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Cosmetic Imaging and the Art of Esthetic Case Presentation

April 1, 2011
by George E. Kirtley, DDS


“So, what do you think?” Hey, it looks fantastic! Can I really look like that? Yes, you can. Great, let’s book it!” It would be awesome if it could always be that easy in a smile consultation. Interestingly it is becoming more that way. The old adage “a picture is worth a thousand words” is never more true when a patient observes an artistically designed image of their proposed smile; something that allows them to accurately view themselves as they are and how they could look. Notice, I said, “artistically designed and accurately viewed.” There in lies the difference in technique and software programs involved in digital imaging.

It is amazing that all dentists who are involved in cosmetic/ restorative dentistry do not utilize computer imaging. Computer imaging provides many things to the user and of course the patient. First and most obvious, it provides the information to the patient that enables them to accurately visualize themselves without first having to make the monetary commitment. To see themselves as they accurately can be. To the cosmetic dentist, it provides valuable information in the design of the case. It allows the dentist to establish the parameters he has to work within. It allows for the anatomical shape or design of each tooth that best fits the patient facial context. It allows for selection of shade, the design of the gingival architecture, and correction of buccal corridor deficiencies. All which are critical elements of proper smile design and can be conveyed through photographs and computer digital imaging technique.

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When a patient comes to your office for a cosmetic evaluation, what do you provide? Is your interest in telling them about all your credentials, showing them before and after photographs of someone else’s work or maybe yours. Or just trying to convince them that you can make their smile better…..that they just have to trust you because you say you are a cosmetic dentist and then charge them for the time spent with you. That is the scenario of a lot of cosmetic consultations and it truly falls short of what the intended experience should be.

How about this: The patient seeking cosmetic consultation calls your office. They are met with a voice of interest in helping them and are scheduled within a few days to see you, not weeks. When they come into your office they are again met with a voice and a face consistent with the kindness exhibited on the telephone when their appointment was made. Not only by your receptionist but also by each staff member they come in contact with. They are courteously escorted to your treatment/consultation room where they are asked if they would like some bottled water. They are seated in a room which is nicely appointed and clean. The assistant who escorted them stays with them and never leaves. The assistant first and foremost focuses on the establishment of trust and friendliness through questions unrelated to dentistry. Once established, the assistant politely asks what they are seeking to attain in their visit to our office. It is at this time they will begin to tell the assistant what problems they have and the concerns they have about their smile. The assistant will hand them an attractive hand mirror which allows them to point out specifically what they are concerned about. The assistant will ask leading questions and note their response to subconsciously educate them about their smile and to help in their own diagnosis. Questions regarding the imbalance of the gum tissue , or the broadness of their smile (buccal corridor deficiency) and proportion (teeth that are too short or square) and of course color. The assistant will speak to the concerns of lip support, which all women are concerned about. All of this taking place before you (I) enter into the room.

When you enter, it is with a smile and a handshake and a thank you for coming to our office. This is about creating rapport, which means initial conversation is never about dentistry. Once established, your conversation is then directed toward dentistry by stating, “How may I help you today?” At that time the patient, although already having communicated to the assistant, will again present their concerns about their smile. Your position to them is always eye level, never above or below. Your body language tells them you are interested by leaning slightly forward and maybe acknowledging them through an occasional and slight nod of the head. All the time the assistant is making notes to their concerns. Their feeling at this time is one of trust, warmth and caring. They have done most of the speaking. They know they are being heard, not by one person but, by two or more. Acknowledging their concerns is the quickest way to establish trust and caring.

Now, it is your turn to speak. “Ms. Jones, you have done a great job at helping me see your concerns. There are a number of methods I use to help us find the answers to the problems you have. I would first like to lean you back and examine the teeth more closely. Once we complete this exam I would then like to take some digital photographs to enable me to see your teeth and smile more comprehensively. We have the technology in our office to take these photographs and through my computer I can then computer-image these photographs to show you what you could look like before any treatment would be started. This will take a day or two to complete but, when you return we will sit in the privacy of my office and I will review the findings with you, show the imaged photographs and also show you some true life cases that I have done that are similar to yours.” At this point, you would proceed to do the exam and take a full series of photographs (AACD). Once completed, your statement to the patient is that you are looking forward to seeing her very soon. You then dismiss yourself and the assistant again takes over scheduling the patient and walking them to the front office expressing excitement about the upcoming final consult appointment. The patient incurs no expense for this experience yet they leave with an established relationship, an experience of knowledge from you and your staff, the perception of high end technology and an excitement for the next visit in a few short days! No pressure, just good vibes.

The patient is sent a note by the staff member who attended her at her first visit. This note is a simple “thank you” and “it was nice to meet you” acknowledgment. The second consult visit is usually within a week (the patient is eager to see the images and we want to keep the experience fresh in their memory). On the return visit the assistant who attended her at her first appointment again meets the patient. The patient is escorted back to the private consultation room where they are introduced to the (my) treatment coordinator. She has a moment to converse with the patient and to establish a rapport before I come in. This is by intentional design. Everything has been prepared on my consultation computer. The picture on the screen is the existing preoperative natural smile of the patient; how they presently look (Figures 1a,b, pre-op views of patient on screen in consultation room). It is in full view for them to look at while they are seated and waiting. When I enter the room I again begin my conversation unrelated to dentistry. I will sit next to the patient at the round consultation desk. Not across from them. I review with them that we will go through the photographs taken at last visit and that I will show them an imaged view of what they would look like with the proposed changes. Each preoperative photograph is viewed (12 in total, AACD series). Particular attention is paid to the frontal and lateral 1:2 views, the frontal and lateral retracted 1:2 views and any other photographs that are deemed necessary. Each view is critiqued drawing attention to soft tissue asymmetry, broken fillings, dark fillings or failing restorations. The frontal natural view usually exposes the deficiency of the buccal corridors and lack of a widened or full smile. This will come more in
to play when they see the computer-imaged 1:2 frontal view and their full face view. The significance of a patient viewing a full screen retracted photograph of their own dentition and its detriments is profound. Self-diagnosis is the ultimate educator and motivator toward seeking treatment.

Once the preoperative photos are fully viewed by the doctor and the patient the last pictures shown are the before and computer-imaged full face smile, the before and computer-imaged view of the front natural smile, and the before and computer-imaged lateral smile view and (Figures 2a,b,c; 3a,b,c; 4a,b,c. All images created with Envis­ion­a­smile Imaging Soft­ware, www.Envisionasmile.com). The patient now has the perspective on how they are viewed socially not only from the frontal view but also from the side and of course full face.

At this point I will then immediately go into a series of before and after photos of cases I have done. Some of which are similar to the patient we are consulting with and some which are just profound before and after results. This allows the patient to further see the abilities we have to change smiles that are even more dramatic than theirs. This lends further credibility to our skills and techniques. The before and computer-imaged view is returned to the screen in front of them as I continue with the consultation. Once we are through the presentation, I further speak to the procedure itself in terms of length of time and turn around of the case.. I speak as though they are going to accept treatment. Most are amazed that we can complete this dramatic treatment in less than two weeks and two appointments. I then ask the patient if I have been thorough in my explanation of the procedure and if they have any further questions. Most often they are complimentary of the thoroughness of the consultation. At that point I politely dismiss myself and say that Laurie (my treatment coordinator) will go over the scheduling and treatment costs of the procedure and that I will look forward to helping them in any way I can.

The success of this consultation method is proven by a very high acceptance rate. It is a method which focuses on establishment of trust and rapport and education of the patient. It is not about money because they are charged nothing for each of the two visits spent in our office. We have had the time to give them without demand of money. It is only about addressing their need. One of my statements at the close of consultation is to say “Ms. Jones whether or not you choose to have us provide for your treatment, I know you will at least be able to leave here armed with the proper knowledge to make your decision where ever you go”. This expresses humble confidence in the patient’s eyes.

The quality of the imaging technique is of the utmost importance in replicating what would occur naturally. Many techniques in imaging put teeth in positions that are impossible to attain in a true clinical scenario thereby misrepresenting what can be attained, frustrating the patient and doctor alike and potentially leading to litigious action. If however, the computer imaging is designed properly then the resultant image is one that fits within the context of what the patient presents anatomically. This image is not only highly esthetic, it is reproducible in the true clinical sense and serves as a fantastic reference for the ceramist to follow when designing the esthetic restorations (Fig­ures 2a,b,c, Fig­ures 3a,b,c and Fig­ures 4a,b,c show­ing full face, frontal and lateral views of before, imaged and true clinical result; note the comparison and anatomical correctness from the preoperative photos to the Envisionasmile imaged photo­graphs to the subsequent true clinical outcome in all views).

The method of this consultation is purposeful. Many clinicians would ask at this point, “What about the diagnostics necessary to do this case?” Obviously, that is very important. However, the rationale in this two- appointment consultation method is to minimize clinical dentistry and the costs of it. It is solely about creating a relationship, establishing trust, educating, showing the possibilities and then allowing the patient to make an informed decision. Once this is established and the patient decides to move forth, then diagnostic models, radiographs, face-bow mountings etc. are all implemented. The patient is informed during the smile consultation that treatment is subject to change based upon these diagnostic results. This rationale promotes good faith and again, estab­lishes trust and rapport.

Cosmetic imaging is an art form. Consultation method is an art form. Both can be taught and learned. Being able to image a smile to anatomical correctness requires knowledge of smile design, a quality imaging software program (www.envisionasmile.com) and a clear understanding of the wants of the patient. Master­ing of this art form along with a personalized consult method as explained above yields a higher degree of success in cosmetic case acceptance and office pro­duc­tivity.OH

Dr. Kirtley is an Esthetic/Res­torative dentist Accredited by both the American Academy of Cosmetic Dentistry (AACD) and the British Academy of Cosmetic Dentistry (BACD) and is an active member of American Society for Dental Aesthetics and the Euro­pean Society of Cosmetic Dentistry. He is the designer of Envisionasmile Imaging Software (www.envisionasmile.com) and Director of the Mid­west Center for Advanced Dental Education (MCADE) in In­dianapolis, Indiana. He teaches and lectures on hands on programs in esthetic/restorative dentistry and computer imaging technique. Oral Health welcomes this original article.