One of the challenges of aesthetic dentistry is setting clear expectations for patients. The more we can use visual tools over words the easier this becomes.

Over the years I have found that looking at photos with patients, both of their teeth and of the teeth of other people whose smiles demonstrate the principles I am explaining has made patient understanding much more successful. I always ask permission to show a patient the photos of their teeth as I find sometimes they are shocked by what they see. The photos can also be used to show them the changes being proposed. Drawing shapes and lines on the images communicates the information without the risk of setting unattainable expectations, which I fear using photoshop might.

The Third Aesthetic Zone Ration

The next of the esthetic zone ratios looks at tooth proportion. Upper anterior teeth look their most esthetic when the ratio comparing width to length is between 70-80%. This proportion can be measured on a computer screen in pixels using programs like Keynote or Powerpoint.  Insert the image into a slide and trace the outline of the tooth with the freehand shape tool. Once the shape is complete click on it and hold your mouse curser over the corner. The pixels for width and length will apear and you can calculate the ratio. It is also easy to figure out this ratio by measuring on a stone model with digital calipers, or from a printed image using a ruler.

(Width/Length) * 100= Tooth Proportion Ratio

What the Ratio Means

Teeth with a ratio of less than 70% appear too tall and narrow. If it is greater then 80% the tooth appears too short and wide. If the tooth has a width to length ratio that is less than 70% or greater than 80% and we are going to treatment plan changing it we have to determine where we make the length adjustments at the incisal edge or the free gingival margin. The fist step is to determine the correct position of the incisal edge in the face using a lips at repose or rest photo. From the proposed incisal edge position we can then determine the proper position of the free gingival margin using this ration.

Some simple math can be very helpful when determining the appropriate length to correct this ratio.

• 70%= width times 1.43
• 75%=width times 1.33
• 80%=width times 1.25

It was August of 1995 when I walked through the doors of the Pankey Institute for the very first time.

I was attending a course specifically designed for hygienists and was literally in awe of every aspect of my experience there. Not only was the clinical information fresh and new from what I had been taught in hygiene school, I was also introduced first-hand to the philosophy that has since become the corner stone of my own personal and professional life.

The Power Of Development

Looking back over my shoulder at the past 24 years I realize that none of my learning or growth could have occurred if my “boss” had not invested in me. What I didn’t realize early on was that his investment was not just so that I could be a better hygienist. What happened was that I grew to become an incredibly high performing, deeply engaged, missionary and change agent for our practice. I learned that my thoughts, ideas, feelings, and questions were not only welcomed, but invited and encouraged each and every day. I become a perpetual student and my hunger for personal and professional development was fed and nurtured by the culture that we had intentionally created in our practice.

Today I have the opportunity to work with dental teams across the country, and my mission has evolved from being able to serve individual patients to supporting entire teams as they navigate their own growth and challenges. You see, my own experience as a team member was so powerful that I find it imperative to create my own version of Quid Pro Quo.   Yes, it’s rewarding to help practices learn and practice skills that can enhance every aspect of the patient experience, and even more rewarding to know I’m supporting each Dr and team member to be become the very best version of themselves.

What Does It Mean To Create A Healthy Culture?

Experience tells me it’s where each person is seen, heard, valued, recognized, and appreciated. Of course, it’s important to develop and implement systems, define clinical protocols and establish business operations. I ensure you that when team members feel a part of something bigger than themselves and connected to you and each other, a sense of accountability and responsibility to these standards increase exponentially…as does the presence of positive attitudes. And just in case you’re interested, I’ve also found that every single practice will ALWAYS have challenges, conflicts, and competing values to work out. The highest performing teams will be the ones who consistently push themselves to work ON their issues and work THROUGH their differences.

It was one of the greatest honors of my coaching career to be invited to work with the in-house team at the Pankey Institute last week. I left the building after our meeting filled with more pride than ever in the Institute’s commitment to excellence, and to their team. Your Pankey leadership team is continually helping each person find their voice, serve each participant, “walk the walk and talk the talk” of what it means to be in service and an agent for positive change.

Let me leave you with this question: What is the kind of culture that you want to have in your practice, and who are you willing to invest in to get there? I’m here to tell you, it’s worth the effort!

Aesthetic Zone ratios is one of many ways to evaluate the appearance of a patients smile, and also to plan for changes that will improve overall aesthetics.

In the last article on using aesthetic zone ratios we looked at comparing the width to the height. This ratio allows us to gather data and diagnose issues like vertical maxillary excess and hypermobile lip that cause this ratio to be larger than normal.

Anterior Segment Ratio

The next of the four ratios compares the width of the total esthetic zone, all of the teeth visible between the commissures at a full smile, and the width of just the anterior segment, between the distal of the canines. The first thing to do is measure the two distances. This can be done in pixels by inserting a line over a full smile photo, or measured with a mm ruler on a printed photograph. Make sure your line is placed at the inside of the soft tissue near the commissures. The relationship to real width is irrelevant as we are going to use a ratio. We then divide the width of the anterior segment by the width of the esthetic zone and multiply by 100.

Arch Width Ratio= (Anterior Segment Width/ Esthetic Zone width) x 100

Smiles that are rated as attractive have an anterior segment width ratio between 59-75%, and the average ratio is 66%. The percentages do not have a gender or age bias which makes relying on these numbers easy. If the ration is too small or too large I start to wonder about arch space issues. Often with patients with a large midline diastema you will see this ratio be larger than 75%. In these cases or cases with inadequate space I want to make sure we use wax-ups and mock-ups to ascertain that we can meet the patients aesthetic demands without the addition of ortho to the treatment plan.

Once you want to be a leader and you know yourself well enough, you’re ready to move on to helping others effectively. We have already taken a look at the first two parts of Dr. Rich Green’s leadership definition:

“A leader is a person…

Willing and Able

To influence behavior;

Their OWN FIRST

Then others

To a preferred future.”

-Rich Green, DDS

Leading Others

Building on our willingness and ability to influence behavior (our own first), now we will talk about leading others. It is by leading ourselves well that we “earn the right” and have the highest capacity to lead others.

I’m going to use the four essential areas I discussed in the previous blog as a framework for discussing our leadership of others.

Let me start by saying that we can train someone to assist us or do a great job greeting our patients, or to do stellar financial arrangements, etc. But when we hire, what we really want to look for is someone who has similar values and is inspired by our vision and purpose.

If we are clear about our own values, vision, and purpose/mission, which means we have done our own work to get clear, we will know if our prospective employees are a good fit by asking questions.

If we already have employees and are in transition, meaning we are changing our practice and/or doing work to get more clear on our values (what the practice is about and where we’re headed), we have an opportunity to be in constant conversation with those around us.

The people around us – in this case our team, specialists, lab technicians, and patients – want to know what we believe in and what we stand for. People are hungry for connection on that level.  

Influencing Others

Now let’s look at the four areas I discussed previously and how they help us in our ability to influence others:

1. Our competency and skills.

What we are doing and how we are doing it models for our team what we expect and what we are about. When our team feels competent and skilled, they feel confident and pleased about the quality of their work.

Especially in a high level practice, taking our team to CE and taking the time to work with them on their technical skills as well as communication skills is vital to their success. Most of us know this and probably do this pretty well already.

2. Knowing how we are wired helps us understand how others are wired.

The patterns, beliefs, and behaviors are not the same, but knowing that we have all been programmed and that this is part of the human condition helps us have compassion and a deeper understanding of how people tick.

Remember, most of this programming we were either born with or was “installed” from 0-7. In some way, even if it doesn’t make sense, we all do what we do in order to feel safe, loved, competent, and a sense of belonging. Knowing this gives us compassion for why people do what they do. 

3. Emotions

Being able to be with our own emotions allows others to be with theirs. As we model this and help our team learn it, they will increase their capacity to be with their own emotions and those of others.

Empathy is one of the most important skills to have as a healthcare provider. We have the opportunity to be the leader of this in our practice and in our life. When we work with humans, we work with their emotions and experiences (whether we like it or not).

4. Knowing and owning our truth.

This is an empowered and empowering place to stand. When we own and are clear about our truth, our desires, what we stand for, and what we are about, we can lovingly set boundaries and make clear decisions.

This also helps us honor others as they stand for what they believe. Once we are clear about these things for ourselves, we have an opportunity to share them with our team so that we are all moving toward the same preferred future, which we’ll talk about in the next blog.

Stay tuned …  

There are many different ways to assess and diagnose the aesthetics of a smile. I love learning a different approach, not so I can change to it, but so I can incorporate it into what I am already doing.

I had the pleasure of attending a full day lecture by Dr. Corky Willhite on transitional Bonding. Corky is one of the dentists I respect the most when it comes to composite education, and I had not heard him teach for many years so I was really looking forward to it. With all of the great new tricks I learned about composite, what I came away with that has me most excited is the four Esthetic Zone Ratios, to analyze and improve the attractiveness of a smile.

What Are Aesthetic Zone Ratios?

Esthetic Zone Ratios is an approach to smile design, and can be used in conjunction with or as a replacement for other smile design systems. There are four aesthetic zone ratios:

• Anterior Aesthetic Zone Ratio
• Tooth Proportion Ratio
• Anterior Segment Ratio
• Central Dominance Ratio

Aesthetic Zone Ratio

The first of the four ratios compares the width and height of the esthetic zone at a full smile. The first thing you will need is a full smile photograph of the patient. I typically ask the patient to say “E” to capture this photo so I do not get their posed smile with less display. I utilize presentation software to do the analysis since the program will do the math for me. I insert the full smile photograph into a slide. I then insert two lines one from for the width from inside the upper to inside the lower lip. I then do the same thing for width taking my line from the commissures, just inside the tissue of the cheek or face. You can then get the pixels length of the two lines by placing your cursor over the end of the line and holding.

Now you are going to divide the two numbers into each other, height divided by width, then take that result times 100 and you now have a percentage. The ideal ratio is between 15-30%. If this ratio is great then 30% we can then focus on a diagnostic cause of the smile being too tall or high. This might be things like Vertical Maxillary Excess or a short upper lip. The ratio triggers me to go back and look through other photos and evaluate the face and sift tissue for diagnostic challenges. If the number is smaller then 15% we may have a long upper lip, reduced lip mobility or a short lower face.

Facial and Soft Tissue anomalies are rarely treated when we fix the teeth, but can have a significant impact on the aesthetic outcomes, and when undiagnosed can often negatively impact our dental treatment plan.

Are you routinely taking diagnostic photos with patients?

Chair-side air abrasion has numerous advantages, especially today when we use adhesive retention so much of the time.

The advantages for many years have been outweighed by the logistic challenges. With the advent of small, lightweight, easy to use air abrasion handpieces this is no longer true. When I became aware of the etchmaster I was skeptical, but I am now a believer and use air abrasion int he operatory all day long.

The Clinical Applications

One of the first things that many of us will utilize air abrasion for is to “etch” zirconia restorations for bonding during final seating. The only way to prepare the inside of a zirconia restoration is with 30-50 micron aluminum oxide. The particle size and type is critical. The ideal pressure is 1 bar (15psi). Next on my list is to clean tooth preparations prior to bonding and cementation. To me there is no better way to assure the removal of temporary cement and prepare a tooth for maximal adhesive retention than with 30 micron aluminum oxide.

My list goes on as I have started to prepare small class one cavity preparations using small glass beads in my chair-side unit. Cleaning out the occlusal grooves prior to a sealant and etching un-prepped enamel for anterior esthetic composite margins are other uses. In addition sodium bicarbonate can be used to remove stain. Now that I have a convenient, easy to use unit, I find more and more reasons everyday.

Air Abrasion Made Easy

When I first began to experiment with air abrasion the biggest challenge was the equipment and managing the logistics.  The Etchmaster is a small 3 to 4 inch attachment that connects to either a 3 or 4 hole line on your unit. The pressure is precisely controlled, for great clinical outcomes, and it means the patients mouth is not full of powder when you are done. The powders come in pre-filled tips that slide into the top of the hand-piece. You can choose from a variety of sizes and particle types and sizes. This means no more filling a reservoir with powder, wondering if you have too little or too much. It also means not wondering what particle type and size is in the reservoir the next time you go to use the unit.

Have you explored the clinical advantages of air abrasion? How has this been beneficial in your practice?