The art of presenting cosmetic dentistry

Most of the articles that I have written over the years and the lectures I have given usually contain the theme of ‘art’. It is by design that I have done this. It is because I believe what we do in aesthetic dentistry is truly an art form. And, to be consistent, I teach this in the hands-on programmes done at the World Aesthetic Congress and the American Academy of Cosmetic Dentistry symposiums as will be done this January in London 2009.

‘Art’ has been defined as the skill arising from the exercise of intuitive faculties. We use this when we artistically create a smile through our understanding of smile design and preparation design principles. But ‘art’ can also be used within a different context using that same definition. It can be used in the methods of how we approach presentation of our skills to the patient. Communication method is in itself an art form. The skill of it, or lack thereof, in the end determines the opportunity to express our artistic ability in the technical/physical sense. It is the art of case presentation this article addresses.

Smile better

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 refreshment. They are seated in a room that 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 and dialogue 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 (and unfortunately, at times, things other than their smile). The assistant will hand them an attractive hand mirror that allows them to point out specifically what they are concerned about. The assistant will ask leading questions, noting their response, to subconsciously educate them about their smile and to help in their own diagnosis.

Questions regarding the imbalance of the gum tissue, the broadness of their smile (buccal corridor deficiency) and proportion (teeth that are too short or square) and, of course, colour of their teeth. The assistant will speak to the concerns of lip support, which all women are concerned about. All of this taking place before you walk into the room. When you enter, it is with a smile and a handshake and a ‘thank you for coming to our office’ and always first, the establishment of rapport, which means initial conversation is never about dentistry. Once rapport is established, your conversation is directed toward dentistry by stating simply: ‘How may I help you today?’

At that time, the patient – although already having communicated to the assistant – will again espouse their concerns about their smile. Your position to them is always eye level, never above or below (see picture). 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, using my computer, I can then 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. Would that be all right with you?’

At this point, we have simply asked for permission. And, almost without fail, the patient is compliant with this request.

Second consultation
The patient is scheduled for the second part of their smile consultation. This is done at chairside (not at the front desk) by the same assistant that has been with them from the moment they arrived. This would conclude their first smile design visit and they would then be courteously escorted from the treatment room and dismissed.

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 – no pressure, just good vibes. The patient is also sent a note by the staff member who attended her at her first visit. This note is a simple ‘thank you for visiting our office and we look forward to seeing you at your next appointment’.
You may notice that we have not taken any radiographs, study models, face bow records or attempted any mock-ups in the mouth. This is by design. It is my rationale that the most important thing is to first establish rapport and trust with the patient. The focus is not to inundate the patient with dentistry or ‘things in the mouth’ that could be uncomfortable and would incur treatment expense, but to establish a relationship that entails conversation, quality of people and surroundings and a confidence that they know what you are talking about.
If properly orchestrated, this first appointment also instills a sense of anticipation by the patient to eagerly return for viewing of their proposed smile design.

Most often these patients are scheduled to return within the same week of the first appointment. Again, the psychology here is to maintain a high level of interest and anticipation and not to lose what is fresh in their mind. Allowed to pass over a longer period of time diminishes the sense of urgency by the patient to pursue esthetic treatment. This is not novel. The psychology of the consumer in many sales arenas is that most typically, they ‘want it now’. One might argue then, ‘why not do the consultation all in one appointment – do the exam, do the imaging, take the radiographs and models, stick a mass of composite in their mouth and do a mock up. Don’t have them back for a second appointment: get the answer now!’

My answer to this is, we are not selling a widget – we are providing a high-end service and treatment and the acceptance of that treatment will likely not occur in a hurried and pressured atmosphere where relationships and trust are first not established. The second consult visit is usually within one to four days after the initial appointment (the patient is eager to see the images and we want to keep their experience fresh in their memory).

On the return visit, the patient is again met by the assistant who attended to them at the first appointment. The patient is escorted back to the private consultation room where they are introduced to my treatment coordinator. She has a moment to converse with the patient and to establish a rapport before I come in. All second-appointment consultations involve the presence of my treatment coordinator, myself and, of course, the patient.

The presence of both my treatment coordinator and myself provides two very important aspects of this smile consultation design:
1) There is a more relaxed atmosphere at the beginning of the consultation due to the dialogue generated by the third person, i.e., another relationship within the office is created.
2) During the consultation, there is often a change in the treatment plan as a result of self-diagnosis by the patient from what they see on the photographs. This allows my treatment coordinator to input that change while I am consulting
3) The presence of a third party provides added validation to what was presented.
All photographs have been entered into the case presentation format on the computer (Envisonasmile Imaging Software). As the patient enters the consultation room, they will see a picture on the screen that is their existing preoperative natural smile.

It is in full-screen view for them to observe. 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. The frontal and lateral 1:2 views, the frontal and lateral retracted 1:2 views and occlusal views and the full-face view. Each view is critiqued drawing attention to soft tissue asymmetry, broken fillings, dark fillings or failing restorations or periodontal concerns. The frontal natural view usually exposes the deficiency of the buccal corridors and lack of a widened or full smile. The lateral view exposes the most distal extent of the smile and clearly shows the importance of why we so often need to involve the maxillary 10-12 teeth in our smile designs.

Once the preoperative photos are fully viewed by the doctor and the patient, the last pictures shown are the before and imaged (after) view of the front natural smile, and the before and after imaged lateral smile view and the before and after imaged full-face smile. The impact of the before and imaged views side by side is profound. For the first time, the patient has a perspective on the possibilities of what their new smile can look like. They see gorgeous teeth within the context of their lips, mouth and face. With the Envison A Smile program, they can see themselves from a side or lateral view. This is the perspective that I say to them is most often viewed in a social setting. Rarely do patients get to see themselves from this view. It is truly the most revealing and motivating perspective for the patient to see, and plays a significant role in the case acceptance.

At this point, I will then review 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 that are just profound before and after results of other case types. 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. 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 as little as two weeks. 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 (treatment coordinator) will go over the scheduling and treatment costs of the procedure to attain your smile makeover and that I look forward to helping them in any way I can. It is never about not wanting the treatment. It is now about how they can afford it. Options for payment are presented including third party financing, credit card and cash payments.

The success of this consultation method is proven by an 85% acceptance rate. It is a method that focuses on establishment of trust and rapport and education of the patient. We have given them time and effort without demand of money. It is only about addressing their need. One of my statements at the end of my 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 decide to go’. This expresses humble confidence in the patient’s eyes and it is likely they will not have a more extensive and comfortable consultation experience. Integral to the success of this consultation method is the use of computer generated imaging (Envisionasmile Computer Software, ).

It is amazing that all dentists who are involved in cosmetic restorative dentistry do not more aggressively utilise 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 visualise themselves without having to make the monetary commitment. To see themselves as they accurately can be. It is an educational and emotional stimulant. 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. 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, therefore misrepresenting what can be attained, resulting in frustration by the patient and doctor alike and potentially leading to litigious action. The highly accurate and aesthetic quality of the EnvisionASmile computer imaging system also is an invaluable communication tool between the ceramist and the aesthetic dentist.

An accurate computer-imaged photograph is a tremendous aide to the ceramist in that it shows the shade of the proposed result and clearly depicts the anatomical design and characterisations within the imaged photograph of the ceramic restorations and does so in three perspectives: frontal smile, lateral smile and full face smile.

Master ceramist, Hak Joo Savercool of Labline Signature (an Optident company), states: ‘The value of seeing an accurate image such as is shown through the Envision A Smile Imaging Software, enables me to clearly see what the doctor desires. This translates into results that are predictable and optimally aesthetic.’

Once treatment is accepted, the patient is scheduled for a full comprehensive work up. This includes mounted study models and diagnostic wax up, full series radiographs, panoramic radiograph and, of course, a comprehensive intra oral examination. Obviously, any existing periodontal disease or altered gingival health is addressed prior to aesthetic restorative treatment. The patient is informed that changes in the proposed aesthetic restorative treatment plan may occur based upon radiographic and clinical evaluations. Protocols for aesthetic/restorative design and treatment are then followed.

Suffice to say, no matter how comprehensive and entertaining your consultation may be, if you cannot deliver upon what you say, if you cannot deliver the goods, then you have compromised yourself, your staff and your ethics.

Success will be short lived and failure frustrating. Learning good consultation method and technique and protocol is paramount. It is, however, only as good as your ability as a clinician to deliver on it. This only comes from a defined commitment to continuing education in aesthetics preparation and smile design, occlusion, dental materials etc. It is only then that an excellently planned consultation will be completely successful.

Dr George Kirtley practices privately in Indianapolis, Indiana, USA. His practice is limited to complex restorative and aesthetic dentistry. He is accredited by both the American Academy of Cosmetic Dentistry and the British Academy of Cosmetic Dentistry.  He is a Senior Clinical Instructor for the Aesthetic Advantage in London, New York, Palm Beach.He will be presenting Making faces: veneer preparation hands-on seminar on Saturday 31 January 2009 in London. For information and to book your places, please call 0800 371652, visit or email [email protected]

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