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.

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?

Providing healthier mouths to patients and doing more fulfilling dentistry (and making more money as a result) are admirable goals most practices have. I have written a couple of times about techniques that help us improve case acceptance: creating curiosity and co-discovery, listening, the learning ladder, and more.

This brief overview is an attempt to see the process as a journey for the patient and to consider their perspective:

Patient’s Journey: Eighteen Inches at a Time

It Starts in the Head

Patients first listen to the facts about dental care, their need and wants, issues or diseases that they have, and potential treatment solutions. Sadly, facts are not enough.

Developing great listening skills, caring, and trust help patients come to see you as their health advisor. This requires an eighteen-inch ‘Journey to the Heart’! It is there that caring and trust live. The emotional connection is very important in case acceptance. To ignore it is to minimize your success. But that too is not enough.

The patient must schedule, keep appointments, and pay for recommended treatment. This ‘Journey to the Wallet’ is the next eighteen-inch trip the patient must take. It is the execution of the plan from their perspective.

Valuing dental care and oral health is demonstrated by their checkbook and what they spend time and money on. Still not done?

The next eighteen-inches take us to a knee. Appreciation helps fulfill us as caregivers. Most rewards are best when they are balanced, financial, and behavioral: money and warm fuzzies, you get the idea. Money alone does not buy happiness (but it does help you enjoy your misery in some mighty fine places!).

The final journey takes us eighteen inches to the patient’s feet. When patients tell others about your practice and refer their friends, you have come full circle. This trust display is the ultimate compliment to you and your team.

Keep the Patient’s Perspective in Mind

Ask yourself the following and seek answers with your team to enhance patient health, your fulfillment, and mutual rewards:

·       Have you helped nurture movement toward the heart?

·       Did the patient accept and schedule treatment? If not, why not?

·       Were they able to pay with gratitude and appreciation? (borrowed from Dr. Pankey)

·       Did you ask for and receive referrals of their friends and family?

Remember, it’s a journey, not a destination. Enjoy the trip and check the map along the way. You, your team, and your patients will all be the better for it.

A journey is best measured in friends, rather than miles. -Tim Cahill

Trust is a central facet of human interaction, one that cannot be ignored in a dental or business setting. This blog reviews some interesting concepts on trust from Oxford professor Rachel Botsman: 

Trust: Known and Unknown

Botsman is a thought leader and significant contributor to the current conversation surrounding the role of trust in our personal and business relationships as well as our culture. She says that trust lives in the unique tension between our hopes and fears. It is about vulnerability and expectations.

Trust acts as the bridge between the known, where we are comfortable, and the unknown, where we are fearful. She defines trust as, “a confident relationship to the unknown.”

Similarly, when we enter into a relationship with a patient, there is a great deal unknown to them concerning their dental condition. They don’t necessarily sense what is required to establish good health, function, and esthetics.

A Relationship Strategy

According to Botsman, in developing our strategy of building high trust relationships, our goal should not be to build more trust. Our goal should be to become more trustworthy.

The established science of trustworthiness says that it requires high levels of competence, reliability, benevolence, and integrity in our life and practice to be present and experienced by others. Integrity, or aligning our intentions with our actions, is the most important.  

That same science says that real trust takes time and friction, at least some minimal friction, to establish. When a relationship is established seamlessly and instantly, there isn’t even the time and opportunity to ask the question: “Should I trust this person with something that is important to me?” That is the minimum amount of friction required.

Many organizations and a significant amount of behavioral research conclude that the strongest relationships are those that have experienced a problem and found a way to reconcile the issue. In other words, friction strengthened the relationship through solving the problem.

Have you listened to or read anything by Rachel Botsman? Join the conversation below … !

Listening is a skill everyone likes to talk about but very few actually know how to enact. It’s more challenging than we might think to really shut our mouths and pay attention without constantly interrupting or adding our two cents.

In my last blog, I talked about offering an empty presence and letting the person finish their story. Here, I cover other important listening skills. We should all make the effort to speak less and hear more.

Become a Truly Great Listener

Listen for Their Heart

Listen for the feelings behind the words. Can you hear voice fluctuations? Can you read their eyes? Feelings of regret, fear, grief, hope, etc.

Using the balloon symbolism, I picture a red balloon filling with their emotions as I listen for feelings. There is no higher form of communication than heartfelt, empathetic listening. The balloon symbolism may feel silly, but it will help.

You cannot be heard until the patient’s emotional bubble is deflated through your quiet confidence and empathetic understanding.

Ask Permission to Go Forward

When you ask for and receive permission to offer advice, you are much more likely to be heard. This is truly one of the most intuitive questions you can ever ask and does wonders for building rapport: “May I give you some initial thoughts?”  or “May I have permission to consider what you have told me and study possible solutions?” 

Once a person has given you permission, they are more likely to become a partner in solutions. 

There is no greater gift of healing, expression of love and builder of self-esteem we can offer those special people we care about most, including our family, friends, patients, co-workers, and community, than listening. Everyone wants to be heard.

How do you practice listening skills? Let us know in the comments section below!

Dr. Pankey had an advantage most of us do not that made him a world-class listener. Often labeled a disability, Dr. Pankey was hard of hearing. Because of this, he had to learn how to listen intently to his patients.

Dr. Pankey learned to listen for feeling over content. Listening is a skill that can be developed and improved. It requires intention and attention. One must practice! Here are a few tips that help:

Actionable Skills to Become a World-Class Listener

Offer Your Empty Presence

Most important of all is the intent to be present. Be here, nowhere else. Never enter a room without taking a deep belly breath to quiet the sympathetic, judgmental lizard brain and enhance the empathetic brain.

Empty presence is being fully available for the patient with no agenda, no busy talk going on in your mind, no judgment about what is said, no mental correcting or explaining chatter going on in your head for when you get a chance to talk.

I like to imagine an empty white balloon completely devoid of anything. My objective is to simply let the person fill it with their own thoughts and feelings. Really focus on what they say and how they say it and especially the feelings behind it. You are a gatherer of their information, not an explainer, corrector, teacher, or judge.

Let the Person Finish Their Story Without Interruption

Take a deep belly breath again once they have gone silent. What they just told you is simply what they first told you. There is probably more. When a person has finished their story, the silent period is when they are understanding what they just said.

Silently offer your open heart with compassion, allowing them time to spill out everything they need to say. Silently count to 10 before speaking, then use simple encouragements: “Is there anything more,” “Yes, I understand,” “I’m glad to know that,”  “I’m sorry to hear that,” or “Tell me more.”

To be continued …

Our good intentions and true thoughts surrounding a difficult situation with a patient can get lost in the communication process. When we fail to meet patient expectations, we can almost become a different person.

Our patient interprets what we say and do as demonstrations of our character. This is why, if we want to resolve conflicts and make patients feel understood, we need to pay special attention to showing that we care.

How to Show You Care About Patient Concerns

There are many ways to show you care that can be beneficial on both sides. It also helps to take criticism not as a personal affront, but as an opportunity for improving our communication skills. It may seem counterintuitive, but the best way to soothe or diffuse heightened emotions is to let people experience them. Allow patients to fully express their upset, instead of trying to shoot them down or make light of the situation.

Then, truly embrace empathy. Don’t just listen and nod without truly empathizing with their upset. Let them know that you understand how hard the situation is for them. Next, acknowledge the challenge of revealing their true feelings by thanking them for their honesty and for telling you what they think.

And then there’s the hardest part: apologize. You don’t need to admit you’re guilty and beg their forgiveness. You simply need to express how sorry you are that they are experiencing upset. Also, don’t assume that you can guess how to fix the problem.

Ask your patient how they want to be helped and be honest about whether you can make it work. By patiently listening and acknowledging their feelings, you may have already given them exactly what they wanted.

How do you show your patients that you care? Let us know in the comments! 

Throughout my dental hygiene, dental school, and residency programs, I was blessed to have exceptional instructors and role models. All of them encouraged me, believed in me, and most importantly, impressed upon me the importance of lifelong learning. Many of them recommended Pankey, telling me to go there as soon as I could.

A Journey to Deeper Patient Relationships

That journey began in 1994. I will never forget sitting in Dr. Irwin Becker’s philosophy class as he talked about the Crosses of Dentistry. He discussed “Knowing Your Patient” and I remember becoming very emotional.

As a young hygienist, it would bother me when I would see a re-care patient and not remember what we talked about the previous time. I started jotting things down on index cards about each patient and keeping them in a private file. Not the things you would typically see in chart notes, but personal things they felt comfortable sharing.

Each time they came in, I would refer to the personal card file and refresh my memory as to where we left off. There was no way I would have been able to remember all those special discussions, so I had to write them down. Each time they came in, the next chapter began.

I also started sharing more information about myself. I found the more I shared, the deeper the conversations went. I really wanted to know my patients on a much deeper level and that is what happened over time.  

When I came back to the Pankey Institute for the second continuum, I was pleasantly surprised to be greeted by name by Dr. Ernie Anderson, one of the course instructors, as I stepped into the elevator of the condos. Obviously, he had taken time to look at the roster to see who was in the class and that was very impactful. The kindness, thoughtfulness, and encouragement shown to me at the Institute were instrumental in demonstrating how I wanted to make my patients feel during my care.

Time spent getting to know my patients has resulted in lifelong relationships. Of all the things I’ve learned, this is one of the most important keys to a meaningful and enjoyable career.

A key tenant of Pankey philosophy is to know your patient before you treat them. It’s one of the most important lessons learned in our Essentials 1 course, Aesthetic & Functional Treatment Planning You begin to develop a self-awareness that you can cultivate throughout your professional life.

The concept of ‘knowing’ is worthy of much exploration, especially because what counts as knowing your patient is subjective to each individual. It’s about more than simply gathering data on their past dental history and current concerns in a pre-clinical interview.

To know your patient, you must be fully present with them. Then you must listen, truly listen. It’s difficult to remain quiet as your mind jumps from different solutions and possibilities to potential responses. That’s what makes listening a skill worth cultivating.

How to Listen More Effectively in a Pre-Clinical Interview

Start by taking stock of the moment before you even enter the room and acknowledge the patient. Pause. Evaluate your own mental space. Become curious about the unique individual who seeks your guidance and expertise.

Once you’ve transitioned to the interview, remind yourself that the patient should be doing 80% of the talking. It requires practice to stifle the urge to interrupt or re-direct, especially if you’re naturally talkative. On the other hand, during extremely busy days it can be a relief to settle back and focus on someone else’s thoughts.

Create a More Comfortable Environment for the Patient

One thing that helps you begin to know your patient is creating the right environment. Focus on them exclusively so that in the moment they genuinely feel like the most important person in the world. Hold eye contact, but also learn to take conversational cues from the patient. If they seem reticent, give them the space and freedom to be at ease.

During the interview process, ask open-ended questions capable of uncovering their values around health, fears or anxieties, and more. By providing them with answers to their questions and listening closely, you are already performing a service that is likely a rare experience in their daily life.

How do you cultivate understanding and trust in your pre-clinical interviews? Share your tips or advice with the Pankey community!