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Dental Esthetics in Practice:
Part 1 - Focus on the Patient
One aspect of clinical dentistry that offers clinicians almost limitless and exciting challenges is esthetic
dentistry. In a culture where the emphasis on beauty is growing rather than diminishing, patients of
all ages, races, and genders are apt to ask you, the dental professional, how they can improve their
appearance by enhancing their smile. Whether the motive is personal improvement or is driven by the
belief that appearance influences professional success, patients have become aware of their smile, what
changes they might like to see, and how those alternations might come about.
This is part 1 of a 5-part series called Dental Esthetics in Practice. This course reviews concepts
of beauty, factors that influence patients interest in esthetic procedures, and techniques to effectively
communicate treatment options with patients.
OverviewAs a dental professional, it is important for you to know how cultural, societal and individual beliefs about
beauty can influence a patients decision to elect an esthetic dental procedure. Understanding the general
concepts of beauty will help you to understand the factors that influence patient interest in esthetic and
restorative procedures and how to effectively communicate with patients throughout the treatment process.
Learning ObjectivesUpon the completion of this course, the dental professional will be able to:
Understand the concepts of beauty as they relate to individuals and cultures.
Identify the factors that can influence patients interest in whitening and other esthetic procedures.
Learn how to effectively communicate with patients from establishing conversations to
treatment acceptance.
W. Patrick Naylor, DDS, MPH, MS
Continuing Education Units: 1 hour
Continuing Education
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Course Contents The Physical Attractiveness Phenomena
Concepts of Beauty Factors that Influence Patient Interest Communicating with the Patient
Course Test References
About the Author
This online course includes video clipsand interactive quizzes . Please go towww.dentalcare.com and find this course in the
Continuing Education section to take advantageof these features.
The Physical Attractiveness Phenomena
Concepts of BeautyIf only I were.
Just fill in the blank. Weve all said it: prettier,taller, darker, slimmer. The lure of beauty andphysical attractiveness has a near universal
impact on the human condition. And its not justa perception that beauty can bring preferentialtreatment. There is research showing that bias
can exist in favor of the physically attractiveperson.
Even more perplexing, perhaps, is the link that
has been made to equate physical beauty withgoodness and inner beauty. But before you think
this is only reflective of current society, Aristotlewrote about physical beauty and concludedthat beauty is the greatest recommendation a
person can offer.1
Its no wonder that pursuitof attractiveness drives so many people across
cultures and nationalities.
The Physical Attractiveness PhenomenaIn his book, The Physical Attractiveness
Phenomena, Dr. Gordon Patzer explores the
relationship between physical attractiveness andsocial values. His observations include:
Appearance and physical attractiveness areinseparable and inextricably intertwined.
Studies have shown that newborn babies in
hospital nurseries that are perceived as cuterare touched more, held more, and spoken to
more than other babies. These stimuli are
essential to healthy development, but mayonly be available to a select group of babies.
So from birth, determinations on physicalattributes are being made, and responsesrom others are based upon perceived
attractiveness.
alue or worth is strongly influenced, andeven determined or caused, by appearance.
A review of 2,500 lawyers (men and women)indicated that attractive attorneys earned as
much as 14% more than their less attractivepeers. This study also indicated that they won
partnerships earlier and that private practicelawyers were considered more attractive than
government attorneys. This study seems toontradict a commonly held belief that looks
matter less for professionals.3
The Physical Attractiveness Phenomenonranscends culture, time, and geography.
A cross-cultural study compared the ratings ofjudges who were English, Chinese, and Indian
hen they were asked to rate the physical
attractiveness of modern Greek males. Thereas significant agreement in their ratings,
even though there was variability in someategories.
Similar results were obtained from a study
in South Africa. It compared South Africanand American judges and their standards ofbeauty and found the two groups had similar
ratings on attractiveness. In addition, thestandards used by individual judges within
both groups also were similar.4
Determinants of appearance are many andare complicated.
While there are basic elements of beauty thatare universal, appearance also has multiple
dimensions such as physical attractiveness,
age, ethnicity, gender, race, sex appeal,socioeconomics, fortune-misfortune, health-illness, respect, liking, suspicion-trust, etc.
A further complexity with appearance is thatit is judged by the eye of the beholder. For
example, Dusty Springfield, who had hits
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of Son of a Preacher Man and Wishinand Hopin, was described by Elton John
as comparable to Aretha Franklin. Yet herbiographer wrote that despite recognition andaccomplishments, Dusty never could lose the
feeling of being an awful fat, ugly middle-class kid.
The Physical Attractiveness Phenomenon
transforms appearance into a value that can be ablessing or a curse, an asset or liability, a benefitor a detriment. It can make the individual strong
or weak, liked or disliked, desired or undesired.
The irony is that the Physical AttractivenessPhenomenon is often unrecognized or denied,
but its characteristics help us to understandpatients views and their desires to become moreattractive.
Concepts of Beauty
Facial and Dental Features
The smile is at the heart of esthetic dentistry.(Figure 1) What makes a smile attractive? Whatmakes it unattractive? How do smiles differ?
What do they have in common? To answer thesequestions, the concepts of beauty covered in this
section focus on two main areas: the face andthe mouth.
The Face
The Golden ProportionThe idea that relationships exist between forms in
nature is a concept that has survived for literallythousands of years. In dentistry, the principles
of the golden proportion can be applied to dentalesthetics. In practical terms, the mesio-distal
width of a maxillary central incisor is 1.618 timesgreater than the adjacent lateral incisor whenviewed from a direct facial angle. According to
the golden proportion, this same relationshipholds true when comparing the maxillary canine
to the lateral incisor or the canine to the adjacentpremolar.
n clinical practice, the golden proportion mayprove helpful when restoring or recreating a
dentition to ensure that the teeth appear naturaland in proportion to one another.
Facial Symmetry
Surprisingly, what is perceived as beauty infacial form is more likely a manifestation ofasymmetry than actual facial symmetry. Closely
examine a photograph of an attractive male
or female. Divide the face into vertical andhorizontal planes. Do you see mirror images?Most likely, the answer is no. The nose may be
larger on one side than the other or the eyesmay not lie on exactly the same horizontal plane.(Figures 2, 3)
These asymmetries are normal. In fact,
when viewers judge individuals to be pretty orhandsome, asymmetrical features are accepted
and likely go unnoticed. Instead, the generalombination of features results in an esthetically
pleasing appearance.
Figure 1. The smile is at the heart of estheticdentistry.
Figure 2. The generalcombination of facial featuresresults in an estheticallypleasing appearance.
Figure 3. Asymmetries in thehuman face are normal. Here,the right side of the face wastrasposed to the left side.
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The Mouth
Dental MidlineThe dental midline is a focal point that shouldbe evaluated and repositioned, if necessary,
to ensure it is properly aligned with the facialmidline. (Figure 4) In restoring a dentition with
artificial teeth, care must be taken to ensure thejunction of the maxillary and mandibular central
incisors lie in the correct vertical orientation.Even minor errors in the re-creation of the dentalmidline are apt to become strikingly apparent
when patients smile, laugh, or otherwise exposetheir anterior teeth.
Lip Line and Form
Lip shape and contour vary from patient to patientand can be influenced by the position of anterior
teeth. Variation is common between genders andamong different races. Care should be taken to
maintain or, in some instances, restore a natural-appearing lip line and form when anterior teethare being treated or replaced.
Artificial teeth placed incorrectly in the saggital
plane (too far forward or retruded) do not providethe lip support needed for natural appearance.
Consequently, the lips (the upper lip in particular),may appear flat or protruded leading to anunaesthetic and unnatural appearance. (Figure 5)
Smile Line
A smile line is defined by an imaginary line
running along the occlusal/incisal edges of themaxillary teeth shown during a wide smile. In apleasant-appearing youthful smile, the anteriorteeth are lower at the midline than the teeth
located at the corner of the mouth. The extentof the curve is dependent on the length of the
exposed maxillary central incisors. (Figure 6)
n contrast, in an older patient with severe wearof the anterior teeth, the line is shallower or even
flat depending on the extent of tooth loss. Anincrease in the display of the maxillary anteriorteeth transforms a flat smile line to a far more
esthetic appearance. (Figure 7)
Figure 4. The dental midline.
Figure 5. Incorrect placement of the anteriorteeth makes the upper lip appear flat, affectingthe esthetic appearance.
Figure 6. In a pleasant-appearing youthfulsmile, the anterior teeth are lower at themidline than the teeth located at the corner ofthe mouth.
Figure 7. In contrast, in an older patient withsevere wear if the anterior teeth, the line isshallower or even flat depending on the extentof tooth loss.
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Tooth ColorThe outward appearance and color of teeth, both
natural and artificial, is framed by the face andlips. (Figure 8)
A classic example can be seen in any photograph
of a female patient wearing red lipstick. Thebright red hue on the lips contrasts markedly withthe teeth, particularly the maxillary anterior teeth.
(Figure 9)
In that same regard, a darkened skin tone alsomakes white teeth look whiter by providing
ontrast. The same shade of teeth on someonewith a fair complexion would not look equally as
striking.
Tooth SpacingAside from the notable diastema of entertainerDavid Letterman and a few other celebrities, most
individuals want any noticeable anterior spacesremoved in favor of a continuous display of
tooth structure. Diastemas create black spaces
between the teeth that readily draw the attentionof even the most casual observer. (Figure 10) In
fact, even with a casual glance viewers are likelyto divert their attention from the eyes to the mouthonce the diastema is spotted. Consequently,
diastemas are generally considered unestheticand patients turn to the cosmetic dentist to
resolve this condition through bonding, veneers,or, in some cases, complete crowns.
Tooth FormWhether it is conscious or not, we generallyassociate tooth forms and appearance differently
for men and women. There are no female andmale teeth, but subtle differences in appearance
an exist between genders.
emales typically have teeth with rounded incisalline angles making for a softer appearance.
(Figure 11)
Males teeth, in contrast, are often associatedwith sharper line angles and flatter incisal edges.
(Figure 12) With the incisal line angles intact, the
Figure 8. The outward appearance and colorof teeth is framed by the face and lips.
Figure 9. The bright red hue on the lipscontrasts markedly with the maxillary anteriorteeth.
Figure 10. Diastema.
Figure 11. Females typically have teeth withrounded incisal line angles making for a softerappearance.
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incisal embrasures are smaller and the teeth may
appear larger (longer) than a female counterpartfor someone of the same age.
While its relatively easy to characterize a smilein terms of the anatomical components of tooth
shape, color and lip form, personality is equally
as important but more difficult to capture.Weve all heard someone described as havinga captivating smile or an infectious smile.
This intangible aspect of beauty captures onesattention just as readily as the shape and colorof the teeth. When the teeth are in harmony
with a patients eyes and face, the resultingsmile is perceived as natural and attractive and
personality can shine through.
Factors that Influence Patient InterestPatient satisfaction with the dental and facial
features previously described can affect interestin esthetic and restorative treatments. Non-physical factors, however, should also be
onsidered in evaluating a patients motivation toimprove his or her smile.
Personality
In talking to candidates for cosmetic services, itis important to consider the patients personality.Individuals with a positive attitude toward their
teeth and smile are often more apt to conveyonfidence and have an extroverted personality.
While they may exude more confidence, they may
not be completely satisfied with their smile. Theyshould still be presented with treatment optionsthat could further enhance their smile.
In contrast, individuals with missing orunattractive anterior teeth may be more likely to
refrain from smiling. To compensate for this, they
may develop a personality that is reserved andintroverted. Others may perceive them as distant,
standoffish or unfriendly when, in fact, theymerely seek to avoid direct public contact simplyto avoid exposing this limitation. In this instance,
an unflattering smile is linked to personality andvice versa.
Life Stage
atients of all ages have needs for estheticservices, but life stage can influence their levelof interest. For example, those in the baby
boomer generation are often prime candidatesfor cosmetic and restorative treatments as
they seek to retain their youthful appearance.mproving the smile can be a good way to
motivate baby boomers to achieve oral healthgoals as well. Patients in their teenage years andearly twenties are also typically more conscious
of their appearance.
n general, younger individuals have teeth thatare undamaged by wear or trauma; their teeth
are more likely to be lighter in shade, and morevisible. (Figure 13) Over the course of decades,
Figure 12. Males teeth are often associatedwith sharper line angles and flatter incisaledges.
Figures 13 & 14. The appearance of the teethis likely to change with age.
Figures 14.
Figures 13.
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the appearance of their teeth is likely to change.Trauma and years of use may result in wear
of the incisal edges, microfractures, chips,scalloping, and a color shift (darkening).(Figures 14, 15)
Life EventsCertain life events tend to make people moreognizant of their smile, such as weddings,
proms, graduations or reunions. Patientsmay also have a heightened interest in theirappearance around certain annual events,
including holidays and the back to schoolseason. In general, any occasion that involves
greater social interaction and the opportunity forphotographs tends to make people more aware of
their smiles.
Profession
Another factor to consider is the patientsprofession. Impressions play a role in virtually
every occupation, but appearance has a greaterinfluence on success in some fields than in
others. For example, people who work in sales,real estate, or the entertainment industry
are often more concerned about having anattractive smile.
Communicating with the PatientWhen assessing patients for cosmetic and
restorative procedures, its important to first
evaluate the patients health needs. Remember:function first, esthetics second. Once anyhealth needs are addressed, possible esthetictreatments can be discussed and even used as a
tool to engage patients in their dental health, andtherefore simultaneously improve function and
appearance.
While cosmetic dentistry is growing rapidly,some patients may not be completely aware of
the services that are available. On the otherextreme, some patients may have unrealisticexpectations of potential outcomes. It is
important to communicate effectively with patientsto understand their needs, make them aware of
their options and set appropriate expectations.
Establishing ConversationsTooth whitening can provide an easy point ofentry to initiate conversations about esthetic
services since most patients are familiarwith whitening products. To ensure patient
satisfaction and simultaneously enhance practice-building initiatives, dental office staff should learn
how to start conversations with patients aboutwhitening and other esthetic services.
Here are some tips:
Use non-verbal communication to instilltrust and create a comfortable atmosphere
Greet patients with a smile and talk to themwhile they are sitting up (not lying down in
dental chair) to facilitate conversation.
Become an expert listener
Open or close dental appointments by askingthe patient open-ended questions that draw
out his/her values and concerns. A greatplace to start is by having patients describetheir impressions of their smile or what they
would change.
Get to know your patients and theirlifestyles
Use knowledge about a patients professionalor family life to start discussions related to
dental care, such as removing tooth stainsassociated with coffee, tea or smoking.
Be mindful of seasons and occasions
Weddings, graduations, reunions, vacations,etc. are all occasions where people want to
look their best. Find out if the patient plans toattend such an event in the near future.
Figure 15. Older individuals teeth often aredarker than those of younger individuals.
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Use smile assessment forms PDF: SmileAssessment Form and patient education
tools.PDF: Cosmetic Dentistry PatientEducation Sheet
The patient may feel more comfortable writingdown his/her wants than directly stating them.
You can review the smile assessment formtogether and use educational materials to
explain procedures and treatments.
Maintain an email address
Email is a quick, easy way to communicate
with your patients. Use it to send outinformation about procedures and new
products or services as well as to answerpatients specific questions.
Case Acceptance
Communication is important at every stage,but particularly as patients consider moreomprehensive treatments that involve higher
fees and less familiarity as compared to a routineprophylaxis. Once the conversation aboutwhitening, or any other esthetic dental procedure,
has begun, its important to really listen to theoncerns, wants and needs of the patient and
shape recommendations around them.
The decision to undergo cosmetic or restorativeare is influenced by the relationship patients
have with their dental professional and how theproposed treatment fits into the patients life interms of time, budget, work, family and other
obligations.6
Patients seeking esthetic services, especiallyomprehensive dental care, are often looking
for quality of life changes. The clinicalrecommendations are the means to attainsomething the patient values appearance,
omfort, function or peace of mind. If you knowwhat the patient wants and needs, its easier to
give it to him/her.
Here are some steps to consider in the treatmentacceptance process:
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1. Conduct a face-to-face patient interview tonot only give you insight into what the patient
wants and expects but to also show thatyou value patient relations. Be sure to
ask open-ended questions to uncover thepatients true concerns about his/her smile
or image in general.
2. Be completely honest about your
findings, their implications and yourrecommendations. This will build a level of
trust between you and the patient and showthat you wont hold any findings back that
may surprise the patient later on.
3. Be thorough and deliberate during the
examination. You could use an intraoral
camera to show the patient what you findthat appears to need treatment. Makeyour findings known as you discover them
using lay language. This helps to promoteco-discovery. Also, be sure to empathizewith the patient. Saying something like, Ill
bet this is not what you expected how doyou feel? allows you to acknowledge the
patients feelings.
4. Summarize your findings andrecommendations at the end of theexamination and be sure to put them inwriting so the patient can refer to themlater. The plan presented to the patient
should include the following: number ofvisits, the expected esthetic result, how
much discomfort to expect and how it willbe managed, cost of treatment, expected
payment schedule and financing options.
5. Encourage patient acceptance. Do this
by answering all the patients questions,addressing concerns, overcoming objections
and asking the patient to schedule a visit to
begin treatment.
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Personalize Pages For Your Patients.Enter information about your practice in the eldsbelow (name, address, phone, e-mail, etc.), and itwill appear at the top of the page when printed.
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To receive Continuing Education credit for this course, you must complete the online test. Pleasego to www.dentalcare.com and find this course in the Continuing Education section.
Course Test Preview
1. Which of the statements below is notone of Dr. Patzers observations about the relationshipbetween physical attractiveness and social values?
a. Appearance and physical attractiveness are inseparable and inextricably intertwinedb. The Physical Attractiveness Phenomenon does not hold true across cultures, time and geography
. Determinants of appearance are many and complicatedd. Worth is strongly influenced, and even determined or caused, by appearance
2. The golden proportion dictates that the mesio-distal width of a maxillary central incisor is howmany times greater than the adjacent lateral incisor when viewed from a direct facial angle?
a. 1.618b. 0.681
. 2.816d. 1.575
3. The human face is perfectly symmetrical.
a. Trueb. False
4. Males teeth are often associated with having sharper line angles and flatter incisal edges thanfemales teeth.a. True
b. False
5. Lip shape and contour can be influenced by:a. Tooth color
b. The position of the posterior teeth. The smile line
d. The position of anterior teeth
6. Which statement does notdescribe individuals with a positive attitude toward their teeth?
a. They are often apt to convey confidence and have an extroverted personalityb. They may not be completely satisfied with their smile
. They should not be presented with treatment options that could enhance their smiled. They usually do not refrain from smiling
7. Which age group often has a high level of interest in esthetic services?a. Baby boomers
b. Teenagers. People in their twenties
d. All of the above
8. Any occasion that involves greater social interaction and the opportunity for photographstends to make people more aware of their smiles, and therefore, can heighten their interest inesthetic services.
a. Trueb. False
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9. A persons profession rarely influences his or her decision to undergo esthetic dentistry.a. True
b. False
10. When assessing patients for cosmetic and restorative procedures, the guideline to follow is:
a. Esthetics first, function secondb. Esthetics, esthetics, esthetics
c. Function first, esthetics secondd. None of the above
11. Which topic provides an easy point of entry to initiate conversations about esthetic ser-vices?
a. Whiteningb. The patients financial situation
c. The patients definition of beautyd. The patients health history
12. A way to use non-verbal communication to instill trust and create a comfortable atmospherefor patients is:
a. Greeting patients with a smile
b. Talking to patients while they are sitting up (not lying prone in the dental chair)c. Both choices aboved. Neither choice above
13. A smile assessment form is a valuable tool in helping patients feel comfortable writing downhis or her wants in regards to dental esthetics.
a. Trueb. False
14. Treatment acceptance is often influenced by:
a. Timeb. Budget
c. Patients relationship with his or her dental professionald. All of the above
15. When examining a patient, it is best to present your findings at the end of the examination aspart of a comprehensive treatment plan.
a. Trueb. False
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References1. Cooper L. (Trans.) The Rhetoric of Aristotle. New York: Appleton-Century-Crofts, 1932. Cited in
Patzer, The Physical Attractiveness Phenomena.2. Morales M. Looks Count. Inland Empire Magazine, Oct 2002, pp. 21-22.3. Good-Looking Lawyers Make More Money, Says a Study by Economists. The Wall Street Journal,
11/4/96. Page 1, Vol CXXXIV, No. 3.4. Patzer GL. The Physical Attractiveness Phenomenon. New York: Plenum Press, 1985.
5. Levin EI. Dental esthetics and the golden proportion. J Prosthet Dent. 1978 Sep;40(3):244-52.6. Homoly P, Maples SS. Mastering complete care. The other skills you need to stay ahead of the
curve. Dent Today. 2003 Mar;22(3):118-23.7. Roth S. Tools Every Dentist Needs. Dental Economics, Aug 2002, p. 48.
About the Author