to more attractive faces.1 When humans are viewing an attractive face the
fusiform gyrus that handles facial recognition activates the nucleus accumbens, the
brain’s reward center. It also stimulates activity in the amygdala where humans handle
emotional responses. The frontal cortex, which is related to higher-order reasoning, is
also impacted as is the orbitofrontal cortex, which handles decision making. Finally, ac-
tivity is also present in the caudate nucleus, which formulates and activates repetitive or
stereotyped behavioral responses when viewing attractive faces.
This chain of events indicates that the human body has an innate propensity to react
to a face it perceives to be attractive by sending multiple rewarding signals to our
brain. The brain receives these signals and begins a chain-reaction-like process of
stimulation. As a result of this stimulation and that process, the brain can begin formu-
lating and reinforcing stereotypes.
Those stereotypes, because of that reward system that is activated, become hard-
wired and cause humans to equate perceived attractiveness with positive emotions.
There is also reason to believe that although the process is multifaceted, it occurs
quickly: The brain can recognize and determine attractiveness in less than
13 milliseconds.8,9
ATTRACTIVENESS AND BEAUTY IN THE AGE OF SOCIAL MEDIA
With the advent of the Internet and the rise of social media, basic concepts of attrac-
tiveness have become heavily influenced by what is popular nationally and globally.
Influencers, movie and television stars, pop culture icons, and the likes have all
impacted what the general population considers attractive. The pervasive reach of
the Internet has led to a propagation of norms of attractiveness, and those norms
are now more easily recognizable than ever. The results of this phenomenon are a ho-
mogenization of beauty standards, because those on the receiving end seek to alter
their own appearance to emulate that of their idols.
Although beauty norms are impacted by popular culture, there is still evidence that
the general population leans on an evolutionarily predisposed ideal for attractiveness
that includes facial symmetry, plump lips, and full cheeks. Finally, the obsession with
youthfulness, which dates back to antiquity and is alive and well today, dictates a large
part of today’s beauty standards. Thus, traits that betray the process of aging, such as
wrinkles, marionette lines, or jowls, are considered undesirable. Dentists, who spend
their professional lives working in and around the mouth and the face, are more than
familiar with signs of extreme aging.
SIGNS OF AGING: THE SKELETON AND FAT PAD ATROPHY
The human skeleton changes throughout its life via osteoblastic and osteoclastic ac-
tivities. Patients in their twenties have skulls that are at their densest and as aging pro-
gresses, the skull morphs, leading to adjustments in one’s facial appearance. These
ongoing skeletal changes impact the overlying soft tissue, the skeletal muscle attach-
ments, and the ligaments (Fig. 1).
In addition, the body’s process of storing and distributing fat changes with aging.
The compartmentalized fat pads that once gave babies their plump cheeks and
held up the skin tautly begin to lose volume, and gaps develop between different
662 Tran Cao
Fig. 1. Facial bone changes over time. (ª 2020 Kevin Cease. All rights reserved.)
compartments. These changes are magnified by gravitational pull and a concurring

loss of collagen in the skin, leading to weaker, less elastic skin. Taken together, these
physical changes lead to an altered facial appearance, commonly described as
sunken or uneven, that is indicative of aging.10
Additional changes occur with fat pads around the temporal fossa (Fig. 2). As they
atrophy, temporal hollowing develops, compromising the integrity and support they
have provided to the skin. The result is a sagging of the skin that contributes to the
drooping of the lateral eyebrow to or below the level of the superior orbital rim; this
sinking can occur in one or both orbital rims with age.11 With more advanced aging,
the appearance of wrinkles, hollowed cheeks, malar bags, and jowls provide further
evidence of the deterioration of fat pads over time.
Fig. 2. Fat pad changes with aging. (ª 2020 Kevin Cease. All rights reserved.)
CHANGES IN THE PERIORBITAL CAVITY AND MANDIBLE AS AN INDICATOR OF

AGING
When discussing signs of aging, one cannot overlook the periorbital cavity. The peri-
orbital cavity expands with time but not always in the same way. The changes to the
inferolateral orbital rim occur by middle age, whereas those to the superomedial rim
lag in time. Both, however, experience greater bone resorption than the remaining as-
pects of the orbital rim. Moreover, the infraorbital fat pad loses its integrity, forming an
indentation that becomes more pronounced over time.
The jaw bone, anterior nasal spine, and pyriform aperture recede with age for pa-
tients who have teeth and those who no longer do.12 This posterior movement is
accompanied by a displacement of the soft tissue that lays over each.
664 Tran Cao
These collective movements, coupled with the atrophy that occurs in the nasolabial
fat pad, create a fold in the nasolabial region of the face. Furthermore, when the ante-
rior nasal spine recedes backward, the columella also recedes. The result is that the
nose tips downward and can appear longer than it had before.
The mandible itself undergoes some changes with age that can impact a patient’s
appearance. The ramus experiences a shortening effect and the chin bone is
resorbed. The mandible’s measurements are reduced with aging, in height and in
length. The resorption of the mandible’s prejowl area creates a concave shape that
does not offer enough support for the overlying soft tissues in that area. The result
is often a less defined jawline, evidence of jowls, and further indication of aging.13
These changes beneath the skin can impact the superficial appearance of the face
at the skin level (Fig. 3).
Fig. 3. The appearance of skin over skull. Changes happening beneath the skin change the
superficial appearance of the skin. (ª 2020 Kevin Cease. All rights reserved.)
AESTHETIC DENTISTRY APPROACHES TO ADDRESSING AGING AND IMPROVING

PERCEIVED ATTRACTIVENESS
Dentists are able to enhance a patient’s personal appearance, and aesthetic dentistry
has been tasked with this mission since its inception. In general, dentists find them-
selves working within the lower third of the face, working to provide a full, bright,
and beautiful smile to patients who seek dental care. Those who perform aesthetic
dentistry procedures may work to reduce excessive buccal corridors by combining or-
thodontic treatment and veneers. The goal, in this case, is to provide support for a pa-
tient’s hollow cheeks and the results would ideally be a more youthful and plump
cheek appearance and symmetry.
Dentists may also work to enhance facial appearance by adjusting the height of the
lower third of the face. This may mean increasing the vertical dimension of occlusion or
using orthognathic surgery to decrease that same section. The result, in either case,
would be to address protrusion or recession and achieve the desired facial aesthetic
for the patient.
OTHER POTENTIAL MEASURES TO IMPACT A PATIENT’S PERCEIVED

ATTRACTIVENESS
Aside from the aforementioned dental procedures, dentists have access to other tools
that can support patients in achieving their aesthetic dentistry goals. In recent years,
facial injections, such as the neurotoxin BTN, and facial fillers, such as hyaluronic acid,
previously reserved for the cosmetic surgeon and aesthetician’s practice have become
available to other specialties. Indeed, a growing number of states have extended the
approved use of these dermal fillers and injections to include provisions that allow den-
tists to offer these services to their patients in the dental office. This affords dentists
the chance to further help patients achieve their aesthetically related treatment goals.
BOTULINUM TOXIN
BTN is produced by the obligate anaerobic bacterium Clostridium botulinum. At a

basic chemical level, BTN consists of a light chain and a heavy chain connected by
a disulfide bond. The heavy chain has a high affinity for nerve terminals that uptake
acetylcholine, and is responsible for BTN entering the neuron through endocytosis.
Once inside, the light chain becomes detached from the heavy chain, infiltrates
outside the vesicle membrane, and targets the snare protein cleaving part of the
SNAP25 protein. This prevents the acetylcholine vesicles from binding to the presyn-
aptic receptor, blocking the release of a signal that would cause muscle contraction.
This leads to localized paralysis. Once the SNAP25 protein is destroyed, it is no longer
able to release the neurotransmitter responsible for contraction. When practitioners
who inject BTN target specific muscles, the result is a smoothing and relaxing of
the skin, and reduction if not effacement of wrinkles.
There is also evidence that BTN may be beneficial for the treatment of myofascial
pain, bruxism, and controlling the occlusal force.14 Furthermore, because myofascial
pain is often associated with the constant contraction of particular muscle groups,
practitioners can target these trigger points to impact the pain pathway and interfere
with the way pain travels to other parts of the patient’s body.14
HYALURONIC ACID
Hyaluronic acid is a clear gel-like polysaccharide substance found in the human body.
It is a nonsulfated glycosaminoglycan distributed throughout the connective,
666 Tran Cao
epithelial, and neural tissues (see Fig. 1). Hyaluronic acid is highly hydrophilic in nature
and helps lubricate joints and allows the skin to appear smooth.
Most hyaluronic acid fillers that are used in aesthetic medicine are derived from
bacterial cultures. Hyaluronic acid molecules are typically cross-linked to slow
down the degenerative process. The advantage of hyaluronic acid fillers is that their
effects are reversible with the use of hyaluronidase. Because vessel occlusion is not
an uncommon scenario, it is common best practice to keep the antidote on hand
when offering hyaluronic acid fillers. The manner in which hyaluronic acid fillers
are applied significantly impacts the results. Placing these fillers under the skin
can result in hydrated, plump skin appearance, which is often considered a sign of
youthfulness. When hyaluronic acid fillers are placed with care and strategy under
certain muscle groups or on bone, they can support and alter the location of the
skin.15,16 Hyaluronic acid and dermal fillers can also be used to address hollowing
of the cheeks.
USE OF HYALURONIC ACID AND BOTULINUM TOXIN IN AESTHETIC DENTISTRY

Occlusal Force
Aesthetic dentists understand that each patient’s characteristics demand an individ-
ualized approach. Controlling for the occlusal force, for example, remains a great chal-
lenge. A dentist may provide well-designed veneers or crowns but cannot account for
occlusal force acting on those prostheses over time. These long-lasting procedures
are impacted by a patient’s propensity to wear down teeth or to develop masseter hy-
pertrophy. In addition, patients’ compliance is also a challenge in this area, and BTN
may be a remedy for this issue. Injecting the masseter muscle with BTN may lead to a
slimming of the face or jawline through atrophy of the masseter muscle, which may
also impact occlusal force.14,15
Black Triangle
Black triangle or loss of interdental papillae volume is another challenge that aesthetic
dentists face when working with patients. Although a common approach to the black
triangle is to adjust the shape of the patient’s teeth, hyaluronic acid fillers may also be
a helpful measure. The filler is highly effective in treating black triangles when injected
directly into the papillae. This causes the area to plump up and can minimize the void
or black triangle.17
Gummy Smile
Another common cosmetic challenge dentist’s face is the gummy smile. A gummy
smile is usually the result of an amalgamation of several factors, including a thin upper
lip, gingival hyperplasia, the skeletal position of the maxilla, delayed passive eruption,
and labial hypermobility. If a patient has a minor gummy smile, fillers are used to in-
crease the volume of their lips. This volume decreases the amount of gingival display
and can enhance the overall appearance of the smile.
A gummy smile can also be addressed by targeting the levator labii superioris alae-
que nasi and the levator labii superioris located lateral to the alae of the nose. In so
doing, practitioners weaken the elevation of those muscles and correct the hypermo-
bility of the lip, thereby correcting the gummy smile.
SUMMARY AND IMPLICATIONS FOR FUTURE PRACTICE
Given the deeply ingrained evolutionary, social, psychological, and biologic forces
driving the pursuit of a more appealing physical appearance, patients will continue
to seek out the assistance of aesthetic dentists and clinicians to help them attain some
personal measure of improved beauty. This desire to appear more attractive is indeed
deeply human. It dates back to the beginning of mankind; it is enduring and will
continue to grow throughout our existence. It is central to the craft and profession
of aesthetic dentists.
In the past, dentists who wished to change their patients’ appearance for the better
were limited to addressing their teeth and smiles, working primarily with crowns, ve-
neers, and mandibular adjustments or surgeries to achieve beneficial results. Howev-
er, as more tools and options become available in this task, the dental profession will
find itself faced with several decisions. It will need to decide whether as a community,
it has the obligation to learn to use these tools, and how best to apply them in the ser-
vice of patients. It will also need to decide if dentists should seize this opportunity to
move toward addressing the upper two-thirds of the patient’s face. Finally, the profes-
sion will need to decide if dentists should step forward to become a trusted source to
guide the use of new and emerging science and tools.
Two such tools relevant to aesthetic dentistry are hyaluronic acid and BTN. In both
cases, the field should take note. BTN is used to address facial tensing related to the
constriction of muscles in the face and can reduce the appearance of fine lines and
wrinkles. Hyaluronic acid may be used to plump and smooth the appearance of
skin leading to a more youthful appearance. These tools are already in use in dental
offices across the country, and their application will only continue to grow as word
of their effectiveness reaches even more patients. Whether it is through relief of
pain, reduction of sagging and plumping in the skin, and easing of wrinkles, these
two tools have been shown to create youthful, attractive, and positive results for pa-
tients who receive them.
In a society preoccupied with physical appearance, it is conceivable, and
becoming more commonplace, that dentists will find themselves asked by patients
not only for a new and brighter smile, but also for a remedy to their sagging wrinkles
and aging facial features. Although cosmetic surgeons and other professionals may
be able to offer these services to their patients, dentists are uniquely positioned to be
of service in this area in a comprehensive way. Patients may purposefully seek out
their dental professionals specifically because dentists know the face intimately
and study it rigorously, and because their unique area of expertise, the smile, rests
at the core of an attractive face. A dentist’s years of training and practice may give
patients confidence in his or her ability to safely and effectively offer BTN and hyal-
uronic acid fillers.
It bears mentioning that dentists need not ignore or overlook the use of veneers,
crowns, or even orthodontia. In fact, in some cases, it may be preferable to resort
to one of these approaches instead of BTN or hyaluronic acid fillers. However, arming
themselves with a wide array of options allows dentists to offer the most appropriate
and impactful treatment to each patient based on his or her unique needs. These prod-
ucts may be combined with a full array of other relevant approaches. The goal remains
the same: to provide the best possible care and achieve the best possible outcome for
each patient.
As aesthetic dentistry continues to evolve, it is imperative that dentists consider how
adoption and incorporation of these tools can change the lives of their patients and
how it may help shape the future of the profession.
DISCLOSURE

668 Tran Cao
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A Beginning Guide for
Dental Photography
A Simplified Introduction for Esthetic Dentistry
a,b,
David J. Wagner, DDS *
KEYWORDS
Dental photography Beginner’s guide Esthetic dentistry
KEY POINTS
Dental photography is a simple and available tool that can transform a dental practice.
Dental photography is a skill that is needed in order to perform high-level, predictable
esthetic dentistry.
Dental photography plays a critical role in the continuous journey of self-improvement for
esthetic dentists.
BEGINNING THE JOURNEY
My first introduction to dental photography was during my Advanced Education in

General Dentistry residency at University of California, Los Angeles (UCLA) School
of Dentistry. We were required to buy a simple digital single-lens reflex (DSLR) camera,
macro lens, and ring flash. Looking back, I lacked a full understanding of photography
concepts and its value for a dentist. I had a scarcity mindset: the goal was to spend the
least amount of money while satisfying the program requirements, rather than to truly
understand the process of dental photography and its value. I did not have a workflow.
When my photos were of poor quality I was not sure why. When my photos were of
good quality, I simply got lucky. I was learning a tremendous amount about complex
restorative dentistry, implants, and esthetics, but I was not using my camera with
intention as I do today. I did not fully understand the camera as a necessary instrument
for the type of dentist I wanted to be: practicing esthetic, restorative, and comprehen-
sive dentistry at the highest level possible.
Two things occurred in my career that shaped my path. First, I started a continuing
education (CE) journey with purpose, seeking high-level courses that taught compre-
hensive, patient-centered, relationship-based approaches to dental care. These
courses all used photography as the foundation upon which to build a relationship,
a
Private Practice, West Hollywood, CA, USA; b UCLA Center for Esthetic Dentistry
* 8733 Beverly Boulevard #202, West Hollywood, CA 90048.
Dent Clin N Am 64 (2020) 669–696

670 Wagner
trust, and understanding with a patient as well as perform accurate diagnosis and form
a treatment plan. Second, I started taking dental photography courses. Third, once
some formal photography education was underway, I began teaching photography
at the UCLA Center for Esthetic Dentistry. These experiences, and many hours to tak-
ing photos in a private setting, have shaped my ability to understand photography as it
relates to dentistry. More importantly, it has allowed an evolution to continue to distill
the complex into more and more simple workflows.
VALUE AND PURPOSE OF DENTAL PHOTOGRAPHY

Documentation
Patient education and case acceptance
Collaborating and communication with colleagues
Marketing and branding
Dental education
Evaluating outcomes
Documentation
Beyond esthetic dentistry, creating thorough records is imperative to operating a
compliant and responsible practice. All new patients should have photographs taken
of their starting condition as they enter the practice for clinical reference as well as
medical-legal protection for the dentist. Initial photographs serve as a time stamp of
the patient’s existing state when they first become a patient. It is important that these
photographs are of high quality and include multiple views of the patient’s face, smile,
and dentition. Furthermore, within dental esthetics, a workflow should be developed in
order to provide consistent, high-level documentation throughout all stages of treat-
ment, including follow-up.
Patient Education and Case Acceptance

Photography is an integral part of communicating with patients. It allows the dentist to
show the patient the starting point, existing conditions, findings, simulated treatment
options, and examples of finished procedures for understanding and motivation.
When discussing esthetic treatment, it provides a conduit to clearly understand pa-
tient goals, and aspects of their smiles they do not like and would like to enhance.
One approach developed by dentist Bob Barkley in the 1960s and still taught in highly
regarded CE courses is the process of codiscovery.
This process involves dentist, patient, and photography, and results in the patients
gaining a thorough understanding of the conditions of their dentition and oral health.
Bob Barkley spoke to this issue brilliantly when he said, "No greater risk of failure
can be run than that of attempting to use traditional patient management procedures
in a health oriented restorative practice. Examining and treating a patient’s mouth
without prior attitudinal development is an error of omission for which the dentist
pays handsomely with time, energy, stress, and money.”1 Photography is key for
this process and results in the success of the attitudinal development of patients,
where patients can see their dentition, begin to fully understand and take ownership
of their conditions and problems, and strongly value high-level treatment.1
In dental esthetics, through the process of diagnosis, treatment planning, and digital
smile design, photography is used to develop a clear path for a patient’s treatment. A
smile design and proposed outcome can be presented to a patient. A digital simulation
of the outcome has a profound impact emotionally on patients because they are able
to experience how esthetic dental treatment can influence their overall appearance.
Beginning Guide for Dental Photography 671
Fig. 1. (A) Initial Patient Presentation. (B) DSD Outline Form. (C) DSD Virtual Smile Simula-
tion. (D) Prototype Try In based on Wax Up. (E) Final Restorations. (Courtesy of Yair Y. White-
man, DMD, Los Angeles, CA.)
Fig. 1 shows the steps of a completed case motivated by photography and a digital
smile design process. The more clinicians are able to communicate in this visual
fashion, the more patients tend to understand their options and how esthetic dental
treatment can help accomplish goals of improving their appearance.
Collaborating and Communication with Colleagues

Esthetic dental treatment is often interdisciplinary, involving close collaboration with
other specialists. Esthetic dental treatment always requires detailed laboratory
communication. Photography, presentation development, and digital smile design al-
lows for optimal communication for interdisciplinary treatment planning to occur. If a
dentist does not practice in close proximity to the dental lab that will be fabricating the
restorations where a custom shade appointment can be accomplished, then photog-
raphy will be required for shade matching purposes (Fig. 2). Photography is also used
for evaluating restorations at the try-in appointment and then communicating to the
laboratory if modifications are needed. Esthetic dental treatment cannot be done
accurately or predictably without photography.
Branding and Marketing

Photography is needed when branding an esthetic dental practice as well as market-
ing the practice to both grow and maintain its relevance. Photography is used both
internally and externally for these purposes. Before-and-after photos of patients can
be shown to patients during a consultation. Specifically, completed treatments from
672 Wagner
Fig. 2. Shade matching for esthetic treatment.
cases similar to a patient’s condition can be used as a relatable example of someone

else that underwent treatment and experienced an excellent outcome. Examples of
completed cases should be included in your overall online presence to help patients
find you for the type of treatment you are offering and they are seeking. Photography
can help differentiate a dental practice from others depending on the quality that is
performed and the style that is displayed.
Dental Education
Photography allows content development for lectures, study clubs, forums, and other
aspects of education and collaboration among colleagues. When attending high-level
dental meetings, incredible dental photography can be witnessed in presentations.
Even if not currently teaching, documenting cases in a complete manner helps to build
a library of content that may be used in the future should a teaching or lecturer position
ever be pursued.
Evaluating Outcomes
Photography allows dentists to see the outcomes of their work as well as to evaluate
successes and shortcomings.
This is one of the most important factors for growth and development for practitioners of
esthetic dentistry: every case, when documented well, scrutinized, and reviewed with col-
leagues and other experts, leads to exponential learning opportunities.
Routinely taking photographs at each step of treatment (diagnosis and treatment

planning, prototype try-in, preparations, provisionals, final restoration try-in, cementa-
tion, and postoperative) collectively provides information that would otherwise not be
available for fully understating outcomes, creating a path to mastering clinical skills.
PHOTOGRAPHY SETUP
Like other dental equipment and instrumentation, photography equipment comes in

varying levels of quality and a wide range of price. So many options for photography
equipment exists that it can be overwhelming for first-time users who are not sure
where to start. Smartphones, point-and-shoot, and DSLR cameras are all options for
the dentist and team. Although smartphones and point-and-shoot cameras are conve-
nient, less expensive, and less technical, they do not have the overall functionality and
nor do they produce the overall quality that DSLR cameras provide. Therefore, it is rec-
ommended that a DSLR camera be the primary camera for dental esthetics. There are
multiple brand options for cameras and lighting that satisfy the level of quality desired;
the aim of this guide is to simplify the shopping list with function, ease of use, and
attainability in mind. There are five main categories encompassing proper photog-
raphy setup:
DSLR camera body
Macro lens
Lighting setup
Accessories
Laptop computer
Digital Single-Lens Reflex Camera Body

The camera body is the main part of the camera minus the lens and lighting setup.
Camera bodies come in 2 types: full frame and cropped sensor (Advanced Photo Sys-
tem type C [APS-C]). Full-frame cameras are what professional photographers use.
Cropped-sensor cameras have a smaller sensor and are less expensive but are still
of excellent quality. A full-frame camera will work for dental photography; however,
a cropped-sensor camera is all that is needed for high-level dental photography. By
choosing a cropped-sensor camera, a dentist can save thousands of dollars without
sacrificing the quality that is needed. Because of their smaller sensors compared with
full-frame cameras, APS-C cameras capture only part of the image produced by the
lens. This feature is known as a crop factor.
To work around this small variation in sensor size (crop factor), the photographer
simply needs to move slightly away from the subject to capture the same image at
the same distance as a full-frame camera. This technique results in a magnification
phenomenon that influences the focal length once the lens is connected to the
body, which means that, depending on the space present in a dental practice, the
proper lens type paired with a cropped-sensor camera allows the dentist to take pho-
tographs comfortably in a small operatory room setting, versus a larger studio space,
which is not always available in a dental practice.
Macro Lens
The type of lens needed for dental photography is referred to as a macro lens. A lens is
selected by brand, quality, focal length, and cost (Table 1). The lens is perhaps the
most important aspect of the photography setup, where its physical quality is a greater
determining factor of overall photo quality outcome than other parts of the dental
photography setup. The number on the side of the lens signifies the focal length of
the lens. The focal length determines how close the dentist needs to be to the patient
in order to capture the desired photo. The appropriate focal length for dental photog-
raphy is a range (85–105 mm), depending on the type of camera as well as how much
space is present in the dental operatory or studio setting.
As discussed previously in this article, a cropped-sensor camera has a multiplying
effect (crop factor) of 1.5. Therefore, an 85-mm macro lens placed on a cropped-
sensor camera translates to a focal length of 127.5 mm (85 mm 1.5). A 100-mm
macro lens placed on a cropped-sensor camera translates to a focal length of
150 mm (100 mm 1.5). The 85-mm lens (lighter, smaller, and less expensive
674 Wagner
Table 1
Macro lens recommendations
Lens Pro Con

Nikon AF-S Micro Lighter in weight Slight lower quality
Nikkor 85 mm f/3.5 Smaller in size compared with
Less expensive Nikon 105 mm
Decreased working
distance required
compared with
Nikon 105 mm
Nikon AF-S Micro High quality Heavier in weight
Nikkor 105 mm f/2.8 Excellent optics Expensive
Smooth, fast focus Larger in size
Increased working
distance required
compared with
Nikon 85 mm
Tamron SP 90 mm f/2.8 Excellent optics Cannot get as close
Middle price range to patient as
Can work closer to Nikon 85 mm
patient than
Nikon 105 mm
Tokina atx-i 100 mm f/2.8 Least expensive Slow focus speed may
Excellent optics be off-putting and
Light in weight slows efficiency
compared with the 100-mm macro lens) therefore allows the dentist to be closer to the
patient when taking photos. This closer proximity of the dentist to the patient has sig-
nificant advantages for shorter individuals as well as those with space restrictions who
will be taking all photos in a standard dental operatory versus a studio space within the
dental office.
Lighting Setup
An understanding of how to use and manipulate light is perhaps the most technical
and important aspect of learning to deliver predictable dental photography at a high
level. There are multiple lighting configurations for dental photography. With each
lighting configuration option comes advantages and disadvantages. Within these con-
figurations, 2 major categories exist: on-camera lighting and off-camera lighting.
Lights used for high-level dental photography are called either speedlights or
strobes. Speedlights are less expensive, battery powered, portable, and can be
used on or off camera, whereas strobes are more expensive, more delicate, only
used off camera, and most need to be plugged into an electrical outlet. Both speed-
lights and strobes can easily be purchased online or at a photography store. When
speedlights are used on camera, they are held by an adjustable bracket that is
attached to the bottom of the camera body (Fig. 3). Multiple options for brackets to
hold speedlights for on-camera lighting are available online. When speedlights or
strobes are used off camera, they are positioned on a stand near the patient. These
stands can easily be purchased online or at a local camera store.
A commander is the required piece of equipment that allows communication be-
tween the camera and the lights. The commander is also responsible for controlling
the flash power, or the amount of light output each time the light flashes. In photog-
raphy, the nomenclature used for flash power on both a commander and light source
Fig. 3. Camera setup.
is as follows: 1:1 for full power, 1:2 for half power, 1:4 for one-quarter power, 1:8 for
one-eighth power, and so on. Depending on the needs of the dental photographer,
different levels of flash power may be used. Although some cameras have a built-in
internal commander, it is recommended to use an external commander attached to
the top of the camera for efficiency reasons, because the settings can be quickly
viewed and changed on the commander display (see Fig. 3).
Light Modification
Light in flash photography can be modified from its original state to produce a superior
image. Light is changed by forcing it to pass through a medium or directing the light
elsewhere (filtering or scattering the light particles) before it reaches the subject.
The process of filtering and scattering the light decreases the concentration of light
particles and therefore results in what is referred to as modified light. An example of
this is a reflector, diffusor, bouncer, or soft box that can be used in conjunction with
speedlights and strobes (see Fig. 3). One elegant do-it-yourself approach to light
modification that is commonly used is white paper stock placed in front of speedlights
to function as a diffusor, which can function exactly like more expensive light modifi-
cation equipment to create a more pleasing image (Fig. 4).
Unmodified light is typically described as harsh, creating undesired reflections that
can block critical detail. Light that is modified by a diffusor or bouncer is described as
soft, which produces more pleasing images. For example, in close-up photography,
diffused light can help produce desired reflections that highlight nuances of teeth
characterization, such as line angles and incisal translucency. In portrait photography,
diffused light produces images with more flattering features, such as smoother skin,
creating an overall more professional-looking and emotionally charged image. Note
that, when using modifiers, additional flash power may be needed, or camera settings
changed, to allow more light to the camera sensor, compared with settings without
modifiers, in order to achieve an image with proper exposure. Light modifiers (reflec-
tors, diffusors, bouncers, soft boxes) can easily be purchased online.
Ring lights, a type of speedlight where the lights are concentrated at the edge of the lens, are a
common type of light used in dental photography. However, these lights are better suited for
intraoral or surgical pictures and are not flexible for achieving high-level photos for all-around
esthetic dentistry.
676 Wagner
Fig. 4. Camera setup with white paper diffusors.
Light Arrangement
In photography, the position of the lights in relation to the subject influences the
outcome of the image. Lights can be positioned closer to or farther from the lens as
well as closer to or farther from the subject for both on-camera and off-camera light-
ing. Depending on the location of the lights, more or less highlight and shadow is
created, leading to more or less depth. For clinical diagnostic photos, there should al-
ways be symmetrical lighting, where there is a lighting source on each side of the lens.
For portrait photography, this rule does not always apply; depending on the type of
image desired, a single light, either behind the photographer or off to one side of
the subject, can result in slight shadowing on one side of the face. This shadowing cre-
ates a more interesting, dynamic image with additional depth and mood.
On-camera lighting position is changed by moving the speedlights attached to the
adjustable bracket being used. Typically, lights are positioned next to the lens for
intraoral photos and angled at 45 to the subject on each side for close-up smile
photos and portraits.
Off-camera lighting with speedlights or strobes can be positioned in a similar
fashion, either closer to the lens or at 45 angles to the subject. However, as
mentioned before, often a single strobe with a soft box is appropriate for close-up
smile or portrait when using strobe lighting. This single strobe light can be paired
with a single reflector, or 2 reflectors (1 held by the patient). As mentioned before, re-
flectors are a form of light modification and help to bounce light and fill deficient areas,
creating a more balanced and pleasing image. Note that certain strobe lights provide
so much soft light that it can eliminate details of the teeth (commonly referred to as a
washed-out appearance). It is often said that soft boxes can result in images that
make the patient’s restorations look like plastic denture teeth, which lack the vitality
and sophistication of high-level, layered porcelain veneers. The type of lighting should
be selected based on the intention of the clinician: diagnosis and treatment planning,
documentation for patient education, building a before/after portfolio, or emotional im-
ages for branding and marketing.
Accessories
Various accessories are used in dental photography. Table 2 includes a basic list.
Additional accessories can be used depending on needs.
Laptop
In order to store, manage, edit, and present dental photography images, a computer is
required. A laptop with photo editing software as well as presentation software is
Table 2
Accessories
SD memory card Multiple SD memory cards should be available.

SD memory cards are reliable, but can easily
become damaged, and therefore 64-GB
memory capacity or less is an appropriate
investment. Uploading photos to a hard drive
and backup storage is recommend regularly,
at least at the end of each clinical day
Lip retractors Required to lift patient’s lips away for intraoral

photos. Can be metal or plastic. Metal is
desired because plastic becomes scratched and
faded easily when sterilized. Multiple sets of 2
should be sterilized together and kept
packaged and ready for use
Occlusal mirrors Paired with lip retractors, required for occlusal
(highlighted in yellow) intraoral photos. Mirrors come in a variety of
shapes and sizes, and additional accessories
such as handles, for ease of use. Mirrors can be
warmed to reduce fogging when in a patient’s
mouth. Stainless steel versions are available as
well for a less fragile option. Proper handling
and sterilizing reduces scratching and
increases longevity
Buccal/lingual mirrors Paired with lip retractors, required for buccal
(highlighted in yellow) intraoral photos. Mirrors come in a variety of
shapes and sizes, and additional accessories
such as handles, for ease of use. Mirrors can be
warmed to reduce fogging when in a patient’s
mouth. Stainless steel versions are available as
well for a less fragile option. Proper handling
and sterilizing reduces scratching and
increases longevity
Black contraster Paired with lip retractors, required to isolate
areas of dentition (ie, maxillary anterior),
moving lips out of the frame of the image and
blocking out opposing dentition and other
soft tissue. Comes in a variety of types and
final photos will require editing in computer
software
recommended, which can be easily used for putting together presentations for pa-
tients, specialists, and lectures. Note that dental photography images should not be
manipulated so as to change reality; obtaining quality images with the camera itself
is the goal, and simple cropping, rotating, and exposure changes can be accom-
plished with the computer software.
PHOTOGRAPHY CONCEPTS
Photography concepts must be understood in order to master dental photography.

Understanding these concepts leads to understanding camera settings and therefore
yields excellent photos: images that are in focus, have an appropriate depth of field, an
accurate color tone, and proper exposure (Table 3).
678 Wagner
Table 3
Photography concepts
Concept Definition Relationship What It Means

Focal length The distance from the The smaller the number, The smaller the number,
glass of the lens to the the wider the frame the closer the dentist
sensor inside the of the picture; 1.5 can get to a patient
camera body crop factor for DX when taking photos
(cropped-sensor
cameras)
Aperture (f-stop) The opening of the iris The lower the f-stop, A different f-stop is
of the lens when the more light enters used for different
taking a picture. the camera types of dental
Controlled and The higher the f-stop, photos. In general:
measured using the less light enters f/11, portraits
f-stop. Regulates the the camera f/22, close-ups
amount of light that f/32, intraoral
is allowed into the
camera to the sensor
Depth of field What is in focus, The higher the f-stop, A greater depth of field
influenced by the the greater the depth allows all teeth to be
aperture (f-stop) of field. The lower the in focus from anterior
f-stop, the smaller the to posterior
depth of field
Shutter speed Regulates the rate of The slower the shutter In dental photography,
opening of the iris, speed, the more light shutter speed is set at
and thus the amount enters the camera. 1/125, and not
of light that enters The faster the shutter changed; no need for
the camera. speed, the less light adjustments
Measured in fractions enters the camera
of a second
ISO Measure of the The higher the ISO, the Because of a controlled
sensitivity of the more sensitive the environment with
sensor to light. A sensor is to light, and flashes in dental
digital sensor can be the brighter the photography, ISO
adjusted to be more picture. The lower the should be set at 100
or less sensitive by ISO, the less sensitive or 200 and not
changing the ISO the sensor is to light, changed. If ISO is too
setting in the camera and the darker the high, pictures get
picture grainy with “noise”
White balance The color balance on a Measured in degrees For most flash setups for
digital camera. Can Kelvin dental photography,
be adjusted Low white balance including the Nikon
depending on the results in more cool R1C1 speedlights, the
lighting conditions or (blue) tones white balance should
lights being used to High white balance be set at 5500 K.
give proper color results in more warm Other lighting setups
balance (orange, red) tones may require different
settings
Abbreviation: ISO, International Standards Organization.

Table 4
f-Stop
Type of
Photograph F-stop
Portrait F10–F11
Close-up F20–F25
Intraoral F29–F32
Table 5
Photography settings
F-stop F10–F32 Modify settings based on the type of photo

being used
Shutter speed 1/125 Set and leave it. No need to change for
dental photography
ISO 100–200 Set and leave it. May need to change
between 100 and 200 if additional light is
needed
White balance 5500 K Set and leave it. Most lighting setups use
5500 K. Some require slight modification
Flash power 1:1, 1:2, 1:4 Set and leave it. May need to change if
additional light is needed
Camera mode Manual shooting Set and leave it. No need to change for
mode dental photography
Lens mode Automatic or Automatic focus is preferred for easy
manual focus workflow. Manual focus may be used in
extreme close-up situations where
automatic focus is unable to function
properly
PHOTOGRAPHY WORKFLOW AND SETTINGS
Once a camera is obtained, it is important to coordinate the camera settings to

facilitate proper function for dental photography. Camera settings for dental
photography are surprisingly simple: many are set once and not adjusted again.
Other settings are modified easily and minimally based on workflow. An efficient
way to develop a workflow is to change settings based on the type of images being
captured. For the purposes of this article, three main categories of images are used
in dental photography: portrait (full head); close-up (patient smiling, capture lips
and some skin beyond the lips); intraoral (those taken with lip retractors, including
facial, buccal, and occlusal views).
The most common setting to change is the f-stop, which regulates the aperture of
the camera. For portrait images, the camera is farthest distance away from the patient,
more light is required compared with close-up or intraoral images, and therefore a
lower f-stop is appropriate. For portrait images, f-10 or f-11 should be used. For intrao-
ral images, the camera is the closest to the patient, less light is required for a proper
exposure, and therefore a higher f-stop is appropriate. For intraoral images, f-29 or
f-32 should be used. Close-up images require a level of light in between portrait
and intraoral images, and therefore an f-stop of 20 to 25 should be used (Table 4).
The appropriate f-stop paired with other appropriate settings gives the proper expo-
sure and depth of field for the image (Table 5).
680 Wagner
Within the 3 main categories of photos, there are multiple images that should be
obtained to acquire all views required for diagnosis and treatment planning and
case work-up. An abbreviated set of images can be used based on needs. For
example, fewer photos may be needed for a new patient with no treatment needs
and images simply for initial documentation versus a patient with complex treat-
ment needs, where all images should be taken for maximum visual data.
Appendix 1 contains an image series outlining a recommended clinical workflow,
illustrations for reference of position of patient and dentist, patient image examples
of dental photographs, and associated camera settings. This guide can be copied
and taken into the operatory for an easy reference. This workflow requires one
photographer and one assistant. It is recommended that dentists master photog-
raphy first and then they can train team members to take the dental photographs
if competency can be achieved.
SUMMARY
Photography is a simple and available tool that, once mastered, can enable dentists
to perform esthetic dentistry at the highest, most predictable level. However,
photography is like other aspects of dentistry: it must be practiced over and over
to reach a level where the dentist is confident and proficient to obtain excellent re-
sults every time. Photography allows patients to find and choose dental practices;
without this, little esthetic dentistry will be done. Photography allows dentists to
communicate to their patients what is possible and it allows the transfer of informa-
tion among the entire team behind creating a new smile. Ultimately, photography al-
lows the achievement of optimal clinical outcomes that will be life-changing for
patients and plays a critical role in the continuous journey of self-improvement for
esthetic dentists.
DISCLOSURE
REFERENCE
1. Codiscovery. Co-discovery and co-diagnosis: what’s the difference?. Available at:

https://codiscovery.com/paul-henny/co-discovery-co-diagnosis-whats-the-difference/.
Accessed February 3, 2020.
APPENDIX 1:
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Courtesy of David Wagner DDS, West Hollywood, CA

Dentist-Ceramist
Communication
Protocols for an Effective Esthetic Team
a,b, a,c
Sivan Finkel, DMD *, Peter Pizzi, CDT, MDT
KEYWORDS
Communication Photography Smile design Esthetic dentistry
KEY POINTS
Close dentist/ceramist communication is critical for successful esthetic dentistry, and it is
the dentist’s responsibility to accurately convey the patient’s desires to the ceramist.
Digital photography is an indispensable tool for the esthetic dental team.
Each patient should be analyzed from the facial (full face), dental-facial (lips and teeth),
and dental (teeth only) perspectives.
The most important element and starting point of any smile design is the three-
dimensional position of the maxillary central incisor’s incisal edge within the face.
Whenever possible, an intraoral esthetic evaluation is performed at the outset. This eval-
uation serves to motivate the patient, identifies any potential limitations, and allows the
team to assess the plan before performing any irreversible treatment.
Teamwork: the combined action of a group of people, especially when effective and
efficient.
INTRODUCTION
No matter how skilled and well trained esthetic dentists or technicians may be, they
cannot deliver results without a proper partnership. Close ceramist-clinician commu-
nication is a critical component of successful esthetic dentistry. In order to design an
esthetic vision, convey this vision to the patient, and then execute the vision success-
fully, there must be effective communication between the ceramist, the clinician, and
(most importantly) the patient.
a
Advanced Program for International Dentists in Esthetic Dentistry, New York University Col-
lege of Dentistry, New York, NY, USA; b The Dental Parlour, New York, NY, USA; c Pizzi Dental
Studio, 4038 Victory Boulevard, Staten Island, NY 10314, USA
* Corresponding author. 434 East 57th Street, New York, NY 10022.
Instagram: @drsivanfinkel (S.F.)
Dent Clin N Am 64 (2020) 697–708

698 Finkel & Pizzi
To execute high-level esthetics, both members of the dentist/technician team must

have a deep understanding of tooth position, preparation design, form, color, and of
the indications/limitations of the many materials available.
Although it is easy to connect with people via social media these days, if hoping to
partner with a like-minded, serious counterpart, a beginning dentist or ceramist would
be wise to attend symposiums and courses geared toward both groups. Aside from
the quality of the lectures and educational value of these events, the networking
element is equally important. Those who spend the time and money to travel to these
sort of conferences and courses are serious about their profession. It is also inspiring
and educational for anyone just starting out to rub shoulders with those who have
already achieved greatness in the profession. As the saying goes, if you are the smart-
est person in the room, you are in the wrong room.
The authors of this article, both New Yorkers and both on New York University fac-
ulty, only met for the first time in California, during a conference’s networking session
6 years ago. This article highlights some of the philosophies they share, as well as an
overview of the key communication protocols that have proved effective for this team.
Philosophy
As restorative options evolve, our understanding of each material’s optical and func-
tional properties must evolve. Each patient presents unique challenges and the solu-
tion is never 1 size fits all. It is crucial for ceramists to be comfortable with a wide range
of materials, and that clinicians understand the differences in preparation design and
cementation that each material necessitates.
In terms of practicing conservative dentistry, the authors aim to be minimally inva-
sive whenever possible, but with the understanding that some patients call for a less
conservative approach. For example, a 0.3-mm porcelain veneer in a patient where
the tooth substrate is extremely dark might not make as much sense as a full-
coverage crown. The authors share the view that, in the words of Dr Marcelo Calamita,
clinicians should be less concerned with minimal preparation and more concerned
with appropriate preparation.1
Another viewpoint the authors share is that the ceramist must be involved from the
beginning of each case, during the initial planning phase. Material considerations often
have implications on not only the tooth preparations but also the surgical aspects of a
case. A common example of this is situations where there is a soft tissue deficiency.
The decision must be made at the outset whether the pink deficiency will be solved
surgically (grafting) or prosthetically (pink porcelain), because this affects the extent
of preprosthetic surgery needed. The early involvement of the ceramist in every pro-
cedure also relates to managing patient expectations, because a thorough discussion
between dentist and ceramist allows the dentist to explain any limitations of a proced-
ure to the patient at the beginning.
INITIAL RECORDS
Photography
The dentist-ceramist team relies heavily on the use of photography, a topic covered in
depth elsewhere in this issue. Essentially, the clinician moves through a series of facial
(face and teeth), dental-facial (lips and teeth), and dental photographs (teeth only)
(Fig. 1). These photographs, beginning with the full face and zooming in to analyze
just the teeth, help the team move through a mental checklist of diagnostic criteria,
from macroesthetic to microesthetic elements. The macroesthetic elements are those
such as midline canting, incisal plane, and buccal corridor, whereas the microesthetic
Dentist-Ceramist Communication 699
Fig. 1. The facial, dental-facial, and dental perspectives. (A) Face and teeth. (B) Lips and
teeth. (C) Teeth only.
elements include aspects such as zenith levels, axial inclinations, and shade.2 These
facial, dental-facial, and dental photographs will be repeated after the provisionals are
cemented, and again on cementation of the final restorations. Table 1 shows the com-
plete list of macroesthetic and microesthetic elements that are analyzed as these pho-
tographs are taken.
In our offices, we have recently also incorporated video, allowing us to more fully
grasp our patients’ wants and needs by seeing who they are and what they want to
gain from this experience. From a diagnostic perspective, video allows us to capture
each patient’s lip dynamics during speaking, and phonetic analysis, both of which are
hard to capture via still photography alone. Technically, the simple setup consists of a
Table 1
Macroesthetic and microesthetic elements to analyze while taking photographs
Facial
(Macroesthetic) Dental-Facial (Macroesthetic) Dental (Microesthetic)
Interpupillary line Height of smile Tooth form
to occlusal plane Tooth exposure at rest Tooth proportions
Dental midline to Dental midline to philtrum Shade
facial midline Degree of buccal corridor Axial inclinations
Nasolabial angle Amount of teeth displayed Zenith positions
Ricketts e-plane in smile Papilla positions
Dominant/ Embrasures and contacts
nondominant Texture
sides Translucency
1 facial symmetry Opalescence
700 Finkel & Pizzi
tripod-mounted 4K high-definition (HD) video camera with a light-emitting diode (LED)

ring light (Fig. 2). The patients are seated in front of a black backdrop and asked to
discuss their expectations, then asked to smile both naturally and with an exaggerated
smile. A video of no longer than 30 seconds should be sufficient, and, from this video,
HD still images can be extracted for analysis.
Kois Dento-Facial Analyzer

The maxillary and mandibular impressions obtained at the initial appointment, either
conventionally with polyvinyl siloxane (PVS) or via intraoral scan, must be related to
the true horizontal plane before any esthetic improvements can be made. To accom-
plish this, we use the Kois dento-facial analyzer, a replacement for the conventional
ear-borne facebow. It is well known that the ears (and all facial features) are more often
than not asymmetrical.3 The Kois dento-facial analyzer is essentially a fox plane, with
leveling bubbles and a perpendicular vertical post meant to represent the midline
(Fig. 3). This device allows us to orient the maxillary plane in relation to the true hori-
zon, instead of relying on facial features. The mounting plate is transferred to an artic-
ulator at a set 100-mm axis-incisal distance. According to Dr Jon Kois’ research,
“approximately 80% of the population are within 5 mm of the average 100 mm axis-
incisal distance, which is approximately the same percentage reported in research
comparing arbitrary earbows.”4 In the authors’ experience, even large-scale cases
involving occlusal vertical dimension change can be successfully performed using
this system in lieu of a traditional facebow. Once the maxillary cast is mounted, the
mandibular cast can be mounted against it, using a PVS bite registration material,
or, whenever possible, hand articulation. The mounted models, together with the
Fig. 2. Simple setup of a tripod-mounted 4K-HD video camera with an LED ring light.
Fig. 3. A Kois Dento-Facial Analyzer, with leveling bubbles and a perpendicular vertical post
meant to represent the midline.
complete diagnostic photographic series, allow a diagnostic wax-up that allows us to

evaluate the function and esthetics of our proposed smile design.
Ideal Maxillary Central Incisor Length and Incisal Plane

There are many ways to convey the esthetic plan to the ceramist, but, at the minimum,
the clinician must determine at the initial records visit (1) the ideal maxillary central
incisor edge position as it relates to the face, and (2) the true horizon, which is also
the incisal plane. Having these 2 references, combined with the diagnostic
photographs, allows the ceramist to design the entire smile, following the many
well-known rules of esthetics.5 Assuming the existing incisal edge position is not
acceptable (sometimes it is), the authoring team’s 3 most common methods for visu-
alizing the ideal central incisor position are:
Chairside flowable composite (Fig. 4) can be added to deficient maxillary central
incisal edges quickly and easily. This composite can be reduced with a sand-
paper disk if needed, until it looks appropriately long and appropriately level
with the horizon. Once established, an impression or intraoral scan of the arch
is taken, to be used for a waxing index. The flowable composite can be added
to just the 2 central incisors, or (even more helpful for the ceramist) extended
to the anterior 6 or 8 teeth. Two photographs of the entire face, smiling with teeth
apart and with lips separated at rest, are also taken at this point (Fig. 5) to confirm
our placement of the maxillary central incisal edge.
Black Sharpie: if a tooth is too long and the solution might be to shorten it, a
black Sharpie is used to simulate the reduced tooth length (Fig. 6). This
702 Finkel & Pizzi
Fig. 4. Chairside flowable composite added to tooth #8 to match the length of #9.
simulation could then be photographed alongside a periodontal probe for

measurement.
Digital planning. By laying a grid over the face, we can establish vertical and hor-
izontal references, plan the ideal tooth positions based on the face, and then cali-
brate the design to real-world measurements. Two examples of digital planning
protocols are Photoshop Smile Design (Ed McLaren) and Digital Smile Design
(Christian Coachman).6
Detailed Laboratory Prescription

This prescription is a written description giving as much detail as possible and identi-
fying the patient’s goals. Fig. 7 gives an example of a typical laboratory prescription.
Remember it is the clinician’s responsibility to convey the patient’s hopes and expec-
tations to the ceramist accurately.
The following list shows the items that must go to the ceramist after the first appoint-
ment, in order to obtain an ideal functional and esthetic wax-up:
Maxillary and mandibular impressions or scans
Bite registration (either PVS or scan) in maximum intercuspation or centric rela-
tion depending on the procedure
Kois mounting plate
Impression/scan of proposed ideal maxillary incisal edge or digital design
Complete set of diagnostic photographs
Fig. 5. (A) The entire face, smiling with teeth apart. (B) The entire face, with lips separated
at rest.
Fig. 6. If a tooth is too long and the solution might be to shorten it, a black marker is used
to simulate the reduced tooth length.
Fig. 7. A typical laboratory prescription.

704 Finkel & Pizzi
Laboratory prescription
All these records drive the diagnostic wax-up. When the wax-up is completed, the
patient returns for the crucial second step in the process: the esthetic evaluation.
DIAGNOSTIC WAX-UP AND ESTHETIC EVALUATION
It is critically important to show the patient what we are planning, before picking up a
handpiece and irreversibly altering the teeth. To achieve this, whenever the situation
permits, we test our design intraorally and in the context of the face and lips. This
step, the esthetic evaluation, is an opportunity not only for the patient to visualize
the proposed treatment but also for the clinician-ceramist team to confirm that the
design makes functional and esthetic sense.
The records described earlier drive our wax-up (Fig. 8), which becomes the blue-
print to the procedure. It is worth noting that the author charges a fee for the diagnostic
wax-up, and explains to the patient that it will:
1. Allow the patient to visualize the outcome
2. Become the template for the provisionals (temporaries)
3. Help us keep the amount of tooth preparation as minimal as possible
A wax-up can either be done additively, with no reduction performed on the stone
model, or reductively, where the stone model is modified first to make the wax-up
more ideal. Examples of additive wax-ups include diastema closure, or cases where
purely length and volume are added to the teeth. Examples of reductive wax-ups
include midline correction, or cases that involve shortening teeth or reducing tooth
mass. Making the distinction between additive and reductive is important, because
only additive wax-ups can be transferred into the mouth without any tooth reduction.
Because the esthetic evaluation step is so critical, in patients requiring reduction, the
ceramist produces 2 wax-ups: a less ideal, additive-only version, for the purpose of
esthetic evaluation and patient motivation, and an ideal reductive version, for the pur-
pose of provisionals and preparation control. In cases where we are shortening incisal
edges or cusps, the additive wax-up shows the original stone projecting beyond the
wax, and this area is blacked out with a fine Sharpie once the wax-up is transferred
to the mouth.
The wax-up is transferred to the mouth via an acrylic or putty index, using a bis-acryl
material (Fig. 9). With the design in place, once again a video is taken of the patient
speaking. The patients are encouraged to speak naturally and tell a story, but to
keep their lips animated.
At this point, the patients should be shown the video of themselves, or selected
screenshots from it. It is worth noting that, up until this point, the patient has not
been given a handheld mirror. This bis-acryl design over unprepared teeth often
does not look as beautiful as the provisionals and final porcelain will be, and pa-
tients could get discouraged or confused, especially in reductive cases when the
Fig. 8. A wax-up.
Fig. 9. The wax-up is transferred to the mouth via an acrylic or putty index, using a bis-acryl
material.
purely additive first wax-up is noticeably bulkier than the second, ideal wax-up. For
the patients, seeing the design for the first time through our video, from a conver-
sational distance and in the context of their full faces (Fig. 10) is extremely impact-
ful and helps motivate them to accept treatment. Still photographs can be
extracted from the video and emailed to the patients if they would like some time
to decide.
TOOTH PREPARATION
Just as the diagnostic wax-up communicates the esthetic vision to the patient, it is
also the blueprint for the tooth preparation and thus an important communication
tool between dentist and ceramist. The teeth should always be prepared in relation
to the final volume and final position that the wax-up dictates, and according to the
requirements of the specific material being preparing for. Putty indexes can be
trimmed into buccal and incisal reduction guides, and an even more precise method
is to prepare the teeth directly through the intraoral bis-acryl prototype. This method is
known as the Aesthetic Pre-Evaluative Temporaries technique, first described by
Galip Gurel.7
Once tooth preparation is completed (Fig. 11), impressions of the teeth are made
conventionally or with an intraoral scanner. These are the full list of records that are
sent to the laboratory at the completion of this appointment:
Fig. 10. For the patient, seeing the design from a conversational distance and in the context
of the full face, is extremely impactful and helps motivate the patient to accept treatment.
706 Finkel & Pizzi
Fig. 11. Completed tooth preparations.
1. Final impression/scan of prepared teeth

2. Impression/scan of opposing arch
3. Bite registration; preps against lower arch, or prep to prep in full-mouth cases
4. Photographs
a. Desired shade photographs: photographs, with shade tabs, of the relevant
tooth/teeth being matched to.
b. Preparation shade photos: photographs, with shade tabs, of the completed
preparations. These photographs are usually taken with the teeth slightly
moistened.
5. Diagnostic wax-up or impression/scan of provisionals if anything has been
changed
6. Facial, dental-facial, and dental photographs of approved provisionals
PROVISIONALIZATION
Another powerful communication tool between the dental team and the patient is the
provisionals (Fig. 12). Our provisionals allow the patients to test the shade and form of
Fig. 12. Provisionals.

Fig. 13. The final porcelain restorations, a combination of laminate veneers and full
coverage.
the final restorations, and the dental team should welcome any and all input. The pa-
tients are encouraged to be critical. In most cases, the patient is brought back a week
later, without anesthesia and thus with regular lip mobility, to discuss the shade and
form. Any changes to form are made chairside, photographs are retaken, and a new
impression/scan is obtained for the ceramist.
TRY-IN AND CEMENTATION
Once the restorations are delivered to the clinician (Fig. 13), the patient returns and the
provisionals are removed. The restorations are tried in, 1 by 1 and then all together.
The restorations are usually tried in with just water, but, in the rare instance that the
shade needs to be adjusted, colored try-in paste (followed by the corresponding
colored cement) may be used.
Fig. 14. Final photos.

708 Finkel & Pizzi
The patient is shown the restorations seated without any cement, and, if approved,
the restorations are cemented. Note that, before cementation during the try-in, (1)
function cannot be tested, and (2) the patient does not have a chance to see these final
restorations in the context of the entire face, only close-up and usually with the lips
retracted. Phonetics cannot be tested with uncemented restorations either. It is for
these reasons that it is imperative the final restorations follow the exact length of
the approved provisionals.
FINAL FOLLOW-UP PHOTOGRAPHS
Two weeks following cementation, the patient returns for a follow-up visit, at which
point we make any corrections to the occlusion, deliver a nightguard if necessary,
and obtain our final photographs (Fig. 14). These final photographs are extremely
important: even though the procedure is completed, the follow-up photographs allow
us to self-evaluate, judge our work, and consider what we can improve next time.
In summary, thoughtful and thorough communication protocols between dentist,
ceramist, and patient are critical to our success, especially in the realm of esthetics,
where there is no right or wrong. The quality of our communication defines our ability
to deliver the results that we promise.
DISCLOSURE
The authors have nothing to disclose.
REFERENCES
1. Coachman C, Gurel G, Calamita M, et al. The influence of tooth color on prepara-

tion design for laminate veneers from a minimally invasive perspective: case
report. Int J Periodontics Restorative Dent 2014;34(4):453–9.
2. Levine JB, Finkel S. Chapter 1 - Esthetic diagnosis: a three-step analysis. In:
Levine JB, editor. Essentials of esthetic dentistry: smile design integrating es-
thetics and function. New York: Elsevier; 2016. p. 1–42.
3. Namano S, Behrend DA, Harcourt JK, et al. Angular asymmetries of the human
face. Int J Prosthodont 2000;13(1):41–6.
4. Tak On T, Kois JC. Digital smile design meets the dento-facial analyzer: optimizing
esthetics while preserving tooth structure. Compend Contin Educ Dent 2016;37(1):
46–50.
5. Rufenacht CR. Fundamentals of esthetics. Hanover Park (IL): Quintessence; 1990.
p. 116–9.
6. Coachman C, Calamita MA. Digital smile design: a tool for treatment planning and
communication in esthetic dentistry. Quintessence Dent Technol 2012;35:103–11.
7. Gurel G. The science and art of porcelain laminate veneers. Chicago: Quintes-
sence; 2003. p. 248, 249, 257, 260, 261, 485.
A Communication Guide for
Orthodontic-Restorative
Collaborations
An Orthodontic Perspective on the Importance
of Working in a Team
Kathryn Preston, DDS, MS
KEYWORDS
Orthodontic terminology Orthodontic-restorative communication
Orthodontic anterior esthetics Smile esthetics Occlusion
KEY POINTS
Excellent communication between provider and patient, as well as between providers, is
critical for case success.
The restorative dentist’s understanding of basic orthodontic terminology and general or-
thodontic case considerations is useful in optimizing communication.
Although esthetics are an important component, the functional and biologic limitations of
the hard and soft tissues need to be carefully respected.
Though orthodontists use cephalometrics and normative data, these are just some of the
considerations when developing their treatment plans and goals.
Early and consistent involvement of both restorative dentists and specialists can help pro-
vide patients with more complete and informed decision-making abilities, and can
improve outcomes.
INTRODUCTION: NATURE OF THE PROBLEM
Multidisciplinary cases can be some of our most challenging yet rewarding experi-
ences as providers. Restorative and orthodontic collaborations are frequently encoun-
tered when discussing multidisciplinary care. It is not uncommon for restorative cases
to benefit from some degree of orthodontic care to support an esthetic and functional
result. Likewise, orthodontic cases often are esthetically improved by involving the
restorative dentist in optimizing tooth morphology.
Section of Orthodontics, UCLA School of Dentistry, 10833 Le Conte Avenue, Box 951668, Los
Angeles, CA 90095, USA
Dent Clin N Am 64 (2020) 709–718

710 Preston
Communication is of paramount importance to a successful treatment outcome.

Understanding the goals of our patients assists in managing and meeting their expec-
tations. In multidisciplinary cases, excellent communication not only between provider
and patient is expected, but seamless collaboration between the involved practi-
tioners is a requirement in achieving an outcome of the highest standard. Similarly, pa-
tients should not only be fully participatory in treatment discussions, but they should
be provided consultation with indicated specialists when appropriate. Communication
at all levels is at the core of these concepts.
Logistical challenges are not uncommon, but at the heart of interprovider commu-
nication is using standard terminology. In this article, an introduction to basic ortho-
dontic terminology often used to describe certain components of occlusion,
function, and esthetics is presented. In addition, global insight into some comprehen-
sive orthodontic case planning considerations will be discussed to indicate that it is
more than just simple tooth positioning; rather, specialty knowledge is imperative in
recognizing limitations of jaw relationships, as well as anticipated effects on the
hard and soft tissues. The scope of this article is limited in nature to give the restorative
dentist an introduction to several factors included in case assessment from an ortho-
dontic perspective. It is intended to augment their awareness of orthodontic consid-
erations, promote discussion among different specialties, and to encourage
inclusion of multidisciplinary practitioners in case planning.
ASSESS THE PATIENT’S GOALS, AND BUILD YOUR TEAM
In the dental profession, we are gifted in that we have the ability to collaborate with
both our patients and other colleagues in a concerted effort to achieve excellent
results.
As illustrated in Box 1, first and foremost, it is important to ascertain the specific
goals of the patient to determine what is and what is not in the realm of possibility
with restorative and/or orthodontic treatment alone. Second, as the professional, it
is our duty to determine if these esthetic goals are still supportive of overall function
and health. Third, both specialists and restorative dentists must recognize when
certain aspects of care are outside their realm of expertise, and must refer and consult
accordingly. These concepts are in support of the American Dental Association’s
Code of Ethics and Professional Conduct, which highlights the importance of enabling
patients to make fully informed treatment decisions, as well as providers recognizing
the potential limitations in their own expertise.1
Of note, a patient’s concern may not be able to be addressed by orthodontics or
restorative means alone. An example of this might be a patient’s discontent with a
gummy smile, and the diagnosis may be vertical maxillary excess of a skeletal nature.
Similarly, a patient may want to address a large overjet, but it is determined that the
Box 1
Questions to consider when evaluating a case
What are the patient’s expectations and goals?

Is this goal achievable with restorative and/or orthodontic treatment alone?
Can this esthetic goal be met while still providing an outcome that is functionally and
periodontally sound?
Do I have the knowledge base to make these multidisciplinary decisions? With which
specialists do I need to confer?
Communication Guide for Orthodontic-Restorative Collaborations: An Orthodontic Perspective 711
skeletal discrepancy between the jaws is beyond simple tooth repositioning or restor-
ative care. In these examples and others, certain presentations may benefit from sur-
gical assistance to avoid jeopardizing oral health and function. Therefore, a third
provider should be consulted, which is in many cases an oral and maxillofacial sur-
geon, to fully diagnose and triage certain cases as well. Although the emphasis in
this article is on orthodontic and restorative communications, it should be noted
that certain cases often require involvement of additional specialist providers to sup-
port case success as well.
In summary, it is recommended to involve the indicated specialists in the discus-
sion and decision-making as early in the assessment process as possible. When
referring to a specialist or any outside provider, creating a supportive document to
indicate your findings and goals for the referral would also prove helpful. This team
perspective of involving multiple qualified providers can work to provide the best
comprehensive plan for our patients, and allow them to make more fully informed
decisions.
GENERAL ORTHODONTIC TERMINOLOGY: THE BASICS OF COMMUNICATION
Initial orthodontic assessment of facial morphology and proportion is performed in 3

dimensions (anterior-posterior, transverse, and vertical) at rest and various active
states, such as when smiling and speaking. Supplemental angles and views of the
face also can be helpful. This evaluation is executed with clinical observation of the
patient, as well as review of records in the form of photographs, radiographs, and
study models. In the facial assessment, the entirety of the face is considered when
developing an orthodontic treatment plan, but for the limited nature of this article,
the focus is on the lower third.
The main ingredient to proper communication is standardizing terminology. No mat-
ter what terminology a dental team uses, it is critical to ensure it is consistent and there
is full understanding of the definitions. Although not intended to be a comprehensive
list of factors or considerations in orthodontic functional and esthetic assessment, this
summary of basic terms (Table 1) may often be discussed when reviewing cases and
should serve as an introduction to orthodontic terminology.
COMPREHENSIVE ORTHODONTIC CASE ASSESSMENT: CONSIDERATIONS BEYOND

THE NUMBERS
Another important factor known to orthodontic specialists is the role of normative

values in case assessment. What restorative dentists may not realize is that although
specialists take these values into account, they do not necessarily let them dictate
treatment absolutely. Although it is important for the restorative dentist to have an
awareness of these concepts, a specialist should have the training and experience
to understand the nuanced applications of these considerations at a higher level
and can apply them to the decision-making process.
The normative and/or ideal values presented in the previous Table 1, as well as in
other published literature regarding cephalometrics, imply that there are strict and nar-
row parameters for what is considered “esthetic”; this is simply not the case. Beauty
truly is in the eye of the beholder and can vary immensely. A critical consideration to
bear in mind when reviewing published hard and soft tissue normative values is that
these often are population-specific, and norms and even esthetic preferences natu-
rally vary between people of different ages, sexes, and ethnicities.16,17 For instance,
it is known that people of different ages, sexes, and ethnicities have varying soft tissue
712
Preston
Table 1
Basic orthodontic terminology in anterior esthetics
Term Definition Related General Esthetic Considerations

Overjet (Fig. 1) Horizontal (anterior-posterior) distance measured from the The ideal is commonly 12 mm. Reverse overjet (in anterior
labial surface of the mandibular incisors to the incisal crossbite) as well as significant excess overjet have been
edge of the maxillary incisors. reported to be considered less esthetic.2,3
1 value, if the maxillary anterior teeth are forward of the
mandibular incisors.
value, if the maxillary anterior teeth are posterior to
the mandibular incisors (i.e., anterior crossbite)
Overbite (Fig. 2) Vertical overlap of the maxillary and mandibular anterior The ideal is generally 12 mm. A deeper bite is more
teeth. esthetically pleasing than an open bite, however.4,5
1 value, if the teeth overlap.
value, if there is no vertical overlap of the anterior
teeth (i.e., open bite)
Smile arc (Fig. 3) Relationship of the lower lip curvature with the arc formed The maxillary incisal edges should follow the contour of
by the incisal edges of the maxillary anterior teeth. the lower lip when smiling.6 Consonant smile arcs are
Described as reverse, flat, consonant, or excessive. generally more preferred.7,8
Dental midlines (Fig. 4) Midlines are generally taken between the maxillary and Despite some variation in the literature, generally slight
mandibular central incisors, and measured relative to midline deviation (approximately 2–3 mm) may be
one another as well as the facial midline. considered acceptable, depending on the observer;
however, angulated dental midlines (reportedly 10 ,9 or
2 mm as measured from papilla to incisal embrasure10)
tend to be more noticeable and less desirable, as
discussed in a systematic review.11
Buccal corridors (Fig. 5) Space observed between the buccal surfaces of the Based on review of studies assessing natural smile images
maxillary posterior teeth and the inside of the cheeks rather than digitally induced buccal corridors, the
when smiling. This may impact the appearance or presence of buccal corridors does not necessarily detract
perception of a full or narrow smile. from smile esthetics.11 The literature is inconsistent with
regard to acceptable buccal corridor dimensions.8
Communication Guide for Orthodontic-Restorative Collaborations: An Orthodontic Perspective
Occlusal canting Asymmetric tilting of the occlusion, when viewed from the Generally, the line following the incisal edges of the
frontal perspective. anterior teeth should be parallel to the interpupillary
line (assuming level orbits), and therefore no occlusal
canting.12,13 An occlusal cant has been reported to be
observed when exceeding 2.8 ,4 or when the incisal
plane is rotated 1–3 mm.10
Gingival display (Fig. 6, in green) Vertical assessment of maxillary gingiva observed when This varies depending on age and sex, with younger female
smiling. individuals tending to have more gingival reveal than
older male individuals. With regard to esthetic
preference, the literature is variable on indicating the
threshold for acceptability.8
Incisal display (see Fig. 6, in red) Vertical assessment of maxillary incisor show while at rest This varies depending on age and sex, with younger female
and when smiling. individuals tending to have more incisal display than
older male individuals.6,14 Like gingival display, the
esthetic parameters and etiology of incisal display are
multifactorial.15
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714 Preston
Fig. 1. Overjet (in red).
Fig. 2. Overbite (in red).
Fig. 3. Smile arc (in orange).

Fig. 4. Dental midlines (in orange).
Fig. 5. Buccal corridors (in blue).
Fig. 6. Gingival display (in green) and incisal display (in red), on smiling. At rest not shown.
716 Preston
thicknesses, and therefore often respond to treatment differently; this individuality can
impact treatment goals and the mechanics needed to achieve them.
Likewise, although numerical normative values can be useful, they do not neces-
sarily ensure a clinically esthetic outcome.18,19 Rather, these values should be treated
more as guidelines and not necessarily as mandatory treatment goals in every case.
Similarly, an advanced understanding of these values includes knowing the related
factors that can impact them, and accounting for that in the treatment decision-
making process. In orthodontics, we often say “don’t treat to the numbers,” and
this mantra implies this principle: aim to treat to a facial and occlusal esthetic outcome
that still provides oral health and functional stability, and not solely to satisfy cephalo-
metric or anthropometric normative data. In other words, an esthetic outcome that is
still simultaneously supportive of health and function may not necessarily always
reflect agreement with hard and soft tissue normative values. Each case should be
considered independently, and objectives set accordingly; orthodontic care is not a
one-size-fits-all service.
Orthognathic surgery literature discusses similar philosophies of treating to esthetic
visual proportions in their field, rather than absolute quantitative normalcy.20,21 Sur-
geons, like other specialists, are trained to combine the art and science of their disci-
pline to maximize facial balance and harmony while planning for stable and healthy
results. However, it should be emphasized that overriding the normative values
does not give permission for full subjectivity without regard for the biologic limitations
of the occlusion, periodontium, or facial structures. Rather, intelligently and prudently
weighing the visual qualitative assessment with the numerical quantitative measure-
ments in the context of the entire patient presentation is an important skill needed in
comprehensive case planning. As always, the biologic limitations should be
respected.
With software options and appliances on the market that offer diagnosis assistance,
case planning support, and appliance fabrication, technology can aid the provider in
making and carrying out treatment decisions. However, a limited understanding of
specialty principles, including those presented here, might mistakenly lead some pro-
viders to believe that these systems or appliances can accurately deliver specialist-
level results, often in place of the case itself being assessed by a specialist. It is impor-
tant to recognize that these systems are tools to be wielded wisely with proper edu-
cation and with full understanding that, despite advances in technology, they are
not substitutes for good clinical judgment and experience.
In summary, it is important to evaluate cases on their own merit and with compre-
hensive team expertise. Software should be used to aid providers, and not substitute
for them. Blindly following numerical norms or not recognizing unique age, sex, and
ethnicity factors can hinder case success. Recognizing the unique considerations of
each case provides a more global, advanced understanding of the complexities
involved in excellent care, and the indicated specialists should be sought out to pro-
vide this knowledge in multidisciplinary cases.
SUMMARY
Team care is of benefit to the patient and all providers involved in the case. It is impor-
tant to recognize that restorative dentists and specialists all have their respective
areas of expertise, and should be consulted accordingly on multidisciplinary cases.
It is not the job of the restorative dentist to personally fulfill every role on the team,
and therefore they are expected to recruit specialist teammates to support excellent
and comprehensive care. The goal of this article is to encourage the dialogue of
trained and experienced specialists and restorative dentists with one another and with
patients to devise esthetic outcomes that are supportive of overall oral health and
function, using the unique skills of each provider in unison rather than in place of
the other.
This pursuit of excellence starts with unifying terminology to achieve effective
communication of goals, expectations, and limitations. In addition, a deeper compre-
hension of normative values and their role in treatment planning is important for a more
complete understanding of case assessment. Furthermore, effective treatment is not
simply treating to what a cephalometric or software program dictates, but rather to
use excellent clinical training and sound judgment to help ensure an esthetic and func-
tional outcome; this goal can more readily be achieved through involvement and
proper communication within a skilled and knowledgeable team.
DISCLOSURE
REFERENCES
1. American Dental Association. Principles of Ethics and Code of Professional

Conduct. 2018. Available at: https://www.ada.org/w/media/ADA/Member%
20Center/Ethics/Code_Of_Ethics_Book_With_Advisory_Opinions_Revised_to_
November_2018.pdf?la5en. Accessed January 30, 2020.
2. Soh J, Chew MT, Chan YH. Perceptions of dental esthetics of Asian orthodontists
and laypersons. Am J Orthod Dentofac Orthop 2006;130(2):170–6.
3. Sierwald I, John MT, Schierz O, et al. Association of overjet and overbite with
esthetic impairments of oral health-related quality of life. J Orofac Orthop 2015;
76(5):405–20.
4. Springer NC, Chang C, Fields HW, et al. Smile esthetics from the layperson’s
perspective. Am J Orthod Dentofac Orthop 2011;139(1):e91–101.
5. Chang CA, Fields HW Jr, Beck FM, et al. Smile esthetics from patients’ perspec-
tives for faces of varying attractiveness. Am J Orthod Dentofac Orthop 2011;
140(4):e171–80.
6. Sarver DM. The importance of incisor positioning in the esthetic smile: the smile
arc. Am J Orthod Dentofac Orthop 2001;120(2):98–111.
7. Parekh S, Fields HW, Beck FM, et al. The acceptability of variations in smile arc
and buccal corridor space. Orthod Craniofac Res 2007;10(1):15–21.
8. Parrini S, Rossini G, Castroflorio T, et al. Laypeople’s perceptions of frontal smile
esthetics: a systematic review. Am J Orthod Dentofac Orthop 2016;150(5):
740–50.
9. Thomas JL, Hayes C, Zawaideh S. The effect of axial midline angulation on dental
esthetics. Angle Orthod 2003;73(4):359–64.
10. Kokich VO Jr, Kiyak HA, Shapiro PA. Comparing the perception of dentists and
lay people to altered dental esthetics. J Esthet Dent 1999;11(6):311–24.
11. Janson G, Branco NC, Fernandes TMF, et al. Influence of orthodontic treatment,
midline position, buccal corridor and smile arc on smile attractiveness. Angle Or-
thod 2011;81(1):153–61.
12. Sharma PK, Sharma P. Dental smile esthetics: the assessment and creation of the
ideal smile. Semin Orthod 2012;18(3):193–201.
13. Reyneke JP, Ferretti C. Clinical assessment of the face. Semin Orthod 2012;18(3):
172–86.
718 Preston
14. Fudalej P. Long-term changes of the upper lip position relative to the incisal edge.
Am J Orthod Dentofac Orthop 2008;133(2):204–9.
15. Desai S, Upadhyay M, Nanda R. Dynamic smile analysis: changes with age. Am J
Orthod Dentofac Orthop 2009;136(3):310.e1-10.
16. Hall D, Taylor RW, Jacobson A, et al. The perception of optimal profile in African
Americans versus white Americans as assessed by orthodontists and the lay
public. Am J Orthod Dentofac Orthop 2000;118(5):514–25.
17. Vela E, Taylor RW, Campbell PM, et al. Differences in craniofacial and dental char-
acteristics of adolescent Mexican Americans and European Americans. Am J Or-
thod Dentofac Orthop 2011;140(6):839–47.
18. Sarver DM, Ackerman JL. Orthodontics about face: The re-emergence of the
esthetic paradigm. Am J Orthod Dentofac Orthop 2000;117(5):575–6.
19. Nanda RS, Ghosh J. Facial soft tissue harmony and growth in orthodontic treat-
ment. Semin Orthod 1995;1(2):67–81.
20. Rosen HM. Evolution of a surgical philosophy in orthognathic surgery. Plast Re-
constr Surg 2017;139(4):978–90.
21. Selber JC, Rosen HM. Aesthetics of facial skeletal surgery. Clin Plast Surg 2007;
34(3):437–45.
A Communication Guide for
Orthodontic-Restorative
Collaborations
Digital Smile Design Outline Tool
Yair Y. Whiteman, DMD
KEYWORDS
Multidisciplinary Restorative Orthodontics Communication
Digitally-driven smile design outline tool
KEY POINTS
Orthodontic-restorative multidisciplinary collaboration is a critical aspect in esthetic and
functional treatment outcome.
Ideally, orthodontic-restorative cases are planned jointly.
Facially driven esthetic evaluation sequence is imperative for structured and organized
treatment planning, and the digital outline tool is used to streamline the team’s communi-
cation, which can support orthodontic-restorative improved treatment outcome.
INTRODUCTION
Whenever orthodontic-restorative treatments are performed, it is essential to compre-

hensively assess the case, establish treatment objectives, and plan the sequence and
execution of the interdisciplinary treatment in advance of starting any procedure.1–3
Not including all providers early in the treatment planning process can potentially in-
crease overall treatment time, as well as be burdensome for the patient if changes
need to be made unexpectedly due to lack of communication. For instance, the restor-
ative dentist may be put in the position of restoring the dentition with compromised
spacing and clearance when simple communication between providers could have
prevented this concern. Alternatively, if a dentist proceeds with placing restorations
before the patient initiates orthodontic treatment, the occlusion may change and merit
costly restorative replacement and additional treatment.
Communication and progress follow-up are critical when seeking ideal outcome.
One additional challenge in the orthodontic-restorative collaborative case
Division of Constitutive and Regenerative Science, UCLA School of Dentistry, 10833 Le-Conte
Avenue, Room 33-064A CHS, Los Angeles, CA 90095-1668, USA
Dent Clin N Am 64 (2020) 719–730

720 Whiteman
management is the ability to evaluate case readiness for the completion of the ortho-
dontic phase. Often in the final steps of the orthodontic treatment, the orthodontist will
refer the patient for a restorative esthetic evaluation and verification before removing
the orthodontic appliances. At this point, the restoring dentist will often be asked to
determine if the position of the teeth is appropriate for completion of the orthodontic
phase and initiating of the restorative phase of the treatment. This article discusses a
workflow that can streamline the team’s ability to establish treatment strategies, eval-
uate progress, and effectively communicate course of action when needed.
CONSIDERATIONS FOR MULTIDISCIPLINARY TEAM MEMBERS
The multidisciplinary patient care approach has been shown to be undeniably advan-
tageous for patients as well as providers. The ability to include a number of qualified
providers with specific skill sets while developing a coordinated treatment strategy en-
ables us a far more controlled treatment environment and ultimately improved
outcome.4 To support the excellence of the team, members should continue to
educate themselves as treatment protocols evolve as well as strive to maintain excel-
lent communication. Likewise, it is important to share similar evidence-based treat-
ment philosophies to support treatment decisions.
From the restorative dentist’s perspective, it is essential that the orthodontist in the
team will know what the restorative possibilities are, understand material limitations
and space requirements, and develop an ability to visualize proper tooth position to
accept restorations once the orthodontic treatment has been completed.5–7 Just as
orthodontists should have awareness of restorative concepts, restorative dentists
must also have a respect and appreciation for orthodontic concepts, which includes
fundamental biologic limitations of the periodontium with regard to tooth movement.
Orthodontists also incorporate growth and development principles in their treatment
planning, and can aid the restorative dentist in planning the timeline for definitive
restorative care. Dentists must recognize how orthodontics can serve as a preparatory
step before reductive restorative treatment is initiated, know fundamental orthodontic
terminology, and be aware of biomechanics and other restrictions when planning a
treatment.
COMMON ORTHODONTIC-RESTORATIVE CASES CRITICAL FOR CLOSE

COORDINATION AND COMMUNICATION
The following is a general list of common interdisciplinary orthodontic-restorative

cases encountered in our patient population.
1. Spacing and space management: crowding, diastema, hypodontia and partial
edentulism, and microdontia (ie, peg laterals).3,8,9
2. Worn dentition: with or without loss of vertical dimension of occlusion (VDO).9–11
3. Position and realignment of teeth to allow more conservative tooth reduction for
direct or indirect restorative treatment.
4. Gingival disharmony: excessive gingival display, disharmonious levels, as well as
architecture and imperfect contours.12,13
5. Orthodontic extrusion to create a nonsurgical ferrule to restore root canal–treated
teeth with post and core.14
6. Correction of occlusal plane and improved envelope of function.9,13,15
7. Reposition teeth to allow space for implant placement, implant site switching, and
forced eruption to improve bone level.13,16,17
Communication Guide for Orthodontic-Restorative Collaborations: Digital Smile Design Outline Tool 721
PURPOSE OF DIGITAL SMILE DESIGN TOOL IN ORTHODONTIC-RESTORATIVE

COMMUNICATION
Ideally, the restorative dentist should have an opportunity to conduct his or her own
assessment before placement of orthodontic appliances. Having these appliances
in place makes it particularly challenging to visualize teeth positions, contours, and
anatomy. Moreover, the gingiva is often hypertrophic due to inflammation during or-
thodontic treatment, and it is a suboptimal environment to acquire an impression for
proper diagnostic evaluation. These are important considerations for planning a treat-
ment that is, designed to optimize the overall facial and smile esthetics.
The beauty of applying facially driven smile design fundamentals18–20 with basic
digital smile design tools21 (DSD) is that they can be used in case planning before
or even during orthodontic appliance therapy, and therefore minimize much of the
aforementioned concerns. The outline component of this tool is perhaps the most crit-
ical in optimizing near-immediate communication between providers and patients.
This tool can help dentists and patients visualize possible outcome, communicate
goals, and evaluate progress and ultimate readiness related to the esthetic outcome
in orthodontic-restorative cases (Fig. 1).
The overall dentofacial evaluation sequence is outlined in Box 1. More detailed eval-
uation is described by the macro-esthetic and micro-esthetic evaluation, which is ul-
timately communicated using the DSD outline tool. Macro-esthetics and micro-
Fig. 1. DSD outline tool demonstrating esthetic evaluation of a case as presented on restor-
ative examination. The tool also allows for visual communication back to the orthodontist
to indicate recommended tooth movements to optimize the ultimate restorative outcome,
as demonstrated by the white arrows in the third image.
722 Whiteman
Box 1
Dentofacial evaluation sequence checklist
1. Midline and horizontal lines

2. Identify maxillary incisal edge position
3. Establish and follow smile-line
4. Proper central incisor proportion
5. Interdental proportion
6. Teeth outline and arrangement
a. Teeth general shape
b. Smile line
c. Incisal arrangement (flat, gal-wing)
7. Transfer outline to smile and full-face image.
esthetics will be evaluated once the teeth outline has been established later in the pro-
tocol. For the purpose of this article “macro-esthetics” refers to teeth relative to the
patient’s face and smile dynamics, whereas “micro-esthetics” refers to tooth shape
and size, interdental and intradental proportions, as well as arrangement in the
arch.12,22
Restorative dentists should assess the following macro-esthetic and micro-esthetic
components to determine case progress and readiness for the restorative phase, as
indicated in Boxes 2 and 3.
It is important to note, however, that certain limitations exist in using the DSD outline
tool. Due to the 2-dimensional system, it might prevent evaluation of teeth proclina-
tion, overjet, open bite, malocclusion, plane of occlusion, and anterior-posterior (A-
P) dimension relative to tooth display. Furthermore, because of photographic limita-
tions,23 we cannot rely on the digital outline alone and must also supplement with
more precise measurements (ie, interbracket space distance, 3-dimensional scan-
ning, impressions, and other measurement tools) in the assessment, particularly as
the case is nearing completion of orthodontic treatment. Therefore, these detailed
supplemental measurements must be evaluated before finalizing the orthodontic
phase of treatment.12,24,25
PHOTOGRAPHS REQUIRED FOR DIGITAL SMILE DESIGN
At minimum, 5 images are required to produce a proper smile evaluation using the
DSD tool, which ultimately all will serve to produce the final smile evaluation. These
Box 2
Macro-esthetic components to be evaluated in the digital smile design outline tool
1. Midlines
2. Smile line
3. Occlusal canting
4. Dentogingival interface
a. Gingival display
b. Gingival canting
c. Gingival levels and harmony
d. Gingival symmetry
Box 3
Micro-esthetics to be evaluated in the digital smile design outline tool
1. Individual tooth shape

2. Individual tooth size proportion (intradental)
3. Teeth proportions (interdental)
4. Teeth arrangement
5. Teeth axis and angulation
6. Dentogingival interface
a. Gingival architecture
b. scalloping
7. Overbite
photographs, when sequenced as described, can be considered as layers supportive

of one another to collectively develop the smile esthetic evaluation on its own as well
as in harmony with the face as whole. Additional images, videos, and patient feed-
back, as well as clinician observation and artistry can all be valuable in augmenting
the esthetic assessment.23,26,27
These photographs should be uploaded and imported into the dentist’s or techni-
cian’s preferred software (Keynote, PowerPoint, or comparable smile design program
can be used). The images (Box 4) are used as indicated in the following:
1. The portrait images (smile, retracted, lips at rest) aid in facially driven smile design
evaluation. These involve full-face images that serve as initial orientation. Once
close-up images are assessed, we return to the portrait images in the final step.
i. The smile image is used to establish facial midline, horizontal lines, and smile
line, as well as to evaluate gingival display.
ii. The retracted portrait image allows visualization of the teeth in space without
being obscured by surrounding facial soft tissue, and is used to evaluate hori-
zontal cants.
iii. Lips at rest image is used to evaluate incisal display; typically, 2.0 to 4.0 mm of
incisor display at rest is considered esthetically favorable18,28,29 and serves as
our starting point for placing the maxillary incisal edge position.
Box 4
Required images for digital smile design to use the outline tool
1. Portrait (full face) view

a. Full smile (maximum display)
b. Retracted: teeth together in occlusion with retracted soft tissue
c. Lips at rest (Repose)
2. Close-Up view
a. Smile
b. Retracted
3. Optional additional images
a. Portrait 1 retracted: teeth apart
b. 12 o’clock
c. Profile
d. Portrait and close-up side views
724 Whiteman
2. Close-up images of the dentition are acquired during smiling and lip retraction. The
development of the smile design is performed on these images, before transferring
back to the full-face portrait for final evaluation.
It is important to take all images in a uniform plane and orientation23,27 such that pa-
tients are looking parallel to the horizon, as if they are looking at themselves in a mirror.
In addition, the dentist or technician needs to calibrate the image sizes and crop them
appropriately to scale before initiating the following protocol. This will help in workflow
continuity and will aid in precision and reliability of the final product. This first step is
important and provides the foundation on which we will develop the esthetic blueprint.
WORKFLOW FOR DIGITAL SMILE DESIGN OUTLINE TOOL
Once the dentist or technician has successfully acquired and imported the necessary
photographs, a sequence is followed to perform the DSD evaluation. This section out-
lines the workflow.
To protect patient privacy, only close-up images are shown in this article. However,
the steps including portrait images are still essential for a proper esthetic evaluation,
and are described.
Step 1: Establish Facial Midline and Horizontal Lines

Using the Portrait images, facial midline is a vertical line generally found in the patient’s
midface.20,21,30,31 It can be placed by visualizing the most suitable overall midpoint po-
sition in relation to the face, very similar to the midline generated during denture fabri-
cation. Another method would be marking a center line between the patient’s pupils
perpendicular to the interpupillary line.
To mark the horizontal line, again use the patient’s pupils as a reference point, and
mark the center of the pupils and connect these points. In circumstances in which
midline or interpupillary lines are not ideal due to facial or orbital asymmetry, select
the most appropriate horizontal line by looking at the patient’s overall full-facial images.
Once done, duplicate the horizontal line and position it in the projected maxillary
incisal position in the Close-Up retracted image, as demonstrated in Fig. 2. It is rec-
ommended to place the incisal horizontal line close to the ideal estimated maxillary
central incisal position based off of the image demonstrating lip at rest position, as
it will help simplify workflow and evaluation process.
Both midline and horizontal lines are then moved to the Close-Up retracted image to
establish virtual face-bow transfer. From this point on, most of the sequence will take
place on the Close-Up retracted image and once completed, will be transferred to the
Close-Up smile and Portrait smile images for further evaluation.
Fig. 2. Facial midline and horizontal lines placed on close-up images, demonstrating virtual
face-bow transfer.
Step 2: Establish and Follow Smile Line

Using the patients’ smile image (either Portrait or Close-Up), use the software’s
“shape tool” to follow and mark the lower lip line from oral commissure to the opposite
corner to generate the smile line, as demonstrated in Fig. 3. Smile arc should follow
the curvature of the lower lip.31 Ideally, the smile arc of the incisal edges of the maxil-
lary incisors and canines follows the smile line.32 The smile line can now be transferred
to the retracted Close-Up image, as shown in Fig. 4.
Fig. 3. Smile line (in green) parallels the curvature of the lower lip.
Fig. 4. Smile line is transferred to retracted close-up image.
Step 3: Tooth Proportion Tool

Average central maxillary incisors length to width ratio ranges from 70% to 85%33;
however, the most esthetically acceptable range reported in the literature is 75% to
85%.31 Consequently, depending on facial features and patient desire or as a starting
point, a rectangular frame within this range is placed over one of the central incisors,
as demonstrated in Fig. 5. Place the base of the frame on desired incisal position and
Fig. 5. Tooth proportion tool (blue) on retracted close-up image.

726 Whiteman
resize frame to desired size while keeping proportions constrained to maintain correct
tooth ratio.
Step 4: Teeth Proportion Tool and Interdental Proportion

Different interdental proportion philosophies have been proposed and overridden in
literature in the past decades.30,34–37 In the University of California Los Angeles Center
for Esthetic Dentistry (CED), the Recurring Esthetic Dental proportion (RED) tool is
used as a starting point; however, golden proportions can also be used to evaluate
symmetry, dominance, and interdental proportion.35 It is important to remember
that in the smile design process, using proportion tools serves as a starting point
only and does not define the exact final ratios of the teeth.
Using a pre-made proportion guide, as shown in Fig. 6, resize the selected inter-
dental proportion tool to fit previously placed central proportion frame and align it
with the incisal position. It is important to maintain correct ratio when adjusting the
size to maintain proper proportions.
Fig. 6. Proportion ruler (white) is sized to fit preformed central proportion tool (blue). Both
are placed on projected maxillary incisal edge.
Step 5: Teeth Outline and Arrangement

In this step, teeth outline is created by using existing downloaded libraries, outlining
the patient’s teeth, or by outlining other patients’ teeth images. It is recommended
to create a personal library from which the clinician or technician can pick and choose,
thus being able to develop personalized smile designs for patients.
The teeth outline is then transferred and placed to fit into previously determined
interdental proportion guidelines, as shown in Fig. 7. The teeth outline will now be
resized to fit into the interdental proportion tool. At this point, the clinician can
Fig. 7. Personalized teeth outline fit into predetermined proportion guidelines.

personalize and fine-tune the teeth outline, shape, and length, refine smile arc, and
improve incisal design and gingival architecture to tailor to the patient’s esthetic needs
and wishes.
Step 6: Removal of Reference Lines and Proportion Tools

At this point, all auxiliary guide marks (facial midline and horizontal lines, as well as
proportion tools) can be removed and evaluation for teeth position can take place.
Only the teeth outline should remain (Fig. 8).
Fig. 8. Teeth outline on retracted view.
Step 7: Final Esthetic Evaluation

Once DSD steps are completed on the retracted Close-Up image, the teeth outline
can now be transferred to smile images (both Close-Up and Portrait) for esthetic eval-
uation and communication with the patient and other team members, and case can
move forward for completion. See Figs. 9–12 for reference.
Fig. 9. Outline tool transferred to smile for evaluation.
Fig. 10. Outline tool on the dentition after orthodontic appliance removal.
728 Whiteman
Fig. 11. Case completed close-up retracted view.
Fig. 12. Case completed close-up smile view.
SUMMARY
Orthodontic-restorative cases require precise communication before and during treat-

ment. The challenge frequently met in many of these cases is finding a reliable and
easy-to-interpret method for communicating goals and recommendations. The
described visual benefits of the outline tool in the DSD technique can stream line
the communication process and help ensure understanding among clinicians and
patients.
ACKNOWLEDGMENT
Special thanks to Dr. Kanwar Singh-Sachdeva and Dr. Chirag Chawan from UCLA Or-
thodontics Postgraduate Program as well as Dr. Heba Binabid and Mr. Juan Kang
from UCLA Center for Esthetic Dentistry for their involvement in the cases presented.
DISCLOSURE
REFERENCES
1. Kokich VG, Spear FM. Guidelines for managing the orthodontic-restorative pa-
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2. Spear FM, Kokich VG. A multidisciplinary approach to esthetic dentistry. Dent
Clin North Am 2007;51(2):487–505, x-xi.
3. Gahan MJ, Lewis BR, Moore D, et al. The orthodontic-restorative interface: 1. Pa-
tient assessment. Dent Update 2010;37(2):74–6, 78-80.
4. Spear FM. Forming an interdisciplinary team: a key element in practicing with

confidence and efficiency. J Am Dent Assoc 2005;136(10):1463–4.
5. McLaren EA, Whiteman YY. Ceramics: rationale for material selection. Compend
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6. McLaren EA, LeSage B. Feldspathic veneers: what are their indications?
Compend Contin Educ Dent 2011;32(3):44–9.
7. Kim J, Chu S, Gurel G, et al. Restorative space management: treatment planning
and clinical considerations for insufficient space. Pract Proced Aesthet Dent
2005;17(1):19–25 [quiz: 26].
8. Lewis BR, Gahan MJ, Hodge TM, et al. The orthodontic-restorative interface: 2.
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37(3):138–40, 142-134, 146-138 passim.
9. David SM. Orthodontics & esthetic dentistry: mission possible. J Cosmet Dent
2016;31:14–26.
10. Greenberg JR, Bogert MC. A dental esthetic checklist for treatment planning in
esthetic dentistry. Compend Contin Educ Dent 2010;31(8):630–4, 636, 638.
11. Spear FM, Kokich VG, Mathews DP. Interdisciplinary management of anterior
dental esthetics. J Am Dent Assoc 2006;137(2):160–9.
12. Brandao RC, Brandao LB. Finishing procedures in orthodontics: dental dimen-
sions and proportions (microesthetics). Dental Press J Orthod 2013;18(5):
147–74.
13. Reikie DF. Orthodontically assisted restorative dentistry. J Can Dent Assoc 2001;
67(9):516–20.
14. Morgano SM, Rodrigues AH, Sabrosa CE. Restoration of endodontically treated
teeth. Dent Clin North Am 2004;48(2):vi, 397-416.
15. Kokich V. Esthetics and anterior tooth position: an orthodontic perspective. Part II:
Vertical position. J Esthet Dent 1993;5(4):174–8.
16. Salama H, Salama M. The role of orthodontic extrusive remodeling in the
enhancement of soft and hard tissue profiles prior to implant placement: a sys-
tematic approach to the management of extraction site defects. Int J Periodontics
Restorative Dent 1993;13(4):312–33.
17. Borzabadi-Farahani A, Zadeh HH. Adjunctive orthodontic applications in dental
implantology. J Oral Implantol 2015;41(4):501–8.
18. Mack MR. Perspective of facial esthetics in dental treatment planning. J Prosthet
Dent 1996;75(2):169–76.
19. McLaren EA, Rifkin R. Macroesthetics: facial and dentofacial analysis. J Calif
Dent Assoc 2002;30(11):839–46.
20. Rifkin R. Facial analysis: a comprehensive approach to treatment planning in
aesthetic dentistry. Pract Periodontics Aesthet Dent 2000;12(9):865–71
[quiz: 872].
21. Coachman C, Calamita M. Digital Smile Design: a tool for treatment planning and
communication in esthetic dentistry. QDT 2012;35:103–11.
22. Morley J, Eubank J. Macroesthetic elements of smile design. J Am Dent Assoc
2001;132(1):39–45.
23. Ackerman MB, Ackerman JL. Smile analysis and design in the digital era. J Clin
Orthod 2002;36(4):221–36.
24. Proffit WR, Fields HW Jr, et al. Contemporary orthodontics. Elsevier; 2013.
25. Dias NS, Tsingene F. SAEF - Smile’s Aesthetic Evaluation Form: a useful tool to
improve communication between clinicians and patients during multidisciplinary
treatment. Int J Esthet Dent 2011;6(2):160–76.
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26. Sarver DM, Ackerman MB. Dynamic smile visualization and quantification: Part 2.
Smile analysis and treatment strategies. Am J Orthod Dentofacial Orthop 2003;
124(2):116–27.
27. Sarver DM, Ackerman MB. Dynamic smile visualization and quantification: part 1.
Evolution of the concept and dynamic records for smile capture. Am J Orthod
Dentofacial Orthop 2003;124(1):4–12.
28. Vig RG, Brundo GC. The kinetics of anterior tooth display. J Prosthet Dent 1978;
39(5):502–4.
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2013;29:94–108.
30. Lombardi RE. The principles of visual perception and their clinical application to
denture esthetics. J Prosthet Dent 1973;29(4):358–82.
31. Davis NC. Smile design. Dent Clin North Am 2007;51(2):299–318, vii.
32. Sarver DM. The importance of incisor positioning in the esthetic smile: the smile
arc. Am J Orthod Dentofacial Orthop 2001;120(2):98–111.
33. Magne P, Gallucci GO, Belser UC. Anatomic crown width/length ratios of unworn
and worn maxillary teeth in white subjects. J Prosthet Dent 2003;89(5):453–61.
34. Preston JD. The golden proportion revisited. J Esthet Dent 1993;5(6):247–51.
35. Snow SR. Esthetic smile analysis of maxillary anterior tooth width: the golden per-
centage. J Esthet Dent 1999;11(4):177–84.
36. Ward DH. Proportional smile design using the recurring esthetic dental (red) pro-
portion. Dent Clin North Am 2001;45(1):143–54.
37. Ward DH. A study of dentists’ preferred maxillary anterior tooth width proportions:
comparing the recurring esthetic dental proportion to other mathematical and
naturally occurring proportions. J Esthet Restor Dent 2007;19(6):324–37 [discus-
sion: 338–9].
B r a n d i n g D y n a m i c s f o r th e
E st h e t ic De nt ist
Building Your Brand to Build Your Practice
a,b,
David J. Wagner, DDS *, Julie Loganc
KEYWORDS
Branding Esthetic dental practice Professional identity
KEY POINTS
Branding involves every facet of your professional identity and reputation.
Powerful and effective branding is a must have in building a thriving esthetic dental
practice.
Powerful and effective branding plays a vital role for patients finding and choosing an
esthetic dentist.
Building your brand requires answering many questions, making many decisions, and im-
plementing those decisions into your personal and professional life.
VALUE OF BRANDING
As dentists, we wear many hats. As clinicians, we perform a variety of procedures we

learn in dental school, advanced training programs, and continuing education
courses. As practice owners, whether in solo or partnered practices, there is another
set of critical skills for which we have little to no training.
When operating in the esthetic dental arena, there is a shift in the way that patients
find a provider. Esthetic dentistry is like any other elective or luxury purchase: percep-
tion and emotion play a key role in consumer decision-making and patronage. When
looking for a dentist who is excellent at elective procedures that involve improving
appearance, patients look for a dentist who not only has a sound reputation and expe-
rience, but also one who has an elevated visual presence online, and elsewhere, rep-
resenting their skills, work, esthetic style, and practice environment.
a
Private Practice, West Hollywood, CA, USA; b UCLA Center for Esthetic Dentistry; c
Writing
and Branding Consultant based in Los Angeles, USA
* Corresponding author. 8733 Beverly Boulevard #202, West Hollywood, CA 90048.
Dent Clin N Am 64 (2020) 731–737

732 Wagner & Logan
After years of education and training, it can be surprising and frustrating to young
dentists looking to add an esthetic component to their practice that their skills may
not be the metric by which prospective patients choose to call their office, seek their
services, or schedule a procedure. The reality is that few people outside the dental
field can truly understand the many factors that define clinical excellence and optimal
natural-looking esthetic treatment. The metric that patients must go by is purely our
reputation based on a referral or the image created by branding and marketing efforts
that emotionally communicates our skills, our style, and our commitment to caring,
ethical, and outstanding treatment outcomes.
A promotional piece from the Digital Smile Design Company speaks to this point:
As dentists we invest time and money honing our clinical skills. However, when it
comes to making a decision about a treatment plan, patients don’t consider your
advanced skill in occlusion, nor your training in teeth preparation. In fact, when-
ever a patient makes a decision about treatment, it’s always a leap of faith –
even if you have 100 diplomas on your clinic wall.1
EMOTIONAL CONNECTION
To attract prospective patients to your practice and motivate them to accept treat-
ment with you, these patients have to believe you can deliver the results they
desire. For them to stay motivated and compliant throughout treatment involving
irreversible changes to their appearance, significant out-of-pocket investment,
and multiple visits over a period of time, they have to trust you and the process.
To foster that belief and trust from others, you have to portray an imagine of your-
self as highly competent, likable, and ethical: a true expert. This means that deter-
mining and defining who and what you are, branding, is as equally important as
honing clinical skills to be a successful esthetic dentist.
Done well, branding also sets you apart from your competition, as it emphasizes
your superior points of difference. Once you are clear about your brand, it becomes
not only easier for you to communicate who you are and what you do, but for others
(patients, colleagues, media, family, and friends) to understand you and your practice
and therefore choose you over others.
Although many branded components (printed pieces, social media, signage, and pro-
motion) involve language, ultimately what branding does is communicate in ways that go
deeper than language. Its currency is feeling and impression. When you are on target,
belief, trust, and connection follow naturally for both existing and prospective patients
as well as for your colleagues and community. Like attracts like, and therefore if your
branding is sophisticated, elegant, and warm, you are going to attract a patient base
that responds to businesses and messaging that are sophisticated, elegant, and warm.
BRANDING DEFINITION
‘Branding’ is one of those terms so overused it has almost become meaningless and
can be confusing. Also confusing to the uninitiated is that branding has its own vocab-
ulary (See Appendix 1). The actual meaning fundamentally can be looked at in two ways.
Short definition: Branding defines identity.
Longer definition: Branding expresses identity via goods, services, environments,
and behaviors (and often a combination of the 4) across multiple platforms and in mul-
tiple contexts. In other words, branding works to create a single identity encapsulating
every single thing a dentist and dental practice would say, be, do, offer, display, look
like, occupy, or make.
Branding Dynamics for the Esthetic Dentist 733
There are certain characteristics and qualities that define branding. Good branding
is the consistent or logical identity expression across every platform and context that
is executed with simplicity and clarity. Every element syncs with or makes perfect
sense with the other. This means that your services, your logo design, your social me-
dia, your practice’s décor, printed patient aftercare information, your staff scrubs, and
your promotional videos line up with each other to consistently portray your personal-
ity and message. These are all examples of physical branding components.
It is critical to understand that branding for dentists transcends the tangible, where it
also heavily involves your personal and professional reputation. In addition, it involves
every interaction a patient has with your practice, including the moment any team
member starts interacting with a prospective or current patient: online, on the phone,
or in person. The less friction a patient encounters to learn about your identity, find
your practice location, and schedule an appointment, the better; the level of friction
is reflective of your brand. Both tangible and intangible aspects of brand will help
reduce points of friction for patients, giving them a better experience. A clearly written
web site explains your services, whereas your front office team clearly explaining the
consultation process and value of your high-level services are both integral to instill
enough emotional excitement in a patient leading them to choose you.
Brian Collins, founder of the eponymous Collins, a “strategy and brand-experience
design company based in San Francisco, who works with some of the world’s best
brands including Spotify, Nike, and The San Francisco Symphony,” says this about
brand: “From the moment that you start talking about your company, launch a web
site or have someone answer your phone, there’s a brand there. So my argument is
simple: be conscious of it. Protect it. Manage it like you would any valuable asset.”2
Branding a dental practice is similar to other industries in that the physical and visual
presence is critical. However, it is also unique in that we are health care professionals,
and our reputation as compassionate, caring, and ethical individuals when interacting
with patients, as well as in our professional and local communities matters equally.
Successful dentists fully understand that both facets, the physical and interpersonal,
are critical to their brand building and will constantly work to develop not only their
own skills but also the skills of their entire team and practice culture.
BEGINNING THE BRANDING JOURNEY
Powerful branding begins with astute analysis of self and goals. Developing a brand
requires a detailed, organized strategy and a tremendous amount of focus and prep-
aration. The amount of detail and effort that goes into developing a good brand is often
underappreciated and undervalued, mainly due to a lack of understanding by people
outside of the branding field. This is where we as esthetic dentists are at a distinct
advantage. One thing we do particularly well is focus, deriving precise information
(esthetically, technically, practically, and even emotionally) from what we observe
and subsequently conclude. As a dentist, creating your brand can be done in several
ways: done by yourself, by enlisting the services of a branding professional or agency,
or some combination of the two. Regardless of your desired investment, there is a
general, logical sequence that is pursued to have a brand be realized. Each step of
the process gets you closer and closer to your end goal of an overall cohesive and
recognizable identity.
Typically when starting the branding journey, a document called a brand brief is used as
a beginning point. A brand brief contains a number of questions that must be answered to
start to formulate exactly who you are, inform your vision, map out how you want to be
perceived, and define the demographics of your desired prospective patients so they
734 Wagner & Logan
can be targeted with your marketing and media efforts. Without the brand brief as a foun-
dation, efforts to attract and impress patients become disjointed and unclear, leading to
confusion and potential clients moving on. Just like a great film starts with a powerful
script, so does a great brand begin with a powerful brand brief.
HIRING PROFESSIONALS
Implementing a good branding program does take a considerable amount of work. It is

a commitment requiring a significant amount of time, money, and concentration. It
may also mean securing the talents of a branding professional, graphic designer,
web site designer, social media specialist, interior designer, and perhaps even an
advertising agency, marketing specialist, videographer, or copywriter.
You do not necessarily need to find each of these on your own, although you may
choose a do-it-yourself (DIY) approach is perfectly acceptable and can reduce invest-
ment. However, a DIY approach will require much more time, organization, and research
on the dentist’s part to properly execute a cohesive brand. If you hire a branding com-
pany, agency, or studio, it will take on the role of project manager to find and coordinate
many of the various creative elements. Some companies offer a comprehensive, tem-
plated one-size-fits-all package. This may work for this with less time or money. How-
ever, just like in esthetic dentistry and other elective goods and services, the higher the
sensibility and sophistication, the more investment required.
A reliable metric for hiring compatible creative professionals is to determine if they are
as good at what they do as you are what you do. Looking at specific examples of a brand-
ing expert’s previous work will help determine if their style and esthetic aligns with your
vision. Although each branding project done by a professional should be unique and indi-
vidualized, the overall skill level and ability of the branding professional to sculpt an iden-
tity for themself can be assessed and is also something on which to base a decision.
The other group of individuals that must be involved when executing high-level
branding is your team, because they are, in fact, the most important part of your brand.
Developing your practice’s branding is not something you want to do in isolation and
then spring on your team after the fact. From the outset, you need every single mem-
ber of your team to participate, understand, value, support, and perhaps even help
build your practice’s vision and mission. Branding should be a topic of discussion
at every team meeting, along with public acknowledgment of those with good ideas.
As time goes on, a brand becomes a living, breathing, evolving entity and must be
managed by those individuals involved in the day-to-day operations of the practice.
This evolution happens as services are added, systems improve, clientele demo-
graphics shift, and ultimately the practice elevates its status. Involving the team
from the outset results in them taking a significant interest, understanding, and owner-
ship of the brand and therefore a vested interest in the growth and overall well-being of
the practice. Team members can be encouraged to fill out the brand development
worksheets shown later in this article.
An important point to make is that you may already employ individuals who have a talent
for branding ideas and analysis. Sometimes an astute team member will know you better
than you know yourself and offer valuable insights. A team member who has an affinity for
photography and social media, for example, can best put those interests to work to regu-
larly manage your practice’s content while you are busy seeing patients and producing.
RETURN ON INVESTMENT
In developing a personal strategy to complete a new or re-brand of your practice, bud-

gets are of primary concern. One of the worksheets found later in this article, which will
take a fair amount of research and at least a few weeks to complete, will help you work
to find the creative and technical professionals (and style) you like and the costs for
each service. Learning all this at the outset will prevent financial surprises later and
allow you to plan. It is not uncommon to break up the branding process into affordable
pieces. From there, you will be able to determine who is worth what to you and your
practice. It is also important to note that all possible aspects of branding do not need
to be executed for all dental practices. For example, an esthetic dental practice may
find significant value in social media video content in ways that other practices or spe-
cialists may not. Once you have developed your brand, market research continues the
process to effectively put the brand to work.
SUMMARY
As you start to think about your brand, a strategic mix of the personal, the professional,
and the practice, remind yourself that you are unique, complete with a specific com-
bination of skills, experience, and personality. You have come so far but there is still
work to do. Authentically branding yourself now will be the next step on the road to
greater success.
DISCLOSURE
The authors have nothing to disclose.
REFERENCES
1. Digital Smile Design. What is an emotional presentation and how can it change the
way your patients connect with you?. Available at: https://media.
digitalsmiledesign.com/news/what-is-an-emotional-presentation. Accessed April
23, 2020.
2. Collins B. How to find your brand. Monocle 2020;19.
APPENDIX 1:
Branding Glossary
When you first meet with branding professionals, and these can include agencies, social
media consultants, copywriters, graphic designers, and videographers, they are likely to use
terminology that is unfamiliar to you. Here are a few insider terms to get you started:
Brand: an entity’s identity incorporating a mix of tangible and intangible attributes.
Although it is most often the physical representation of a company’s esthetic, offerings,
and values, it can also exist subjectively in a person’s mind.
Branding: the act of creating, selecting, and blending attributes to differentiate a product,
service, or business.
Good branding: consistency of image and identity across various platforms in an attractive,
meaningful, and compelling way to attract and build loyalty with a specific, targeted
customer base.
Brand brief: a document that spells out all the attributes a company wants articulated by
their branding.
Brand book: also known as a style guide or brand bible, a document that illustrates all
philosophic and visual aspects of a brand, including identity and values statements, target
736 Wagner & Logan
market information, graphic design, proper logo application, templates, color palette,
typography, and media.
Collateral: digital and printed pieces, such as brochures, post cards, and signage.
CTA: call to action. All digital media and collateral pieces should feature a CTA, that is, a
clear indication of what they want the reader/viewer to do (as in sign up, call, schedule,
purchase, order, or respond.)
Mission statement: defines the present state or purpose of a company, service, or product.
It answers three essential questions: WHAT it does; WHO it does it for; and HOW it does
what it does. Written succinctly in the form of a sentence or two, the mission statement is
something that all employees should be able to recite on request.
Vision statement: inward-facing company-eyes-only articulation of desired outcome over
time, its metric for success. These goals can be abstract or tied to something specific, like
customer base or a dollar figure.
Core values statement: a list of a company’s non-negotiable characteristics regarding
ethical business practices, quality delivery, customer service, diversity, sustainability,
transparency, staff support, and kindness.
BRANDING DOs AND DONTs

DO remember that branding is a work in progress, you might not get it exactly
right the first time and your brand may change over time.
DON’T try to do all of your branding at once especially if you don’t have the time
or the budget.
DO approach your brand developing every day, even if it is only in 30-minute or even
15-minute increments at a time. In fact, good ideas often come to you between ses-
sions but only if you keep them up frequently enough to build momentum.
DO always move forward with analysis and writing down your answers step by
step.
DO learn to articulate why you like something or do not like something. Although
it may not come naturally in the beginning, you will get better at this as you go
along.
DO interview and comparison shop multiple candidates/companies for any pro-
fessional service you hire
DO help the decision-making process by finding multiple examples (even outside
the dentistry field) that reflect your taste and goals and compare them with each
other. Show these examples to any professionals you are interviewing or have
hired to help you. Good examples may be specific brands you love, such as a
technology, clothing, shoes, or automobile media content, such as their social
media posts or in print campaigns.
WORK SHEETS
Brand development means asking questions, answering them, and then basing your
plans of action on what you have learned. The good news is that thinking, planning,
and envisioning are free. The more you have figured out in advance, the more astute
you will be in controlling the narrative moving forward. Always remember the most
effective communication is simple and direct.
Preliminary Exploration: What Does Your Profile Look Like?

The descriptive words you note below can be real or aspirational. These can range from
technical to aesthetic to emotional. Feel free to revise this list or add other categories as you
go along. For added insight, you can also ask members of your staff to complete this exercise
too.
For each of the following, note five adjectives that describe
You personally
You professionally
Your practice’s technology and equipment
Your practice culture
Your office’s décor and environment
Your practice’s communication materials, both printed and digital
Your colleagues
Your staff
Your team training
Your traditional media and promotion
Your social media and digital communication
Conclusion: By compiling these you will be building your practice branding profile. Certain
themes will emerge. This profile will function as your branding benchmark by which you
judge every decision you make. Does it sync, does it go, does it work, does it make sense?
Components, Professional Wish List, and Budget

For each of the following, find at least three examples of other brands you like and three you
do not like. Make a spreadsheet on which you note the following:
a. What you like or do not like and specifically why.
b. On the ones you like, find out who created them and their contact details.
c. On the ones you like, note the cost. You may be unable to find this information.
d. Because you are breaking out each and every one of these items individually (and doing it
three times per), do not be surprised at the heft of the document.
This can also serve as a checklist for areas of branding. You may not need all of these. You
may have additional components you desire.
Some of these (advertising, for example) have multiple parts requiring individual pricing.
2-Dimensional design
__ GRAPHIC DESIGN (logo, business cards, letterhead, printed and digital materials including
social media formatted posts)
__ INTAKE FORMS (digital or printed)
__ BROCHURES AND POSTCARDS
__ PATIENT FOLDER AND FORMS
__ ADVERTISING (if yes, where, with whom and what are your desired results?)
__ COPYWRITING (optional, if no, who is going to do it?)
Media and social media
__ WEB SITE DESIGN
__ MONTHLY WEBMASTER MAINTENANCE
__ PHOTOGRAPHY
__ VIDEOGRAPHY
__ MONTHLY SOCIAL MEDIA MANAGEMENT
__ MONTHLY PUBLIC RELATIONS (if yes, where, with whom and what are your desired results?)
Dress, décor, and atmosphere
__ INTERIOR DESIGN
__ SCRUBS, UNIFORMS, AND DRESS CODE
__ MUSIC
__ MEDIA (video)
Staff training and education
__ STAFF SCRIPTS
__ OUTSIDE PRESENTATIONS

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October 2020  Volume 64  Number 4

YAIR Y. WHITEMAN, DMD

DAVID J. WAGNER, DDS

SIVAN FINKEL, DMD

LAWRENCE FUNG, DDS

MARC HAYASHI, DMD, MBA

ALIREZA MOSHAVERINIA, DDS, MS, PhD, FACP

PETER PIZZI, CDT, MDT

KATHRYN PRESTON, DDS, MS

TODD R. SCHOENBAUM, DDS, MS

PHONG TRAN CAO, DDS

DAVID WAGNER, DDS

YAIR Y. WHITEMAN, DMD

Preface: The Journey to Excellence in Esthetic Dentistry ix

Science, Materials, and Technology Update

Science in the Practice of Clinical Dentistry 609

Implementing Digital Dentistry into Your Esthetic Dental Practice 645

the most significant benefits of digital technology in dentistry is the

Team Collaboration and Communication

A Beginning Guide for Dental Photography: A Simplified Introduction for Esthetic

Dentist-Ceramist Communication: Protocols for an Effective Esthetic Team 697

A Communication Guide for Orthodontic-Restorative Collaborations: An

improve treatment outcomes for patients. In many cases, this involves

A Communication Guide for Orthodontic-Restorative Collaborations: Digital Smile

Business Professional Focus

DENTAL CLINICS OF NORTH AMERICA

FORTHCOMING ISSUES RECENT ISSUES

SERIES OF RELATED INTEREST

Oral and Maxillofacial Surgery Clinics

THE CLINICS ARE AVAILABLE ONLINE!

Yair Y. Whiteman, DMD David J. Wagner, DDS

Dent Clin N Am 64 (2020) ix–xi

Yair Y. Whiteman, DMD

THE RATIONALE AND CHALLENGES OF IMPLEMENTING SCIENTIFIC DATA INTO

Dent Clin N Am 64 (2020) 609–619

TYPES OF STUDIES AND THEIR VALUE IN CLINICAL PRACTICE

Study Design What It Is Relevance to Clinical Dentistry

Fig. 2. Randomized clinical trial design.

Statistical Significance or Clinical Significance

Mean ISQ (95% CI)

Power and Sample Size

selected, informed, or controlled, this is in the category of effectiveness. The compli-

The author has nothing to disclose.

1. Esposito M, Grusovin MG, Maghaireh H, et al. Interventions for replacing missing

In modern restorative dentistry, we are overwhelmed with a plethora of different

The author has nothing to disclose.

Dent Clin N Am 64 (2020) 621–631

WHAT ARE DENTAL CERAMICS?

A ceramic is a product made from a nonmetallic inorganic material that is processed

Glass Matrix Ceramics

occurring feldspathic porcelain.13,16 Secondary to the improved mechanical proper-

Resin Matrix Ceramics

In addition, etching the polycrystalline ceramics with hydrofluoric acid seems to be

CASE SELECTION AND CLINICAL CONSIDERATIONS (MATERIAL SELECTION)

Marc Hayashi, DMD, MBA

Dent Clin N Am 64 (2020) 633–643

Classification Steps Generation Examples

Group Pros Cons

October 2020 Volume 64 Number 4