Give patients opportunities to discover what lies beneath their smile

Ewelina is part of my office team. She’s from Poland. She’s beautiful but early in our doctor-patient relationship, I realized she had a closed-smile grin. One day, I asked her if she was aware that she was guarding her smile. She wasn’t but the question made her curious. Later, she came by and said, “I realize it now.”

So, I raised another question, “Now that you notice this, what do you think about your teeth? Were you guarding them subconsciously?”

She thought momentarily and said, “I wasn’t happy with their appearance. I think I unconsciously I do guard my smile.”

So, I raised one more question, “At what point in your life did you say to yourself, I wish my teeth were more attractive?”

Her answer surprised me: “I thought about it when I got married and bleached them, and after I had kids, I thought my teeth looked more unattractive than they did years ago.”

I spoke to Laura Harkin, a dentist I admire, about this. She said that it’s common for women to become more critical of their appearance after having children. Their bodies have gone through so many changes. Ewelina seemed to guard her smile long before she had children so I wondered if there may be cultural differences between her old and new adopted home. I asked her if she became more self-conscious about her teeth after coming to the United States. She answered in the affirmative, “People’s teeth generally look better here than in Poland.”

I loved that there was a long thoughtful pause before her answer. I intentionally gave her time to think between questions. I offered to give her a smile makeover, which she readily agreed to. In doing my case workup, we found she had a two-step occlusion that needed to be corrected. When I got to my wax-up, the anterior changes were minimal and I did an equilibration on the wax-up to try out the results. This set the stage for the changes we would try out in provisional.

Provisional restorations are something I always do to test if the speech will be affected, whether the new occlusion is comfortable, and if the patient feels “good” psychologically about all the changes — not just the aesthetics.

While wearing the provisionals, she began to smile with a Duchenne smile. In photos, I could see a postural difference, too.

My ceramist did an amazing job duplicating in ceramic the provisionals that I created. When the case was completed, I asked Ewelina how she felt. She said, “Great, happy, healthier, cleaner, brighter, very happy.” Cleaner, brighter, healthier, happy – that was a huge learning moment for me! Not once did she mention her teeth, just the feelings around her treatment outcome. It began to dawn on me how much we not only change teeth, but we can change lives!

“I’m happy,” she said. “I think I smile more and I feel like they’re my natural teeth. It’s hard to explain, but I feel like these are the teeth I’ve had all along.”

“How does your bite feel?” I asked. “Were you surprised how the small adjustments made big differences?”

“Before, I felt a little muscle soreness and dull pain back here, but after a day or two of the adjustment, I felt nothing. I feel great,” she said with a big, broad smile.

I think if we spend a lot of time with our patients and develop relationships, it’s ideally like psychological therapy. We give patients opportunities to discover what lies beneath their smile, show them a vision of what could be, and lastly, help them to reach their full potential, as described in Part 1, with a beautiful, confident Duchenne smile.

We have a unique opportunity to not only restore teeth but also change lives through our efforts.

Wax-ups are essential for my aesthetic case designs

Part 2 was originally presented to the Restorative Nation in February of 2023: It’s All In The Smile: Psychologic & Technical Considerations – Restorative Nation

My esthetic evaluation is similar to the curriculum taught in the Pankey Institute Essentials and Aesthetic Focus courses. I generally like to look at every aspect of a patient’s smile through photography, with emphasis on the following:

1. Facial Height – To evaluate possible skeletal defects that can lead to a smile not appearing attractive, I measure the middle 1/3 of the face and the lower 1/3 portion of the face. If there is a one-to-one (1:1) ratio, then I can essentially rule out either vertical maxillary excess or loss of vertical dimension. If there is a one to greater than one (1:>1) ratio, I can look at vertical maxillary excess. If there is a one to less than one (1:<1) ratio, I can look for extreme wear and loss of vertical dimension.
2. Lip Length — The average woman’s lip is 20 to 22 millimeters in height, and the male’s is 22 to 24 millimeters. Our lips, like everything else sag over time. We lose a mm of tooth display after age 41 at a rate of about one more millimeter per decade.
3. Lip Mobility — How high does the lip rise when the patient smiles? The average amount of lip mobility is between six and eight millimeters. A hypermobile lip can give the “gummy smile” and fool us into thinking that there is a vertical maxillary excess
4. Upper Lip Drape — Generally, we like the lip to fall at the free gingival margins of the canines and the central incisors.
5. Lower Incisal Edges –We like the lower lip to cradle the lower teeth with the line formed by incisal edges following the shape of the lower lip.
6. Gingival Heights — We like our gingival heights to be symmetrical. I like canines even, the centrals even with the canines, and the laterals a little lower.
7. Central Incisor Length and Width — The average central incisor is about 10 to 11 millimeters in length, and the average width of a central incisor is about 75% of the length.
8. Other Anterior Teeth Length and Width — The rule of Golden Proportions says that a central incisor should be proportional to a lateral incisor by a factor of 0.6, and the canine should be proportional to the lateral by a factor of 0.6.
9. I photograph the patient in repose, their “regular” smile, and then their “biggest E” smile in order to get a sense of how they look when they present with the Duchenne smile. Patients often will give you some form of a guarded or half smile on photographs and that presentation can be misleading. We need to see their full tooth and tissue display to properly evaluate esthetics.

Once I have had a chance to evaluate the virtual patient via photos, printed study models mounted on articulators, and radiographs, I can then propose esthetic changes. I am a huge proponent of fabricating my own “working wax-up” as I like to call it. It is not presentation quality and can be made from wax or old composite. The importance is that it previews the changes that I am proposing, and I use those workups to either make a silicone index for provisionals or I send them to the lab for cleanup and completion. I always keep an original mounted study cast and then have a second model that I play with.

I always start my working wax-ups by placing upper incisors exactly where I want them in the most esthetic position, then I make the rest of the anterior teeth proportional to those incisors. Once the upper anterior teeth are in optimal position, I’ll place or wax the lower teeth to be parallel to the upper and in contact with the upper lingual surfaces of the anterior teeth. In E4 we teach all of the above concepts and discuss how vertical dimension can be evaluated and altered appropriately with the anterior esthetic evaluation. We then look at developing the axial inclination of teeth and posterior occlusal planes to be in harmony with the anteriors.

I encourage all dentists to practice with “working wax-ups.” It truly shows the patient our expertise and artistry in action not just what the laboratory fabricates for us.

Want to see some of the more complex cases I have done? I invite you to view the Restorative Nation video linked above.

Smile behavior is influenced by the individual’s feelings about their smile.

Smiles are an integral part of human communication. They make us appear more attractive, approachable, happy, agreeable, and attentive. Studies have shown that people who are happy with their smiles are more confident, have a greater sense of well-being, and this is also reflected in their behavior. In one study, subjects were shown photos of people with nice smiles. The subjects deemed these people as being more socially competent, with greater intellectual achievement and better psychological adjustment. These smiles are contagious and It’s easy to reciprocate when someone gives you that “genuine smile.” We’ve all seen this smile, but what makes it genuine?

There are a variety of smiles that reflect a wide array of emotions. From flirtatious to embarrassed, our smiles reflect our mood and communicate our thoughts. Or do they? When people are unhappy with the appearance of their smile they present a variety of guarding. There’s upper lip guarding, lower lip guarding, both lips guarding, covering one’s mouth with a hand, and of course close lip grins.

As dentists, we must be able to spend time with our patients, to see those smiles, and to delve into why a patient may be guarding. In a sense, we must become esthetic psychologists. It is not an overstatement to say that as dentists, we don’t just change teeth; we can change lives. We can shape how others see our patients. If a patient cannot give a genuine unencumbered smile, perhaps, they’ll miss an employment opportunity or meeting that special someone. Perhaps they’ll be seen by others as unfriendly or unapproachable.

So, is there a “genuine smile” that can be quantified? In the 1800s, a French anatomist by the name of Guillaume Duchenne sought to answer that question. Duchenne, through stimulating facial muscles, found that the most genuine, sincere smile occurred when 3 muscle groups fired: the orbicularis oris and zygomaticus major in the mouth and the orbicularis oculi of the eye forming crows’ feet.

Most consider the resulting Duchenne smile to be the genuine smile that is spontaneous and sincere. Studies have shown that this type of smile can elevate mood, change body stress response, and is responsible for the release of endorphins, dopamine, and serotonin. In all, the Duchenne smile is the Holy Grail. It is certainly about the smile but a major component is the formation of crows’ feet around the eyes. Just think of the song When Irish Eyes Are Smiling. The Duchenne smile in all its splendor is sure to steal your heart away. My point is that we need to remember that the Duchenne smile is about the mouth AND the eyes; these elements are interconnected.

What we’ll need to evaluate as Dentists is whether Botox injections and plastic surgery affect the Duchenne smile. Certainly, in the case of the Botox smile, the answer is yes since the elevator muscles of the mouth are injected thus altering the Duchenne muscle contractions. Obviously, it is vital then to take a good health history and determine whether a patient is smile guarding or simply cannot fire the muscles that make up the Duchenne smile.

In making dental changes, we change lives. We shape how others see our patients and how they see themselves. This is priceless work. It is worthy work. But until a patient desires the best results that today’s dentistry can achieve and trusts us to execute the technical aspects of their new smile, we are in listening, understanding, and guidance mode. We are leading them forward with primary, essential care and taking them on a long journey to achieve what is possible. With each new dental restoration, they may smile more broadly and lift their head higher. They will feel the release of endorphins and serotonins. They will experience the positivity of greater self-confidence.

Artful comprehensive dentists are like behavioral psychologists who have the sincere intention of doing their utmost for the benefit of their patients.

You know what greater smile benefits are possible if the patient understands and wants to continue with aesthetic treatment. Patience is a virtue. So, spark the curiosity of your patients and lead gently but with confidence. Never forget that a patient who is concerned about the cost of elective treatment today will be thanking you profusely two to three years from now and saying the decision to move forward with a comprehensive smile makeover was one of the best decisions of their life.

When I was a young dental student, the voice of “right from wrong” came from my instructors. Their voices annoyed me, and I didn’t think that the dental school approach could ever work in the real world. When I got out of residency I began to learn “real world” dentistry from employers and insurance companies. They became my voice of right from wrong. I concluded that cutting corners was the way most dentists practiced—no face bows, no articulators, models or comprehensive examinations.

I found that I had a knack for selling dentistry. I was blessed with patients who allowed me to perform some rather complex dentistry…without articulators, face bows or comprehensive examinations. I became a master at making excuses for my dentistry:

• “You’ll get used to your bite…”
• “The temporaries really can’t approximate what the final will look like….”
• “Your jaw pain is stress. You need to relax…”

I was lucky! Most of my dentistry worked, but it was never predictable. Dentistry became stressful and honestly downright scary sometimes. So, I studied at the Pankey Institute. I heard voices of honorable people. What was right and good and decent for my patients…and me…and my family! I thought that I can’t do this type of Dentistry; it’s like dental school! No one practices like this.

Then, a Voice Appeared

One day I was fabricating a provisional and left an open margin. “So what?” I thought. I became aware, however, of a very faint voice that said, “Do the right thing; close the margin.” Hmm, close the margin. “Why should I?” I thought. “The new crown will be here in two weeks. What’s the big deal?” Again, I heard a whisper, “Close the margin.”

Annoyed, I explained to the patient that I wanted to work more on the temporary in order to make it fit better. The voice stopped whispering. The patient said, “Thank you for caring and being so thorough.”

The voice, once a sheepish whisper, began to speak in clear tones:

• “Carve the restoration the best that you can.”
• “Let specialist perform the procedures that they do best.”
• “Restore that patient only when you really know that person both clinically and behaviorally.”
• “Treating a patient is not about you; it’s about them, always.”

I was really starting to feel that I was going insane until one morning a poem came to me. I titled it “The Voice.”

THE VOICE

Who was this voice that I couldn’t see? It pushed and prodded and bothered me.

The voice was strong and judgement free, and I began to like its philosophy.

As time went on its words rang true, and I began to see the good I could do.

The voice which spoke of doing things right, began to be my guiding light.

I began to live with genuine care, with genuine love, a genuine air.

Who is this voice that I can’t see, that stirs my soul and bothers me?

This voice lives in me deep and strong.

It guides my path. It sings my songs.

It is so much a part of me

Who is this stranger I can’t see?

One day the voice said loud and clear:

“I’m always with you. I’m always near.”

I asked the voice to give its name,

to show its face, to stop playing games.

The voice just laughed. It said with glee.

It’s always been you, yourself, you see!

To the many participants who come to The Pankey Institute to study, I hope that you all let your best inner voice become your guiding light throughout your journey. That voice, that wonderful voice will never let you down!