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mentioned below just by taking a deep breath and closing their eyes for few seconds and analysing their answers(thetrueresponsethatcomes to mind) with professional honesty and humanity. If your conscience re- spondspositivelytoallthequestions, then it is advisable for you to pro- pose the treatment plan and take up the case, but if you give negative re- sponses to the questions, then you should rethink your proposed treat- mentplantosafeguardyourandyour patient’s long-term health, function and aesthetics using a more sensible and less destructive treatment ap- proach. Thethree-waytestconsistsofthree basicquestions: •Would I use this treatment for a member of my own family in this situation? •Am I competent enough to take up thecase? •Will the patient be happy with the biological, financial and time costs oftheproposedtreatment? I have been using this simple test since my early days of practice and enjoyingeverymomentofmyclinical practice without any mental stress and post-treatment professional guilt.Moreover,Ihave foundthatthe end-result of my case has always brought happiness to me and to my entire supporting team with high patient satisfaction. During all my MiCDinternationallectures,training, workshopsandseminars,Ialwaysen- courage my trainees and audience to enhance the quality of their operator factors (knowledge, skills, honesty andhumanity)becauseitisthepillar of successful MiCD. It is my personal beliefthat,ifaclinicianadoptsahabit of testing his or her treatment plan with the three-way test before pro- posingittothepatient,itcancertainly help him or her to promote overall happiness in his or her practice with highpatientsatisfaction. Extension: Invasive dentistry Ifwelookcarefullyatthehistoryof restorativedentistry,theword“exten- sion” (or “invasive”) has always been a point of focus among clinicians.14 Theconceptof“extensionforpreven- tion and retention” was pronounced by Dr G.V. Black 100 years ago and it was appropriate in relation to the restorative materials available at that time.However,withthedevelopment of porcelain-fused-to-metal technol- ogy in the late 1950s, the concept of “extension for functional aesthetics” wasadvocated,whichisstillverypop- ular in clinical practice. In the early 1980s,theconceptofthe“Hollywood smile” was introduced, which estab- lished the concept of “extension for cosmetics”indentistry. In 2002, the FDI World Dental Federation endorsed the approach of minimal intervention dentistry, which has basically focused on the conservativemanagementofcarious lesions, applying the concept of “minimal extension for decay re- moval”. History clearly shows that, since Dr G.V. Black era to the present day, we have been applying the con- ceptof“extensionindentistry”inthe name of prevention, retention, func- tion, aesthetic need and cosmetic de- sire, and caries removal. It is a clinical fact that this concept will remain the focusbecauseeachclinicalsituationis different, as its treatment modalities are guided by multifactorial issues such as patient factors (mind, body, behaviour and surroundings), opera- tor factors (knowledge, skills, hon- esty and humanity), protocol factors (the truth, evidence, experience and common sense), technology factors (health, reliability, affordability and simplicity). The use of science and technologyrequiresconsciousnessin operators and awareness in patients; hence, the operator must use his or herprofessionalknowledgeandskills with honesty and humanity to select theleastinvasiveprocedure,protocol and technology in treatment, so that extensionindentistryisalwaysmini- mal,safeandhealthy. The invasiveness of procedures se- lected in cosmetic dentistry depends on the level of smile defect, type of smile design, proposed treatment types and treatment complexity. MiCD uses the most conservative smileenhancementprocedurepossi- ble. The level of invasiveness in cos- metic dentistry can be classified into four types, namely non-invasive, mi- cro-invasive, minimally invasive and invasive, and the treatment options, various treatment procedures and their biological cost for each are pre- sented in Table I. There is only one principle in selecting treatment mo- dalities in MiCD: always select the leastinvasiveprocedureasthechoice of the treatment.2 Treatment proce- duresmentionedundernon-invasive, micro-invasive and mini-invasive are usedselectivelyinMiCD. MiCD treatment protocol and clinical technique Minimally invasive dentistry was developed over a decade ago by restorative experts and founded on sound evidence-based principles.15–24 In dentistry, it has focused mainly on prevention, remineralisation and minimaldentalinterventionincaries managementandnotgivensufficient attention to other oral health prob- lems. For this reason, I developed the MiCD concept and its treatment pro- tocol in 2009, which integrates the evidence-based minimally invasive philosophyintoaestheticdentistryin thehopethatitwillhelppractitioners achieve optimum results in terms of health, function and aesthetics with minimum treatment intervention and optimum patient satisfaction. The MiCD concept and treatment protocol are explained in an article titled “Minimally invasive cosmetic dentistry—Concept and treatment protocol”;25 hence,inthecurrentarticle, IonlydiscusstheMiCDcoreprinciples (Tab. II), MiCD treatment protocol andclinicaltechniquebriefly(Fig.2). MiCDclinicaltechnique: Rejuvenation,restoration, rehabilitationandrepair The MiCD clinical technique focuses on the aesthetic pyramid of the Smile Design Wheel1 (Fig. 3). Aesthetic components in dentistry aredividedintothreebroadgroups: 1.macro-aesthetics, 2.mini-aesthetics;and 3.micro-aesthetics. Eachaestheticgroupdealswithdif- ferent smile aesthetic components (Tab. III)andeachcomponentmustbe harmonised at the end of treatment. According to the smile defect and pa- tient’s desire, there are four different techniquesinMiCDtoenhancesmile aesthetics: 1. Rejuvenation: to rejuvenate in MiCDistoenhancesmileaesthetics with minor modifications in tooth position, colour and form, also known as the MiCD ABC principles, namelyalign,brightenandcontour (Figs.4–9): •Align: minor discrepancies be- tween the facial and dental mid- lines are acceptable in many in- stances.26 However, a canted mid- line would be more obvious27 and therefore less acceptable in cos- metic dentistry. Similarly, the disharmony in natural progres- sion of axial inclination or the degree of tipping of anterior teeth affects the aesthetic outcome of a smile. The correction to the midline and axial inclination pro- gression,andnecessarychangesto anterior tooth position are carried out using cosmetic orthodontic procedures with fixed or remov- able aligners. Once the anterior teethareinanaestheticallyaccept- able position, the aesthetic con- cerns of the patient generally shift towards the colour enhancement of the dentition. It is to be noted that a well-aligned tooth generally requires no or less tooth prepara- tion during tooth contour (shape and size) modification. This helps the clinician to achieve aesthetic smiles with micro- or minimally invasiveprocedureswithaverylow biologicalcost. •Brighten:toothbleachingorcolour modificationinMiCDiscarriedout once teeth are in acceptable align- ment but before the tooth form is modified.Theleveloftoothcolour modificationdependsonthequal- ity of the existing colour of the dentition and the patient’s desire. Home and office bleaching are popular methods for modifying tooth colour. However, in some cases,proceduressuchasreminer- alisation, micro-abrasion, walking bleach and thin enamel veneers areused. •Contour: a contour is an outline of the shape or form of something.28 In dentistry, cosmetic contouring entailsreshapingteethorgingivae to an aesthetic form. Cosmetic contouring can be performed in twoways,additiveandsubtractive. Additive cosmetic contouring en- tailschangingthetoothformusing tooth-coloured restorative ma- terials, such as a resin composite (direct and indirect restorations) orceramic(veneers),andchanging the gingival shape using graft ma- terials. Subtractive cosmetic con- touring entails removing dental tissue by grinding or texturing, andgingivaltissuebyselectivesur- gical procedures—which are non- reversible in nature and so proper caremustbetaken. 2. Restoration:restorationisaprocess of replacing missing dental tissue to enhance health, function and aesthetics. Restoration is performed usingmicro-tomini-invasivetreat- ment options, such as direct resto- rations, veneers, inlays, onlays or adhesive pontics, depending upon theextentandseverityofthesmile defect(Figs.10a&b&11a–c). 3. Rehabilitation: rehabilitation is the processofcompletereconstruction ofthesmiletoenhancepsychology, health, function and aesthetics using micro- or minimally invasive treatment options to minimise the possible biological cost. Direct and indirect composite resin and feld- spathic porcelain are the materials ofchoiceforrehabilitationinMiCD (Figs.12–14). 4. Repair: the role of repair in resto- rative dentistry is very important. The restoration cycle or each re- restoration process generally in- creases the size of the smile defect by15to20percentperre-restoration. Hence,MiCDprotocolrecommends performing repair wherever aes- thetically appropriate and possible using suitable adhesive restorative materials so that the health of the oraltissuewillnotbecompromised, while maintaining function and aesthetics(Figs.15a–c). MiCD summary ten AftercompletionofanyMiCDclini- cal case, the patient’s overall satisfac- tion and the clinical success must be evaluated.Inordertoevaluateclinical cases comprehensively and practi- cally, in the MiCD protocol, a clinician is advised to always summarise his or her cases under the ten areas listed in TableIV,calledtheMiCDsummaryten. Conclusion Inordertopractisedonoharmcos- metic dentistry, a clinician requires the desire, passion, dedication and will-power to become an honest pro- fessional with humanity because honestyandhumanityarethepillars of do no harm cosmetic dentistry, since the mind controls all other practice factors. The clinician must understandthathonestyandhuman- ity are not scientific like knowledge and skills, which can be learned, copied and applied immediately in the practice. Honesty and humanity areinnerqualitiesofapersonandare deeplyrelatedtothelevelofaperson’s consciousness, which are generally expressed as habits and attitudes. Therefore,weneedtolearnthesequal- itiesathomeandschool,andfromthe professionandsociety. Self-evaluation and the realisation of the level of inner happiness that youobtainthroughyourdailyprofes- sionalworkarevitaltounderstanding andbeginningtopractisedonoharm cosmeticdentistryinyourpractice. Editorial note: A complete list of references isavailablefromthepublisher. 19Cosmetic Tribune United Kingdom Edition | 4/2015 COSMETIC NEWS Dr Sushil Koirala is the Chairman of and chief in- structor at the Vedic Institute of Smile Aes- thetics. He can be contacted at drsushilkoirala@ gmail.com. Aestheticcomponents Smiledesignparameters Macro-aesthetics:dealswiththeoverallstructure •Facialmidline ofthefaceanditsrelationtothesmile.Inorder •Facialthirds toestablishthemacro-aestheticcomponents •Interpupillaryline ofanysmile,thevisualmacro-aesthetic •Nasolabialangle distanceshouldbemorethan1.5m. •Rickett’sE-plane Mini-aesthetics:dealswiththeaestheticcorrelation InM-position: ofthelips,teethandgingivaeatrestandinsmileposition. •Commissureheight Theaestheticcorrelationcanbeestablishedproperly •Philtrumheight whenviewedatacloserdistancethanthevisual •Visibilityofthemaxillaryincisors macro-aestheticdistance.Thevisualmini-aesthetic distanceissimilartotheacross-the-tabledistance, InE-position: whichisnormallywithin60cmto1.5m. •Smilearc(line) •Dentalmidline •Smilesymmetry •Buccalcorridor •Displayzoneandtoothvisibility •Smileindex •Lipline Micro-aesthetics:dealswiththefinestructureofdental •Maxillarycentralincisors(toothsizeratio) andgingivalaesthetics(Fig.8).Micro-aestheticscan •Principleofgoldenratio beestablishedatavisualmicro-aestheticdistance •Axialinclination oflessthan60cmorwithinnormalmake-updistance. •Incisalembrasures •Contactpointprogression •Connectorprogression •Shadeprogression •Surfacemicro-texture Table III: Aesthetic components and smile design parameters. Tenareas Rating 1.Smileself-evaluation Good Satisfactory Compromised 2.SmileHFAgrade Normal CompromisedA CompromisedHFA 3.Aestheticcategory Micro Mini Macro 4.Treatmentcomplexity Simple Moderate Complex 5.Proposedtreatment Accepted Modified Changed 6.Establishedoutcome Improved Nochange Deteriorated 7.Enhancementcategory Preventive Naturo-mimetic Cosmetic 8.Biologicalcost None Verylow Low High 9.Exitremark Excellent Good Satisfactory Belowsatisfactory 10.Clinicalsuccess Excellent Good Satisfactory Needsimprovement Table IV:The MiCD summary ten.