DentaltownUK May 2017 - 63

dental imaging

things by constantly comparing with the
surroundings.
Secondly, for everyone who is not in the
dental profession, the smile or the teeth
make up part of the picture of the face. The
smile is an expression in motion and the
teeth are part of that expression.
They can appear to be in harmony and
pleasing to the eye as part of the human
expression of that entire face, or they can
appear in disharmony, obviously with different degrees. But the smile must be taken
in context or it is largely meaningless.
For this reason, it is difficult for lay people to identify with our words when we are
describing changes to teeth for anything
more than the very simplest of changes.
Obviously if there is one dark tooth or
stained filling then the proposed change
can be understood, but when we start talking about changing the position of teeth or
closing spaces, this is much harder to visualise if you have no prior experience to
draw on.
To visualise something based on words,
we, as humans, need to draw on past experience to create an image of that possibility
in our minds. For those of us in the dental
profession, we have those experiences.
Most of our patients do not. It is therefore very important to use actual images
such as photographs of smiles to improve
communication. It is also important to use
full face photographs. Nobody outside the
dental profession looks at pictures of smiles
only, and especially not of retracted smiles.
We need to be showing full faces with
expression for our patients to make sense of
what they are seeing, remembering that the
smile is an expression-i.e., it reflects a
mood or an emotion.
Our patients do not want dentistry.
Much like when we go to the doctor, none
of us want the operation or even the blood
test. We do want to be healthy. We want to
enjoy our lives with a feeling of well being.
Dentistry is the same but because much
of what we do in aesthetic dentistry is

elective, we can forget that, and we can get
very excited and animated about the wonderful techniques and technology that we
have available, and we forget that patients
don't want any of it.
They don't want the implant, the tooth
whitening, the bonding or the orthodontics. They want the end result-health,
comfort and the self-confidence to interact
with other human beings in a free and
relaxed way, without feeling self-conscious
about their smiles.
Obviously, this means different things
for different people. Fortunately, cosmetic
dentistry has progressed past the point of
making everyone look the same restoratively, and there has been excellent research
and development of systems for analysing,
diagnosing and treatment planning with
health and function and conservation of
tooth structure as the ultimate goals, but
also being able to enhance aesthetics.
And so, when we are discussing the
options with a patient who is considering
or asking about cosmetic or aesthetic
changes, our most powerful tool is photography and video. A picture of the patient
on a large screen can start the conversation
as to whether there is anything that the
patient may change about their smile, and
even before that is asking the patient to rate
their smile on a scale of 1 to 10.
There are three things that make up the
composition of a smile: colour, shape and
position. The relative interactions of all of
these factors for every tooth in the smile
give us the perception of harmony or
disharmony.
So how does dental imaging help us?
Imaging softwares have been around for
well over 20 years, as long as dentists have
been using computers. It is very easy now
to take high quality digital images of our
patients, full face smile from the front.
Some key points here, for imaging to be
effective it helps if we standardise how we
take these pictures. Certain things can be
altered digitally but others cannot.

Patients generally have a pose position
that they go to, having taught themselves
with selfies or in from of the mirror. Imaging works best, currently, on a fully frontal
image ie without any degree of turn of the
head. This can be checked by the operator
looking at how much of either ear is showing. Horizontal shifts can be edited in the
software, saggital shifts cannot. Chin
down is very important as this can create a
false reverse smile if the chin is up, and this
is common when people are trying to minimise a double chin! And lastly the teeth
slightly apart so that the edges of the maxillary teeth have a dark background. The
degree of opening will depend on the
occlusion, Class 2 deep bites need to open
much further than a Class 1 or 3, and we
only want enough opening to just separate
the anterior teeth. Too much and again,
the smile is distorted.
Once we have a good smile photograph,
imaging can do several things;
1. Lightening the whole smile to simulate whitening. This can be an easy and
effective tool. Key reference factors like
the whites of the eyes can be used.
2. Manipulating individual teeth. E.g.,
duplicating and flipping a central and
lateral from one side to the other, simulating bonding to lengthen teeth or close
diastemas.
3. Overlaying another smile to demonstrate large changes. This is, at the basic
level, cutting and pasting someone else's
smile into this patient's face, and can be
effective for demonstrating large-scale
change. Most softwares come with a
smile library and the operator can
manipulate these to suit the patient's
smile.
Criticisms of dental imaging often centre around the idea that by showing a
patient a digitally enhanced image, we are
therefore creating a potentially unrealistic
outcome, and leaving ourselves open to setting unrealistic expectations in the eyes of
the patient.
dentaltownuk.com \\ MAY 2017

63
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Table of Contents for the Digital Edition of DentaltownUK May 2017
