Cosmetic dentistry international No. 1, 2021

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editorial | Dr Sushil Koirala Editor-in-Chief Welcome to the ﬁ rst 2021 issue of cosmetic dentistry Last month, we celebrated World Oral Health Day on 20 March, the theme for 2021–2023 being “Be Proud of Your Mouth”. Customarily, we have acknowledged and highlighted the message to brush twice daily, ﬂoss at least once a day and visit the dentist regularly. We have tried to make healthy mouth habits a cornerstone of the reduction of oral disease burden in society. How- ever to be sure that the objective of celebrating World Oral Health Day is met, we have to raise the general con- sciousness level of people regarding their oral health. Healthy mouth habits have to be understood by an indi- vidual in relation to his or her compassion for his or her health and himself or herself in that the outcome of be- ing aware is much impactful than the outcome of merely being informed. Thus any piece of information sent out cannot have a meaningful impact if it does not have an approach that enhances the self-compassion of the recipient. It is only when an individual is compassionate to himself or herself that he or she can improve his or her quality of life and lead a truly happy life. It is interesting to note that daily toothbrushing has not yet been promoted as an activity of self-compassion and happiness in order to achieve optimal oral health and promote quality of life. We have always focused on the mechanical (removal of dental plaque) aspect of toothbrushing and not on its potential to have a meaningful and positive impact on the person’s mind and happiness as well. The COVID-19 pandemic and its global impact have fur- ther ingrained in me, as a clinician who has practised for almost 30 years, the essence of the Vedic Smile philos- ophy—the body seeks health and the mind happiness, and the only path to satisfying both is by being in har- mony with nature—that I have been practising since early in my dental education. The three-month lockdown pe- riod due to COVID-19 in Nepal gave me an opportunity to understand the power of a simple toothbrushing activity and how it can be incorporated as a meditative tech- nique to instil awareness and compassion by making it a good practice in the daily lives of children and adults. We all can imagine the negative impact of COVID-19 on the emotional health of children, adults and especially senior citizens globally, and it has been proved by mul- tiple scientiﬁc studies that emotional health and happi- ness can be enhanced by simple healthy habits. I ﬁrmly believe that toothbrushing can be an excellent act for the enhancement of mental health along with augmentation of oral hygiene. Thus, with this notion in mind, I have designed a simple and effective protocol which will be known as the med- itative toothbrushing technique (MTB). I believe that this protocol will help practitioners both to keep mouths clean and to promote happy minds. I have decided to work for the future and the future is the children. The Punyaarjan Foundation (www.punyaarjanfoundation.org.np) has de- cided to run an MTB school programme as a charity proj- ect to promote awareness and self-compassion among children so that good oral hygiene becomes a habit. Through this editorial, I would like to appeal to all our readers who also believe that children are the future, to join hands to help our children be healthy and happy. Sincerely, Dr Sushil Koirala Editor-in-Chief cosmetic 1 2021 dentistry 03

| content editorial Welcome to the ﬁ rst 2021 issue of cosmetic dentistry Dr Sushil Koirala opinion Celebrities’ Smile Makeup—the MiCD way Dr Sushil Koirala page 06 interview “To me, dentistry is a consolidation of science, art and medicine all in one ﬁ eld” An interview with Dr Rhonda Kalasho technique LipLase for fuller, smoother lips with no downtime Dr Harvey S. Shiffman page 24 Functional aesthetic speech therapy Drs Valerio Bini, Andrea Piccardi & Gabriele Maria Marzola 03 06 12 16 20 Inspired by the Maya—skull and tooth reconstruction with 3D printing 24 Dr Yassine Harichane trends & applications Bioactivity: Why should I care? Dr Fay Goldstep case report page 34 Simple chords of shades for harmonious restorations Dr Wallid Boujemaa industry report “The perfect match between simplicity and aesthetics offers the clinician several beneﬁ ts” An interview with Dr Adham Elsayed Simpliﬁ ed posterior restoration—eliminating shade selection Dr Piotr Marchewka Cover image courtesy of Fotona (www.fotona.com) feature issn 2193-1429 • Vol. 15 • Issue 1/2021 1/21 cosmetic dentistry beauty & science Sustainable dentistry is a philosophy that offers the best version of ourselves An interview with Dr Primitivo Roig meetings FDI World Dental Congress 2021 will be held online interview “Dentistry is a consolidation of science, art and medicine” trends & applications LipLase for fuller, smoother lips with no downtime industry report Simpliﬁed posterior restoration— eliminating shade selection about the publisher submission guidelines imprint 04 cosmetic dentistry 1 2021 30 34 38 41 42 46 48 50

| opinion Celebrities’ Smile Makeup— the MiCD way Dr Sushil Koirala, Nepal tive smiles that suit their personalities and professions. In the modern world, social media has become the over- arching tool for self-promotion and marketing, and it is now a platform whereby fans follow celebrities, causing them to be increasingly self-conscious of their smiles and beauty. This vicious cycle of celebrities’ desire and need for beauty and their glamour business have fuelled the growth of the smile beautiﬁcation business in dentistry. This article mainly focuses on smile enhancement of social media celebrities using the Smile Makeup protocol developed by the author, based on his established min- imally invasive cosmetic dentistry (MiCD) concept and treatment protocol.4 Who is a celebrity? This question seems simple, but the deﬁnition of “celebrity” may confuse many, as there are varieties of celebrities in the society, and the last century has witnessed a dra- matic shift in the deﬁnition of “celebrity” in terms of cultural and social acceptance. Celebrity status is accorded to someone who is known for being well known,5 and the dictionary deﬁnition of a “celebrity” is “a person who is famous”;6 in summary then, a person who is recognised by the masses for his or her popularity is considered a celebrity. From a psychosociological perspective, celebri- ties are usually presented as role models, and it is a normal part of life development for people to model themselves on their favourite celebrities as part of the process of identity exploration.7, 8 Basically, celebrities have three important societal aspects in common. First, they are well known for being well known within their realm; second, they appear to hold some inﬂuence over the public consciousness; and third, they come from all walks of life, so they may be suc- cessful business leaders, athletes, actresses, politicians, scientists, authors and musicians, among others. Celebrity categories In the past, celebrities used to receive coverage through traditional media such as the press, ﬁlm and TV and had little direct connection to or communication with their fans and followers. However, with the advent of Inter- net-based media, people now can bypass the entertain- ment, press and TV industries and launch themselves as celebrities through the use of social media, including YouTube, Facebook and Instagram. Free social media Fig. 1: Smile Design Wheel, showing four key components of smile design. Introduction In today’s beauty-adoring society, most people have the desire to look and feel their best, since facial and phys- ical appearance have a crucial role to play in an individ- ual’s self-esteem, happiness and eventual success. It is undeniably human nature to attribute positive personality characteristics to attractive individuals, and such peo- ple customarily receive favourable treatment in a variety of situations.1 Beauty is subjective and difﬁcult to delin- eate, as it lies in the eyes of the beholder, and the same applies to a beautiful smile. A substantial amount of re- search has suggested that smiles are powerful social forces that positively inﬂuence interpersonal judgements in innumerable ways. In global business, beautiful smiles are widely used as a marketing tool to produce positive impressions among fans and other consumers. Service with a smile is an established mantra in customer relationship management,2 and smiling faces are omni- present in advertisements.3 It is therefore certain that contemporary celebrities in different ﬁelds desire attrac- 06 cosmetic dentistry 1 2021

opinion | platforms have made available the opportunity to be- come a celebrity even to ordinary people, and the trends of “celebritiﬁcation” have become more pivotal to our cul- ture than ever before. The author classiﬁes his cosmetic dentistry-seeking celebrity patients into two categories in order to manage their treatment in a stress-free, comfort- able and conﬁdential manner. Traditional media celebrities These are celebrities in core and constant areas such as entertainment, sports, politics, religion and business who have worked strenuously to gain recognition, whose journey to fame has been characterised by persistence, and who are widely popular among people in their own country and/or internationally. These celebrities are fre- quently highlighted through traditional media such as press, ﬁlm and TV. Even though these celebrities have their own social media networks, they generally do not interact on a personal level with their fans, followers or au- diences and prefer to separate their professional and per- sonal lives. When accepting celebrities in this category for cosmetic dentistry treatment, the clinician must con- sider that these people are very busy and demand extra attention, such as exclusive scheduling, super comfort, supreme conﬁdentiality and faster treatment modalities. Generally speaking, the day-to-day business of cosmetic dentistry of the clinic cannot fully rely on this category of celebrity, since there are limited numbers of such celeb- rities in any given society. Social media celebrities These are a new kind of celebrity in the contemporary global market. They are groomed or self-created and have become popular using social media networks. Unlike traditional media celebrities, these celebrities focus on developing direct connections with their fans and are active in engaging in an interactive dialogue on social media, fostering the illusion of a personal connection. They believe in self-marketing and promotion, creating per- sonal brands, and invest considerable time in managing their proﬁles, ensuring that their photographs, comments and videos are in line with their overall brand image, ei- ther personally or through their supporting team. Owing to their constant social media activity, these celebrities are now evolving into a wonderful market for cosmetic dentists around the world. Although there is no precise means of categorising social media celebrities in the market, to understand the possible social inﬂuences of cosmetic dentistry-seeking celebrities, the author classi- ﬁes social media celebrities into four levels based on their social media followers and fans (Table 1). Celebrities’ domains In order to become known in a society, a person needs to possess some extra value in his or her domain. From an MiCD practice management point of view, the quali- ties of traditional media and social media celebrities are Fig. 2: Smile Makeup brand logo. divided into four main domains to help MiCD clinicians understand the perceptions, ego and emotions of the celebrity being treated. Attractiveness: In this domain, look, acting, voice and style are considered core virtues, and celebrities from entertainment industries like ﬁlm, modelling, music, acting, fashion, beauty pageantry and TV fall under this domain. The celebrities in the attractiveness domain develop and manage their fan bases through deliberate self-presentation using a variety of traditional media like press, TV and social media; hence, they are very sensitive regarding their facial and smile appearance and always covet the best beauty and style to enhance their popularity. Expertise: Knowledge, skill, experience and qualiﬁcations are considered the core strengths of this domain; thus, famous people in sport, science and technology, busi- ness, management, ﬁnance, ﬁne arts and literature fall under this domain. Depending on their public contact and followers, the celebrities in this domain may also be sensitive regarding their facial and smile appearance but not to the same extent as celebrities in the attractive- ness domain. Trustworthiness: In this domain, genuineness, reliability, trustworthiness, honesty and other similar ethics and inner qualities are deemed key strengths. The celebrities in this domain earn their fame and popularity from ethical business, humanitarian work and deeds; hence, facial beauty and smile aesthetics may not be among their highest priorities. Contrived: This is actually a pseudo celebrity group that does not possess any common trait; however, they are popular or visible in the traditional media or may have Social media celebrity levels based on their number of followers Mega SM celebrity: more than a million followers Macro SM celebrity: between 100,000 and a million followers Mini SM celebrity: between 25,000 and 100,000 followers Micro SM celebrity: between 5,000 and 25,000 followers Table 1 cosmetic 1 2021 dentistry 07

| opinion may become stressful and frustrating and may even fail if the ﬁve Cs requirements of MiCD are not met during treatment. Competency: The ﬁrst and foremost component is com- petency. Evaluating your own and your team’s clinical competency level in handling cosmetic dentistry cases of high-proﬁle celebrities is very important before you ac- cept their case for treatment in your practice. If you think you and your team do not have the requisite competen- cies, then it is your ethical, professional and commercial responsibility to invite suitable experts into your practice or to refer the celebrity to a practice that has the ca- pability so that the celebrity can receive the best pos- sible treatment. Another key area is treatment planning, because any overtreatment or over-ambitious treatment planning proposal may backﬁre on your reputation and business in the long run. Always keep in mind the pos- sible biological, technical and skill limitations that may force you to modify the treatment planning at the exe- cution level. Comfort: Comfort and celebrities go hand in hand, and celebrities generally desire an exclusive appointment schedule, the most comfortable physical environment, careful handling of their egos and emotions, painless treatment procedures, a reduced number of clinical vis- its and timely completion of treatment. Hence, if you think you cannot fulﬁl these universal celebrity desires at your practice, then it is wise to explain these issues clearly to the celebrity or his or her representative in advance. Communication: Communication in cosmetic dentistry plays a vital role in treatment success and patient sat- isfaction. In this regard, the author suggests using the Smile Design Wheel and considering the psychological (perception, personality, desire), health (general, speciﬁc, dentogingival), functional (occlusion, phonetic comfort) and aesthetic (macro, mini, micro) factors during com- munication and smile design. Always ensure that your patient understands the possible aesthetic outcomes, in- vasiveness (biological cost), required time and ﬁnancial cost of the treatment procedures. Clarifying his or her smile aesthetic outcome after treatment for the patient in advance is crucial and helpful for better communica- tion. There are a number of methods that you can use to communicate this once you have done your treatment planning, such as Quick Smile Design (direct aesthetic mock-up), digital aesthetic mock-up using suitable dental software, laboratory-fabricated indirect smile trial and a combination of the aforementioned procedures. Conﬁdentiality: This is the basic right of any dental pa- tient. However, in the case of celebrities, the clinician needs to be especially cautious, since many of them do not want it known that they have visited a dental clinic and undergone cosmetic dentistry treatment to enhance „Xxxxx.“ Fig. 3: Celebrities’ Smile Makeup. a huge number of followers in social media just because they have close association with other celebrities and involvement in their activities. These self-proclaimed celebrities generally have high egos and demonstrate fake emotions. Hence, practising cosmetic dentists should take extra precaution in communication and dealing with celebrities of this domain. Treating celebrities: MiCD ﬁ ve Cs requirements Naturally, a person’s success, high popularity, fame and ability to inﬂuence public consciousness brings about positive or negative changes to that person’s percep- tions, personality and desires. Depending upon the do- main of the celebrity and the level of his or her popularity and public inﬂuence, the type and sensitivity of changes vary. In this article, the author focuses on celebrities in the attractiveness domain, and his 25 years’ of experience in treating multiple categories of celebrities and high-proﬁle patients has revealed that those in the attractiveness do- main are very stressed, are unaware of the value of natu- ral tooth structures and their beauty, and generally have a biased perception of facial and smile aesthetic trends, desiring physical beauty, even if unrealistic. However, in terms of emotional expression, the author has found that the majority of these celebrities are emotionally weak and fragile in nature and are actually confused as to what they want. Hence, the author suggests that a clinician must meticulously understand the psychological components (perception, personality and desire) of the Smile Design Wheel (Fig. 1)9 for these celebrities in depth and han- dle them with care and compassion. Treating celebrities does not necessarily mean beautifying their smiles alone, but also enhancing their emotions positively and bringing some happiness into their lives through dentistry. It is quite natural for a cosmetic dentist to be excited when a celebrity visits his or her practice seeking cos- metic treatment. However, sometimes treating celebrities 08 cosmetic dentistry 1 2021

their smiles. Hence, one should be very careful and ob- tain the necessary permission before capturing photo- graphs of celebrities in the clinic areas and before posting to your social media channels. It is the author’s personal view that placing too much emphasis on celebrities’ vis- its to the practice may disturb other patients’ egos and emotions and may negatively impact on the ethical prin- ciple of equal treatment in clinical dentistry. Hence, as described in the comfort component, it is better to man- age the celebrity’s appointment separately (either as the ﬁrst patient or as the last patient of the day) rather than scheduling him or her between appointments with the general public. If you really want to exploit the publicity mileage of treating celebrities at your practice, then the better and more professional way is to obtain written tes- timonials about your overall services from these celebri- ties and from other clients and to share these together so that everyone feels acknowledged and respected. Consent: In the MiCD clinical protocol, obtaining written informed consent is mandatory for maintaining profes- sionalism and for legal purposes. The content of the con- sent may vary according to the local dental council or the relevant health authority. It is the practitioner’s responsi- bility to maintain the protocol of consent. Once you know your celebrity patient’s category and domain and once you have considered the ﬁce Cs, then you need to categorise the case, that is, what type of cosmetic dentistry treatment your patient actually needs or wants. According to the MiCD clinical protocol, cosmetic cases are divided into four simple categories:10 Rejuvenate: A simple procedure—and the most effec- tive aesthetic procedure in MiCD—that enhances smile aesthetics with slight modiﬁcations of alignment, bright- ness and contour of the anterior teeth—this is also known as the MiCD ABC principle. Restore: A process of replacing missing dental tissue to enhance health, function and aesthetics. Rehabilitate: A process of complete reconstruction of the smile in order to harmonise aesthetics and function- ality for long-term health and happiness—it falls under the MiCD complex category, as it generally demands a multidisciplinary approach. Repair: A process of maintaining and improving previously performed aesthetic restorative and other work. Smile Makeup the MiCD way Since the introduction of the MiCD concept and its treat- ment protocol in 2009, MiCD do no harm cosmetic dentistry has become globally popular and its value and beneﬁts accepted. The clinical experiences of the author opinion | and MiCD Global Academy members at multiple clinical centres has revealed increasing awareness among cos- metic dentistry-seeking patients of the long-term bene- ﬁts of minimally invasive dental procedures in saving the natural tooth structure. It is interesting to note that con- temporary dental patients are curious and concerned about the biological cost (invasiveness) of treatment be- fore starting the procedure. The emergence of such positive changes in consumer awareness regarding the invasiveness of cosmetic den- tistry prompted the author to exclusively publicise the rejuvenate category of MiCD cases among clinicians, the general public and celebrities around the world. Hence, in 2017, based on his MiCD concept and treatment pro- tocol, the author ofﬁcially introduced the Smile Makeup (Fig. 2) of cosmetic dentistry for celebrities (Fig. 3) and the general public.11 The author believes that Smile Makeup should be an inseparable part of the day-to-day personal make-up of any individual. Clinicians must understand that looking good, feeling good and smelling good is an innate human desire in modern society, and the global market of such business is skyrocketing. Therefore, in- troducing the Smile Makeup package in clinical practice can enable clinicians to deliver smile enhancement treat- ment with simplicity, with efﬁciency and at low biological and ﬁnancial cost. Smile Makeup is an innovative, advanced dental proce- dure designed exclusively to enhance and harmonise the smile and facial attractiveness of a person at minimal biological, ﬁnancial and time cost.11 It is composed of three basic components of attraction and glamour, namely the beauty, style and aroma (smell) of a smile. During the Smile Makeup process, the smile’s beauty, style and aroma are analysed using the Smile Makeup Index (Fig. 4), which helps to objectively quantify the status of the existing Fig. 4: Smile Makeup Index. cosmetic 1 2021 dentistry 09

| opinion 6 7 5 Fig. 5: Ms Niti Shah, Miss Nepal International 2017. Fig. 6: Initial situation. Fig. 7: Final outcome. smile and its treatment complexity, making communica- tion with patients easy and fruitful. The Smile Makeup package has the following key beneﬁts:11 – is patient-centric and respects the patient’s right to choose the smile he or she desires; – focuses on naturo-mimetic smile design principles and emphasises individual customisation of smile aesthet- ics rather than creating symmetrical stock smiles; – modiﬁes the beauty, style and aroma of a compromised smile and creates synergistic effects to enhance and harmonise facial attractiveness and the smile; – is painless and has little to no biological cost; – is a fast, predictable, healthy and affordable proce- dure compared with conventional cosmetic dentistry approaches; – does not change the existing occlusion, so is very comfortable for the patient; – reduces the likelihood of overtreatment and safeguards the patient’s trust; – complements facial make-up in a true sense. Smile Makeup experiences Ms Niti Shah, Miss Nepal International 2017 (Figs. 5–7): “I never knew having good teeth makes such a differ- ence in a person’s facial beauty and conﬁdence. I had two small gaps in between my front teeth and the shape of some front teeth were not in harmony with my smile. After winning the Miss Nepal International title at the Miss Nepal competition in 2017, I was introduced to the Smile Makeup International Clinic of Vedic Smile Pvt. Ltd, where a team of Smile Makeup experts did my smile analysis and Quick Smile Design (QSD). After completion of the QSD, I was asked about any modiﬁcation I wanted. Once I had approved the design, the team at the Smile Makeup clinic completed my Smile Makeup procedure without any drilling and touching my natural teeth; hence, I did not have to go through any pain and discomfort. I am so glad to see the result of my Smile Makeup, which has drastically enhanced the beauty and style level of my smile. Now I love my smile so much and have gained the conﬁdence to smile at any context. When I look back at my old close-up pictures, I feel I should have done my Smile Makeup before I participated in Miss Nepal. I am very happy to be one of the clients of the Smile Makeup International Clinic of Vedic Smile Pvt. Ltd.” Ms Sahara Basnet, Miss Nepal Asia Paciﬁ c International 2017 and Miss Intellectual 2017 (Figs. 8–10): “On 2 June 2017, I was crowned Miss Nepal Asia Paciﬁc International 2017 and had begun the race to my inter- national to compete along with girls from 50 other coun- tries. However, even after being a certiﬁed beauty queen, I never truly felt ﬂawless. Glancing at the pictures post- pageant, I realised that, though I looked good, having a visible crooked smile in a way made me look unpol- ished. That is when Smile Makeup was introduced into my life through Vedic Smile. By using the transparent Smile Makeup braces for only two months, my teeth were completely transformed. With the help of Smile Makeup braces, my teeth were perfectly aligned and they were 10 cosmetic dentistry 1 2021

8 opinion | 9 10 Fig. 8: Ms Sahara Basnet, Miss Nepal Asia Paciﬁ c International 2017 and Miss Intellectual 2017. Fig. 9: Initial situation. Fig. 10: Final outcome. also restored and reshaped into perfect sizes, making them look absolutely ﬂawless. This alteration drastically enhanced my smile aesthetics as a model and especially as a pageant queen. My Smile Makeup improved my looks and made me instantly recognisable for my ﬂaw- less smile. This not only boosted my conﬁdence on a day- to-day basis but also allowed me to have a foot forwards when it came to my stage presence on the international platform. This was not only the case in the pageantry world, but also when it came to the corporate world. Having a ﬂawless smile ampliﬁed my conﬁdence, gave me a presentable front and aided my endeavours towards becoming a public speaker. Even in my personal life, Smile Makeup enhanced my smile and made me look more radiant and sociable. Even though I used to feel like my crooked and discoloured teeth never held me back, having the Smile Makeup done has now completely changed my outlook in life. When it comes to the glamour world, now I am recognised as the girl with the best smile by my so- cial media followers and I haven’t looked back ever since. Smile Makeup not only changed the way I view myself, but it has drastically changed the way other people view me as well. The importance of Smile Makeup aesthetically is immeasurable, but it also had a profound impact on my personality and the way I carry myself every day. In a way, Smile Makeup gave me a new identity.” Conclusion The Smile Makeup package exclusively focuses on en- hancing the beauty, style and aroma (health) of a smile with minimal biological and time costs, which is alluring for both the public and celebrities. The free platform of social media has given every ordinary individual the op- portunity to become a celebrity, and the trend of celeb- ritiﬁcation has become more central to our culture than ever before. Moreover, the desire of the general public to become noticeable in social media groups has increased dramatically within the last few years and has opened up a huge market for smile beautiﬁcation and its related business. Hence, the author suggests to all clinicians who desire to treat celebrities and high-proﬁle patients in their practice for aesthetic reasons, to ﬁrst offer the Smile Makeup package because the majority of smile problems are actually related to minor alignment, brightness and contour imperfections of the anterior teeth and gingivae, all of which can easily be beautiﬁed using this simple and minimally invasive approach. Editorial note: This article originally appeared in MiCD Clinical Journal, Issue January-June 2021, and an edited version is provided here with permission from the author. A list of references is available from the publisher. contact Dr Sushil Koirala is the president of and chief instructor at the Vedic Smile Academy in Kathmandu in Nepal. He maintains a successful private practice in Kathmandu. He can be contacted at drsushilkoirala@gmail.com. cosmetic 1 2021 dentistry 11

| interview “To me, dentistry is a consolidation of science, art and medicine all in one ﬁeld” An interview with Dr Rhonda Kalasho By Iveta Ramonaite, Dental Tribune International According to Dr Rhonda Kalasho, cosmetic dentistry should be left to professionals who are skilled in periodontal maintenance and the art of symmetry and ceramics. Dr Rhonda Kalasho has recently been acclaimed as the most detail-oriented dentist in Hollywood. She works at one of the most innovative dental practices in the US, where she offers cosmetic, paediatric, emer- gency and general dental care and treats dental con- ditions such as bruxism and sleep apnea. In this inter- view, Kalasho talks about some of the state-of-the-art tools she uses in her practice and discusses the dan- gers of do-it-yourself (DIY) dentistry and the inﬂuence of social media on smile restoration. She also reveals how COVID-19 has affected her day-to-day work and pres- ents some of the challenges facing cosmetic and restor- ative dentistry. Dr Kalasho, could you tell us a bit about yourself, and how you became a dentist? I was very young when I came to the US from Baghdad, Iraq. We did not have a lot of money when we arrived, and food and survival were more important than oral hygiene. I found myself in the dental chair a lot when I was young, and I experienced what it was like to have extreme dental pain at a young age. I always wanted to be in the medical ﬁeld helping people, but I think dentistry spoke to something more than my yearning to bring health and wellness to the public. To me, den- tistry is a consolidation of science, art and medicine all in one ﬁeld. I love working on patients, and I enjoy every aspect of dentistry—from root canals to veneers. I do it all, and I love it all. Dentistry has come so far, particularly in the last decade with the advancement of 3D printing 12 cosmetic dentistry 1 2021

interview | and scanning technologies, so I always stay up to date with the newest modalities and research and take part in continuing education above and beyond what is re- quired. It is a blessing to be in this ﬁeld, and I am grateful to be a part of it every day. GLO Modern Dentistry is considered to be one of the most innovative dental practices in the US. What are some of the state-of-the-art tools and tech- niques that you use in your dental practice? Our ofﬁce is fully equipped with the latest and the great- est, including CBCT, intra-oral scanners and 3D micro- scopes. I am not one to buy tools that have no purpose and just look fancy. All the equipment we have in the ofﬁce is not only state-of-the-art, but also ensures higher- quality dentistry. Our scanners are incredibly precise, and our implant restorations and implant-retained full-mouth cases are all fully mapped and designed using 3D programs. Patients have full autonomy and are given a vision of what they will look like and what they can expect. Some of the most difﬁcult patients for dentists are those who need molar endodontic therapy or retreatment, and with our 3D microscope by Seiler Medical, the treat- ment of these difﬁcult molars becomes seamless. I have yet to miss a canal using the microscope, and the coolest thing is that I get to perform root canals wearing 3D glasses, which is beyond fascinating. Patients are always taken aback by the technology we have at the ofﬁce, and I am constantly searching for the best so that I can bring them the highest-quality dental care. What is the primary reason patients come to see you—to ﬁx minor imperfections, such as tooth over- crowding or unevenness, or for more advanced dental treatments? I like to think of myself as an old-school dentist using cutting-edge technologies. I perform dentistry on a broad spectrum—including ﬁllings, implants and ad- vanced cases of Invisalign treatment. After the comple- tion of my residency at the U.S. Department of Veter- ans Affairs’ San Diego VA Medical Center, I continued to advance my skill set in multiple specialties to pro- vide my patients with the most comprehensive dentistry at the highest level of care. If I am restoring a Class II cavity or extracting impacted third molars, I immerse myself completely in the procedure, and I love every second of what I do. It is the quality of the extracurricular studies undertaken and a willingness to learn that will allow even a general dentist to perform high-quality specialty care. At times, I refer some cases to my colleagues in the various den- tal specialties. However, for the most part, I treat almost any dental condition or issue that my patients come and see me for. You are known as one of the most stylish and detail- oriented aesthetic dentists in Hollywood. Could you elaborate on that and explain how it affects your role as a dentist? Being in the heart of Hollywood, many patients who see me are on the big screen. They are singers, songwrit- ers, producers and artists, so it was truly a surprise and incredibly humbling to be acclaimed as the most de- tail-oriented dentist in Hollywood. My staff and I have a motto by which we operate—we treat every patient like we would our own families. If you go into every case thinking this, your mood becomes warmer, your hands become lighter and you end up putting a lot of love into your work. “I like to think of myself as an old-school dentist using cutting-edge technologies.” I strive for perfection, and yes, perfection is not always attainable. However, you can get pretty close to it if you concentrate your energy and use your skill set for doing the best work possible. When I look at a patient’s smile, I am not only looking at the size and shape of his or her teeth. You can take a perfect set of teeth and put it in someone’s mouth and he or she will suddenly look off. A smile depends on the harmony with the face shape, lip shape, lip line, nose and chin position. A beautiful smile depends on so many differ- ent things, and I look at all aspects when I am restor- ing a smile. Many patients have resorted to DIY dentistry during the lockdown. What is your opinion about attempt- ing to perfect a smile at home? I was recently asked by the magazine Allure about whitening solutions made at home. My advice is to remain cautious about doing any home remedy type of treatments, be it buying mail-in aligners, using a nail ﬁle to help ﬁx a chipped tooth, moving teeth or treating teeth, since these are all delicate procedures. DIY den- tistry has gone wrong too many times for me to condone it. I have seen an excessive use of baking soda and ac- ids to whiten teeth that eventually lead to tooth erosion and enamel demineralisation. More recently, with the surge of the mail-in clear aligners that are being vigor- ously promoted on social media and in some podcasts, I have seen some devastating malocclusion as a result of patients moving their teeth without being under the care of a dentist. cosmetic 1 2021 dentistry 13

| interview ing, and I managed to acquire all the necessary personal protective equipment (PPE) in order to perform emer- gency dental services safely. We cut our patient load during that time by over 70%. However, it was more exhausting having to treat patients under the stress and fear of contracting the virus while wearing such heavy gear. We have taken extensive precautions at the ofﬁce, not only in wearing the proper PPE, but also in using extra-oral suction with every patient during treatment and making sure that only one patient is in the waiting room at a time. The sterilisation technique is increasingly extensive and thorough, and we test our staff at a cer- tiﬁed laboratory for COVID-19 every two weeks. We still provide the same great quality of care we always have done, just with some more gear. In your opinion, what will be some of the biggest challenges facing cosmetic and restorative den- tistry over the next ﬁve years? One of the challenges is convincing people who want to look like their favourite social media ﬁlter that super-white square boxy teeth are not aesthetic. As more and more dentists who have not studied the art of symmetry and ceramics are performing low-quality veneers or crowns, you will see more of these low- quality ceramics that are bulky and too opaque. These bulky crowns generally lead to periodontal disease and recurrent caries. Social media often inﬂuence people into thinking that they can all do cosmetic dentistry. However, my stron- gest suggestion is that everyone who is treating in the cosmetic arena must be trained in the periodontal main- tenance of the patient and the dental materials involved in high-quality ceramics. The challenge rests mainly on the education that so many dentists are not willing to em- bark on. Continuing education is incredibly important if you want to deliver the highest-quality service to patients. What is the best advice you can give to your patients seeking to enhance their smiles? Every smile is beautiful. If you have a gap, small teeth or gingival hyperplasia or if you have some crowding, keep in mind a smile is not one-size-ﬁts-all. Stick to what looks natural. Chiclet teeth or those overly white veneers or crowns that look so incredibly unnatural will never be in style. I always tell patients to think of the most beautiful person they know, and every time I ask them to name the person, every time, without fail, that person’s smile is natural and not overwhelming. Enhancing your smile means just elevating what you have and getting a co- lour that matches your skin and hair and creating teeth shaped to match your face and lips in order to achieve an overall harmonic appearance that will not overpower your face. Dr Rhonda Kalasho believes that a smile should not overpower a person’s face. Therefore, she recommends that her patients stick to natural smile enhancement treatments. (All images: © Rhonda Kalasho) Moving teeth is not as simple as shoving teeth into a straight line—you need to look at the root morphol- ogy, the periodontal status, the bone quality, existing restorations, and evaluate the patient’s cephalomet- ric parameters in order to deliver the most aesthetic, “Social media often inﬂuence people into thinking that they can all do cosmetic dentistry.” long-lasting results within the available standard of care. I have seen patients no longer able to close on their posterior teeth because they purchased clear align- ers without being under the direct care of a dentist. They then had to pay so much for additional dental treatments just to regain their functionality, which de- feated the purpose of trying to save money by going the cheaper route in the ﬁrst place. Leave dentistry to the professionals. COVID-19 has had a major impact on dental prac- tices worldwide. How has it changed your day-to- day work and the way you treat your patients? Since I perform extractions and root canals, I treated a lot of emergencies during the shutdown. I was part of the Los Angeles Dental Society task force for reopen- 14 cosmetic dentistry 1 2021

| technique m o c . k c o t s r e t t u h S / i y k s r o b m a S n a m o R © LipLase for fuller, smoother lips with no downtime Dr Harvey S. Shiffman, USA One of the fastest-growing industries in the world is facial aesthetics. Yes, beauty might be in the eye of the beholder, but beholders tend to agree. While beauty may be skin deep, its effects run far deeper. A long-standing cliché advocates to not judge a book by its cover, but people do judge books by their covers, as well as people by their appearances, especially by their physical attractiveness. 1 Fig. 1: Upper and lower lip volume scales (Merz Aesthetics). 16 cosmetic dentistry 1 2021

technique | In 1985, Dr Gordon Patzer published the Physical Attractiveness Phenomena, in which he deﬁned these as “the collective realities of physical attractiveness”, which tend to be complex, powerful and pervasive, discomforting and unfair, and despite different notions of physical attractiveness, transcend culture, time and geography. Dr Patzer states that the “components of the face do not contribute equally to the evaluation of physical attractiveness”. There is a hierarchy in that some components are of greater importance. There are ﬁve dominant factors, of which all are facial components, and these components in order of priority are the teeth, smile, lips, eyes and nose. The focus of this article will be the lips, including the modiﬁcation, rejuvenation and correction of symmetry and so much more using the Fotona family of lasers. A natural approach for lip rejuvenation As the world population continues to age and our con- cern with aesthetic appearance increases, more and more clinicians and practitioners are looking for options to offer their patients a natural approach to improving their appearance. When it comes to the lips, age- related changes include loss of volume, perioral wrinkles and fading into the face. When developing a strategy for lip rejuvenation, it is important to understand the anatomy and mechanisms of tissue breakdown. After the age of 25, we lose 1.5% of our collagen synthesis per year. This decrease in collagen production is compounded by an increase in degradation. Matrix metalloproteinases, such as collagenase, are induced by ultraviolet (UV) exposure and factors such as smoking and dietary toxins and are capable of degrading extracellular matrix components. Histologically, this is character- ised by irregular and disorganised collagen ﬁbres. These collagen bundles are also more highly cross- linked than is seen in more youthful skin. The ratio of collagen types also changes, having a predominance to Type III collagen with less elasticity. The most dra- matic loss of collagen is in the upper third of the der- mis, presumably related to the depth of UV penetration into the skin.1 The lips are signiﬁcantly more suscepti- ble because of the thin epithelial layer and should be protected. The traditional indications for using lasers in facial aesthetics include advancing age-related and lifestyle- related loss of facial volume, reduction in elasticity and skin or lip dryness, all of which are caused by loss of collagen. Today, many patients are beneﬁting from the use of laser therapy to maintain a youthful appearance and prevent facial ageing by stimulating collagen and maintaining collagen formation. Use of lasers in aes- thetics includes both ablative (tissue removal) and non-ablative types. In the 2000s, Fotona released the SMOOTH mode protocol, a non-ablative Er:YAG frac- 2 Fig. 2: Lip shape choices for modiﬁcation. tional laser pulse modality that results in much shorter recovery times. Fotona’s proprietary SMOOTH mode pulse modality creates no bleeding and allows for precisely controlled deposition of heat into the tissue. The optical/thermal energy is delivered in a unique sub-second-long pulse sequence, which prevents heat build-up on the surface, but achieves homogeneous heating by thermal diffusion down into the lamina pro- pria level of the tissue. The lamina propria layer is where the ﬁbroblasts are the densest and where, through generation of new collagen, collagen and elastin are formed. Fotona’s LipLase procedure was created to address the rapid increase in demand for restored and or plumper lips. LipLase fulﬁls this need with minimal downtime, 3 Fig. 3: Anatomical structures of the lips. cosmetic 1 2021 dentistry 17

| technique | technique 4a 4b Figs. 4a & b: LipLase case before (a) and after three treatments (b) showing modiﬁ ed volume and shape of the lips. anaesthetics and postoperative discomfort. The result is fuller, smoother lips, collagen synthesis stimulation and remodelling. The patient will see an immediate re- sponse, the plumpness increasing as the treatment continues. Of utmost importance is to monitor the tis- sue response to avoid overtreatment. as a cell phone camera is not adequate for facial aes- thetics owing to wide-angle distortion. We try to have the photographs up on a large monitor (greater than life-size) during the consultation, as magniﬁed images greatly help the patient scrutinise the images during the discussion. LipLase goes through three phases, starting with the inﬂammatory stage, where a series of vascular, cellular and biochemical events occur and water increases in the lips, resulting in an immediate plump as a response to the tissue heat-shock. The extent of lip plumping will be slightly more than the resulting long-term result, so a slight over-plump is suggested. The second phase is a light surface peeling, resulting in the exposure of fresh, younger-appearing tissue. The third phase is the phase in which new collagen is formed. Expectations and treatment planning Most of our aesthetic patients have a speciﬁc idea of what they want, and because of this, the most suc- cessful aesthetic consultations have involved handing the patient a large hand mirror and asking him or her what makes him or her unhappy about his or her facial features. Once the patient has expressed this desire, we review his or her concerns and reconnect the patient with realistic expectations. We use the Merz lip grading protocol to establish the starting point for treat- ment (Fig. 1) and then we provide the patient with a colour copy of the various lip shape diagrams (Fig. 2) as a point of discussion. Patients desire volume and symmetry or sometimes correction in speciﬁc areas and shape change. Thorough photographic documentation is essential both for treatment planning and for medico-legal docu- mentation of the existing condition before the treatment is started. We also include postoperative photographs at each appointment and then again at the follow-up appointment, 21 days after the last treatment of a series. Knowledge of photography is important in aesthetics, Equipment The hardware necessary to provide this procedure is from the Fotona family of lasers (Dynamis/Spectro family, TimeWalker Fotona4D, LightWalker), employing the proprietary Er:YAG SMOOTH mode pulse modality. There are no other lasers on the market that can re- produce this effect in the same way. These lasers have two different wavelengths built in: Nd:YAG, which is ab- sorbed in pigment and haemoglobin as its main chro- mophores, and Er:YAG, which has a high absorption in water as its primary chromophore. These two wave- lengths are some of the most researched wavelengths in laser aesthetics. For the LipLase procedure, the handpieces required are the PS03X, PS03 or FS01 (for the Dynamis/Spectro family of aesthetic lasers) or the PS04 (for the LightWalker dental laser). These hand- pieces are patterned or fractional and produce an ar- ray of deep microscopic thermal injuries that stimulate more repair and new collagen formation. Treatment protocol The LipLase protocol is initially a restorative treatment that ramps up over the course of treatments. LipLase involves primarily treating the mucosal aspect of the lips intra-orally ﬁrst to obtain good lip support, then moving out to the dry part of the lip up to and including the ver- million border (Fig. 3). The necessary energy settings are different for the wet and the dry parts of the lip. Pa- tient sensitivity will increase dramatically on the dry part of the lip if it is allowed to desiccate or the plume con- trol evacuation too close. Rehydration with warm saline or water is very important. Using chilled solutions will defeat the focus of the treatment (deep thermal effect). 18 cosmetic 18 cosmetic dentistry 1 2021

technique | technique | The handpiece of choice must be kept at a 90° angle with the tissue to enable optimal thermal energy pene- tration. The mucosal aspect is treated from right to left, with six SMOOTH mode pulses per spot, keeping the hand steady to drive the heat into the tissue (usually no overlap is needed). This is then repeated a total of six times. On the dry part of the lip, the protocol and energy settings drop, and two to four SMOOTH mode bursts per spot and two to four passes are used, based on the patient’s desired volume. The commissures should not be treated. Once a plump has been achieved, we can evaluate the shape and any deﬁcits. Pharmaceuti- cal-grade vitamin E oil or coconut oil should be applied immediately after treatment, but no pigmented lipstick or lip gloss for four days. Lip products of a sufﬁcient Sun Protection Factor should be used afterwards to prevent UV damage. The treatments are on a 21-day cycle, as that is biologically what is needed for the thermal injury and repair cycle. Results Clinical experience has shown that patients in their twenties to forties plump faster, but tend to need main- tenance after three to four months. In contrast, patients in their ﬁfties to eighties take more time to plump, but the plump will last for more than six months. Maintenance schedules are an important preconsent discussion for treatment, as they are an additional expense. Typical re- treatment is every three to four months to maintain the plump without signiﬁcant loss and usually involves one treatment. Patients who go over six months may require more than one treatment, as this requires restoration of the plump as opposed to maintenance thereof. Typical results are shown in Figures 4 and 5. 5a 5b 5c Figs. 5a–c: LipLase case pre-op (a), after one treatment (b) and after three treatments (c), showing volume and shape change. Conclusion about In conclusion, we have found the LipLase procedure to be an effective aesthetic, restorative and corrective procedure. If done correctly and with adequate train- ing, it is a safe procedure for both male and female patients. Dr Harvey S. Shiffman was born and raised in New York and is a graduate of the former Georgetown University School of Dentistry in Washington in the US. He then completed a general practice residency at Georgetown University Medical Center in Washington with an emphasis on treating medically compromised References 1. Varani J, Dame MK, Rittie L, Fligiel SE, Kang S, Fisher GJ, Voorhees JJ. Decreased collagen production in chronologically aged skin: roles of age-dependent alteration in ﬁ broblast function and defective mechani- cal stimulation. Am J Pathol. 2006 Jun;168(6):1861–8. doi: 10.2353/ ajpath.2006.051302. patients. Dr Shiffman completed his certiﬁ cation with the Academy of Laser Dentistry in three types of laser systems, bringing new technology to the practice, which can offer numerous enhancements to standard procedures and many new and exciting options. Dr Shiffman was recently awarded a fellowship in the Academy of Laser Dentistry. He is personally involved in the use and development of cutting-edge technology and has performed thousands of laser procedures in the last ten years. Dr Shiffman’s dental practice, Boynton Laser Dental Center, is in Boynton Beach in Florida in the US. cosmetic cosmetic 1 2021 dentistry 19 19

| technique Functional aesthetic speech therapy Synergy between dentistry and aesthetic medicine? Drs Valerio Bini, Andrea Piccardi & Gabriele Maria Marzola, Italy The current state of affairs Speech therapy deals with the physiopathology of human communication in its most diverse forms and, for reasons also of a practical nature, it has expanded its scope over time to various areas of intervention, including the study of oral functions.7 In this innovative evolution, the Conselho Federal de Fonoaudiologia (Brazilian federal council of speech therapy) has regulated the application of orofacial motility for aesthetic purposes,8 thus identifying a new possibility of use to evaluate, prevent and stabilise mimetic facial and/or cervical muscles, seeking the symmetry and harmony of the structures involved, with aesthetic results. Myofunctional intervention is considered a new objective of speech therapy intervention concerning aesthetics, with its own foundations and principles, and is aimed at the atten- uation of expression lines that inevitably appear.3 This area naturally integrates with the typical skills and objectives of the established protocols of aesthetic medicine and aes- thetic dentistry. In this regard, various authors have exten- sively studied the inﬂuence of dentofacial aspects on phys- ical attractiveness and self-esteem, and they have clearly demonstrated how dental morphology and related aesthet- ics play a fundamental and decisive role in the perception of beauty and, indirectly, in the determination of the social success of an individual. The physical aspect, self-esteem and the ability to engage in interpersonal relationships are deeply interrelated. Therefore, it is possible to suggest that facial structure, primarily that of the lower third of the face, has a great psychological and aesthetic impact and can certainly be more relevant than dental morphology alone.6 Ageing Ageing is a process that causes an imbalance of homeo- stasis and greater vulnerability of the organism, as well as a reduced adaptation to environmental stimuli, and it affects cells, tissue and organs.9 Anatomically, ageing is determined by the multiple effects of the passage of time and the effect of gravity on the skin, soft tissue, and superﬁcial and deep components of the face, and their mutual inﬂuences and vol- umetric alterations.10 Facial ageing is also determined by the interactions and relationship with the external environment of bones, muscles, ligaments and skin, especially the com- bined effects of gravity, bone resorption, decreased elastic- ity, loss and displacement of components, and superﬁcial and deep subcutaneous fat.11 These relationships between 1 Introduction Aesthetic medicine is increasingly taking on a global con- notation of harmony and balance, deﬁned certainly by historically evolved and shared canons, but progressively corresponding to a biopsychosocially functional proﬁle.1 From this perspective, different practices ﬁnd common grounds of expression, aimed primarily at the interdepen- dence between structure and function, constituting a dy- namic functional unit which possesses characteristic and integrative links.2 In this article, we will take a deeper look at the contributions of speech therapy to facial aesthetics3 and to the reorganisation of stomatognathic functions4 in synergy with aesthetic medicine and aesthetic dentistry5 and in response to the aesthetic patient, deeply interlinked with personal life experience—the most intimate emotions linked to the self and identity.6 20 cosmetic dentistry 1 2021

tissue are mostly represented in the lower third of the face and the perioral area, so the study and treatment of these areas is of fundamental importance in aesthetic and anti- ageing practices concerning the face. In fact, the dislocation of panniculus adiposus related to the collapse of the super- ﬁcial musculo-aponeurotic system (mimetic facial muscles) and reduced muscular tropism of the perioral area12 results in a substantial acceleration of chrono-ageing, which, being genetically determined and hormone-sensitive, remains difﬁ- cult to approach directly. Also, the deterioration of these struc- tures worsens the incidence of photoageing, which is mostly determined by the relationship of the individual with the external environment13 and his or her socio-existential habits (exposure to sun, diet, consumption of stimulants, physical activity, work, other lifestyle factors, etc.), making it difﬁcult to control by professionals in its triggering components.14 Consequently, the study of the muscles of the lower third of the face and the related muscles and tissue changes becomes fundamental15 to physiological functions such as mastication, breathing, posture and facial expressions; to para-physiological conditions such as loss of vertical dimen- sion (Fig. 1), collapse of the superﬁcial musculo-aponeurotic system, preferential mastication, preferential sleeping side and chronic unilateral incidental sun exposure; and to patho- logical situations such as bruxism, previous injuries and trauma, loss of teeth or masticatory tissue, speech or lan- guage dysfunction, and disordered breathing.16 Just as the excessive contraction of the superﬁcial mimetic muscles can promote the formation of wrinkles, so too can dysfunction of the stomatognathic system, consisting of a complex system of organs and tissue responsible for carrying out the respira- tory, mastication, swallowing and communicative functions, cause chronic and repeated muscular contractions. The dysfunction of the respiratory, mastication and swallowing processes is characterised by a multifactorial aetiology and, with structural or functional involvement, is closely related to the expression lines on the sides of the mouth, thus result- ing in speciﬁc postural attitudes. For these reasons, a single treatment is often ineffective. A synergistic approach between the dentist, speech therapist and aesthetic doctor addresses the problem with renewed therapeutic force, allowing better control of the formation of wrinkles and skin sagging and providing good mutual support in the clinical journey. 2 Dentistry and speech therapy Several authors have demonstrated how effective a multi- disciplinary vision and practical approach to the aesthetic clinical dentistry case are. In 2013, Bini proposed a facial aesthetic medical team (Fig. 2), a team of specialists that collaborate through a digital preview, an accurate multidis- ciplinary approach that has now been updated concerning aesthetics by providing for the involvement of speech therapy. The importance of the functional and aesthetic unit, such as the face and the smile, demands the most meticulous analysis of the harmony and beauty relationship, and the aesthetic patient, dysfunctional or not, must be motivated by this type of approach; without patient compliance, no prescription will be successful. The diagnostic and thera- peutic process, as already well established and consoli- dated between orthodontists and speech therapists, must suggest the importance of orthodontic therapy for smile aesthetics related to increasing self-esteem in addition to the psychological and psychophysical well-being of the pa- tient. The coordinated movements of all the orofacial mus- cles, as well as the posture of the tongue in the oral cavity, are essential for the physiological performance of the func- tions of breathing, mastication, swallowing and phonation, which is why in disease prevention and orthodontic therapy they are sometimes linked to facial aesthetic disharmonies. There is also a speciﬁc myofunctional intervention aimed at rebalancing oral function. From an early age, orofacial mus- cle imbalance contributes to the genesis of dental-skeletal abnormalities and the dysfunction of the temporomandibu- lar joints, manifested above all by imbalances in adulthood. Therefore, the critical role that orthodontics plays should not be overlooked in adults as regards the most modern therapies characterised by digital design and therapeutic ﬁnalisation by means of clear aligners. This is so even when the clinical case has a more cosmetic purpose, such as 3 4 cosmetic 1 2021 dentistry 21

| technique 5 minimal tooth movements intended for simple alignment of the parameters useful for improving the smile, that is, the possible modiﬁcation of shapes and sizes of the post- orthodontic dental clinical crowns or simply the objective of conservative direct or indirect additive restorations. In this regard, clear aligners, aesthetic veneers, conservative ad- ditive restorations, prostheses and implant prostheses pos- sess a series of features that characterise such treatment as an aesthetic approach. As a matter of fact, we must consider that any changes in positioning and volume of natural teeth and/or prosthe- ses related to the 3D dimensions of other intra-oral tissue, such as bone and gingivae, can induce new bio-dimen- sional aesthetic such as stretching of vestibular tissue, in- crease of the vertical dimension with the consequent new dentolabial approach, and lifting of a lip induced by func- tional composition (Figs. 3 & 4), and phonetic and subla- bial aesthetics related to dentistry. Static aesthetic analysis (photograph), dentolabial dynamics (video) and articulatory evaluation (audio) are decisive in the phase of consultation between the team’s specialists to be able to record any de- fects or functional and structural abnormalities in particular. It is essential to establish in a rational and economic manner the phases of the therapeutic process. Therefore, consid- ering the aesthetic results, it will prove useful to foresee in the diagnostic stage any need for speech therapy before, during or after dental treatments. The characteristics of the treatment process In promoting facial harmony, which is understood as the highest degree of aesthetic and functional balance, it is es- sential to intercept the cause–effect relationship that exists between the equilibrium of the stomatognathic system, muscle function and the skin.17 Speech therapy interven- tion cannot be separated from an accurate initial multi- disciplinary evaluation with the dentist and aesthetic doc- tor that is very often objectiﬁed through the use of digital images.6 High-resolution videos are essential, capturing the morphological and postural aspects of the following in a static and dynamic state: the face (posture, lips, tongue, dentition, occlusion, hard palate, soft palate, nostrils, eyes); tone (lips, tongue, cheeks, chin); proprioception; mobility (lips, tongue, jaw); stomatognathic functions (breathing, mastication, swallowing); facial symmetry; life- style habits; communication and eating habits.18 Based on the information gathered and the relationships observed between creases, wrinkles and oral imbalances, a per- sonalised therapeutic process is proposed and articulated in different areas3 and can be treated directly within the dental practice (Fig. 5). Elongation and relaxation of the oral and perioral mus- cles through massage of the musculature (small mas- sager roller and small vibrating device), and isometric and isotonic exercises derived from orofacial motility19 They act speciﬁcally on the different muscles of facial ex- pression (orbicularis oris, levator labii superioris, levator labii superioris alaeque nasi, zygomaticus minor, levator anguli oris, zygomaticus major, risorius, buccinator, depressor anguli oris, depressor labii inferioris, mentalis, platysma, orbicularis oculi, occipitofrontalis, procerus, corrugator supercilii, nasalis). Massages, stretches and speciﬁc move- ments seem to promote increased blood circulation, tissue oxygenation, greater balance and muscular balance, and an increase in proprioceptive skills, all decisive in the reduc- tion of the feeling of tension and fatigue. Postural modiﬁcation Starting from the shared physical examination, we look for spontaneous labial occlusion, for the correct positioning of the lingual apex on the incisive papilla (in compliance with the relationships existing between structural and functional elements), and for postural balance in the head and neck region. Rebalancing of stomatognathic functions Through motor learning principles,20, 21 priority is given to nasal breathing,22, 23 bilateral alternating mastication,24, 25 functional swallowing26, 27 and balancing of temporoman- dibular joints. Elimination of compensatory movements Expressive mannerisms and dislocated tensions, possibly resulting from non-verbal communication, are normalised.28 22 cosmetic dentistry 1 2021

technique | The phases of intervention The principle underlying treatment is the close connection between expression lines and orofacial muscle use over time. A structured course of action is therefore proposed,3 in consultation and integration with the dentist and aes- thetic doctor, regarding the clinical process to be followed promptly: 1. Taking of a joint medical history (aesthetic doctor, aes- thetic dentist, speech therapist) and evaluation of the stomatognathic system: Collaboration between the different specialists and the interdisciplinary vision, as well as the capture of digital images processed by software such as Invisalign’s ClinCheck and Aesthetic Digital Smile Design,29 allows one to better individualise the treatment plan, which, thanks to the advent of digital dentistry, can create a standard result predictive of an optimal clinical outcome. 2. Holding of a session aimed at providing information on the proper functioning of the stomatognathic system and the structures involved. 3. Implementing of an intervention process of eight con- secutive sessions, on a weekly basis, in which the patient acquires skills and autonomy in the daily performance of the different activities: In this regard, a daily work pro- gramme that the patient carries out independently for the duration of treatment is agreed on. 4. Holding of additional in-depth or control sessions. Thanks to the stable acquisition of new skills, the patient will be able to proceed independently once the treatment process concludes. Conclusion The available literature on the clinical outcomes of differ- ent facial rejuvenation approaches through manipulation of the orofacial musculature is currently represented by single case reports and small case series and generally shows positive results.30–34 Isometric, static, dynamic exercises, massages, and speciﬁc manoeuvres seem to help prevent and reduce facial wrinkles. The following were speciﬁcally observed: reduction of wrinkles around the eyes, thinning of expression wrinkles, thinning of forehead wrinkles, vol- umetric and increased deﬁnition of the lips, increase in the tone of the cheeks, reduction of wrinkles on the neck, redu- ction of the nasolabial fold, increased skin tone, symmetry of the eyes, improved muscle tone, greater mandibular deﬁ- nition, adequacy of stomatognathic functions and attenu- ation of the signs of ageing. However, these positive ﬁnd- ings must be interpreted in light of the procedures adopted for collecting the results, mainly based on self- assessment questionnaires and conclusive clinical evaluations,35 as well as in light of the very few clinical studies available which provide comparative pre- or post-treatment statis- tical data.32, 36 Therefore, a multidisciplinary intervention-based approach to the aesthetic patient seems even more promising. Such an approach can co-exist with proven mainstream approaches to aesthetic medicine and aesthetic dentistry. In conclusion, it remains essential to promote new inter- disciplinary protocols between professionals in the three ﬁelds, under the direction of the dentist or aesthetic doctor, who, alongside the established aesthetic speech therapy- integrated solutions, can use this multidisciplinary approach to address facial ageing and promote the best degree of functional balance and aesthetic harmony. Thanks to the study of the new protocols proposed and further alternatives, it will be possible in the future to have a better statistical evaluation of the clinical evidence of the speech therapy approach in signiﬁcant samples to enrich the current liter- ature, in which this approach has been under-represented to date. Editorial note: A list of references is available from the publisher. about Dr Valerio Bini obtained his DDS from the University of Genoa in Italy and is also qualiﬁed as a master dental technician. He is in private practice in Cavaglià and Biella in Italy, where he offers aesthetic digital smile design. He also is a member of the research centre for innovative technology and engineered biomaterials at the University of Insubria in Italy. Dr Bini is an active member of the Digital Dentistry Society and of the Italian Academy of Esthetic Dentistry. He lectures internationally on digital dentistry and aesthetic dentistry and has authored a number of research articles on these topics in international journals. Dr Andrea Piccardi is a surgeon specialised in aesthetic dentistry. He is a lecturer and tutor in the second level master’s degree programme in aesthetic medicine and wellness at the University of Pavia in Italy. He is the coordinator of international research groups at the universities of Pavia, Chieti and Seoul. Dr Gabriele Maria Marzola is a speech therapist with expertise in speciﬁc learning disorders. cosmetic 1 2021 dentistry 23

| technique Inspired by the Maya—skull and tooth reconstruction with 3D printing Dr Yassine Harichane, France A Mayan codex in the form of a concertina folding book presents and contains glyphs and representations that together tell a story. This globally unique story deals with their beliefs, practices and rites, but also their sciences. As a matter of fact, Mayan civilisation had a command of architecture, medicine, pharmacology and even den- tistry. Unfortunately, this knowledge went up in ﬂames with the conquistadors. The Mayan codices were held to be sacrilegious, for which the only means of puriﬁ- cation was ﬁre. Consequently, the priests burnt the Mayan records. Today, only three Mayan codices survive; however, two of them are in such poor condition that they cannot be handled. The third Mayan codex, which is regarded as the most beautiful and best preserved, is in safekeeping at the Technische Universität Dresden in Germany. Chichén Itzá is a Mayan city, famous today for its archae- ological sites, including the Temple of Kukulcán. What many tourists do not know is that the Dresden Codex is also from this Mayan city. This codex, however, only contains information relating to the Mayan calendar. It makes no mention of sciences such as dentistry. However, we possess artefacts that document that the Mayans performed dental treatment not only for thera- peutic but also for aesthetic purposes. There is currently no way of bringing back from the ashes a Mayan codex burnt 500 years ago, but we do have the technology to reconstruct 1,500-year-old artefacts. In this article, we will show how we managed to reproduce Mayan teeth using digital tools. Temple of Kukulcán. From time immemorial, people have attempted to transcribe their knowledge. Whether on stone, paper or wood—the various civilisations of our world have em- ployed different media to share their culture. The Mayan civilisation was no exception. A Mayan codex is an ency- clopaedia that includes the knowledge and capabilities of this ancient culture, including even dentistry. The following scientiﬁc article presents the reproduction of Mayan teeth using 3D printing and various composites. 1 2 3 Fig. 1: A Mayan child with growth plates. Fig. 2: Facial reconstruction. Fig. 3: Reconstruction of the skull. 24 cosmetic dentistry 1 2021

technique | 4 6 5 7 Fig. 4: Virtual Mayan skull. Fig. 5: SolFlex 650 (VOCO). Fig. 6: V-Print splint (VOCO). Fig. 7: Mayan skull printed in 3D. tomography (i-CAT, KaVo Kerr). We worked on a scan from our database, for which the patient gave his consent. The result was a DICOM ﬁle that included all the information on tissue density (Fig. 2). Consequently, it was possible to practically remove all the soft tissue, just leaving miner- alised tissue, such as bones and teeth (Fig. 3). Mayan skulls Surprisingly, the Maya already practised craniofacial ortho paedics in their day. When we look at the skeletons today, we can determine that these people had a particu- lar proﬁle. The skull was elongated and lengthy, the fore- head receding and the bridge of the nose even with the forehead until it reached the crown of the head. These craniofacial criteria were the result of a ritual practice: women applied rigid plates to the heads of their children that were bound together in order to steer craniofacial growth (Fig. 1). The Maya employed fontanelles, tissue areas between the skull bones, to shape the heads of their young children. The result was a ﬂattened skull in the forehead and occipital bone, as well as an overall egg-like shape. This arbitrary deformation was not performed for therapeutic reasons, but rather for aesthetic purposes. It was a cultural practice that permitted the ethnic and social group of the individual to be identiﬁed. 3D-printed Mayan skull We attempted to synthesise a Mayan skull with the latest technology. To do so, we took three main steps: data acquisition, design and printing. The acquisition step con- sisted of using data acquired by cone beam computed 8 Fig. 8: Mayan teeth. cosmetic 1 2021 dentistry 25

| technique 9 10 Fig. 9: CEREC Omnicam intra-oral scanner (Dentsply Sirona). Fig. 10: Virtual sectional plane of the dental model base. We isolated the skull of the patient and exported it to an STL ﬁle. The design step included importing the STL ﬁle into 3D-modelling software in order to distort the skull virtually. The frontal bone was ﬂattened, ensuring that the nose tip was in contact with the crown of the head. The occipital bone was less curved, in order to simulate the effect of a rigid plate behind the head. Finally, the skull was modiﬁed to give it an overall egg shape. This resulted in a skull that met the canons of Mayan beauty (Fig. 4). The digital ﬁle was sent to a 3D printer (SolFlex 650, VOCO; Fig. 5) loaded with transparent resin (V-Print splint, VOCO; Fig. 6), to reﬂect the internal bone structures better. This produced a transpar- ent skull with ﬁne details and a global shape (Fig. 7), which resembles the Mayan skulls on display in museums. 11 Fig. 11: SolFlex 170 (VOCO). Mayan smiles Mayan skeletons have been closely examined by multi- disciplinary teams of anthropologists as well as by dentists. The teeth do in fact reveal special modiﬁcations: they are ﬁled, striated or studded with precious stones (Fig. 8). The changes in shape may include the incisal edges, the vestibular surface, and the mesial and distal angles of the teeth. The inlays are composed of various stones: jade, obsidian, serpentinite, haematite, etc. However, one should bear in mind that these changes were conﬁned to the smile, that is, chieﬂy the anterior teeth and normally the buccal surfaces of the teeth. These operations were performed for aesthetic purposes. The teeth were both a symbol of social identity as well as an adornment. The most surprising thing is that these interventions were per- formed with such mastery that, for example, 1,500 years later, the teeth and even inlays still exist. Consequently, these artefacts are the ultimate proof that a dental inter- vention can be both cosmetic and permanent. Mayan wax-up We were able to reproduce three artefacts of the Mayan smile with the technological tools currently at our dis- posal. The previous steps, acquisition, design and 3D printing, were used in order to digitally produce a wax-up and two mock-ups. The ﬁrst step required the use of an intra-oral scanner (CEREC Omnicam, Dentsply Sirona; Fig. 9). The maxillary arch of a patient was scanned down to the tiniest detail in order to produce the most realistic artefacts possible. The scan was exported as an STL ﬁle to facilitate easy processing by the software. In a second step, a plannable basis was created for the 3D printing of a dental model, using modelling software (Fig. 10). This was printed directly in 3D (SolFlex 170 and V-Print model, VOCO; Fig. 11) in order to preserve the patient’s dental arch (Fig. 12). To optimise the light poly- merisation, the model was placed in an ultraviolet ﬂash- light device (OtoFlash, VOCO; Fig. 13). The wax-up was 26 cosmetic dentistry 1 2021

technique | 12 13 Fig. 12: Dental model before characterisation. Fig. 13: Ultraviolet ﬂashlight device for light polymerisation. inspired by Mayan smiles. The shape of the anterior teeth was modiﬁed to meet Mayan aesthetic criteria. The incisal edges were ﬁled, and a step applied to the cen- tral incisors. The teeth were coated with ﬂowable com- posite (Admira Fusion Flow, VOCO) in Shade A3.5 for the molars, Shade A3 for the premolars, Shade A2 for the canines and Shade A1 for the incisors. Effect com- posite (FinalTouch, VOCO) was used to achieve a realis- tic reproduction. The brown composite was introduced into the grooves, and the orange into the embrasures. Inlay work was performed with green and blue compos- ite (Twinky Star, VOCO) on the buccal surfaces of the teeth in order to simulate precious stones, and ﬁnally, the gingivae were simulated using pink composite (Amaris Gingiva, VOCO). The ﬁnal result was a realistic Mayan dental arch, produced 50% digitally and 50% manually (Fig. 14). Mayan mock-up Reproducing a wax-up in the mouth is possible using a mock-up. To do so, we implemented two different work- ﬂows. The ﬁrst workﬂow involved acquiring the dental arch using an intra-oral scanner (TRIOS MOVE, 3Shape; Fig. 15). The STL ﬁle was sent to a dental technician, who developed a digital wax-up. This wax-up was produced according to the criteria of Mayan aesthetics: a mesial cut on the central incisors, an incisal reduction on the lateral incisors and dental jewellery from canine to canine (Fig. 16). The digital wax-up was converted to an STL ﬁle, which was printed in 3D using a special printer (SolFlex 170 and V-Print model; Fig. 17). A silicone key was produced from the 3D-printed model (V-Posil Putty Fast and V- Posil X-Light Fast, VOCO; Fig. 18). 14 Fig. 14: Dental model after characterisation. cosmetic 1 2021 dentistry 27

| technique 15 17 19 16 18 Fig. 15: TRIOS MOVE intra-oral scanner (3Shape). Fig. 16: Virtual Mayan wax-up. Fig. 17: Mayan wax-up printed in 3D. Fig. 18: Silicone key. Before being inserted into the mouth, it was ﬁlled with colour composite and temporary composite (Structur 3, Fig. 19: Trying out the Mayan mock-up. VOCO). As soon as the polymerisation was completed, the silicone key was removed to display the Mayan mock-up (Fig. 19). The result was astonishing, since it was simultaneously natural and supernatural. A few sim- ple steps were sufﬁcient to create a 1,000-year-old smile. Mayan mock-up printed in 3D A classic mock-up has to be destroyed to be removed. In this workﬂow, we used a 3D-printed Mayan mock-up. After scanning the dental arch, the STL ﬁle was sent to the dental technician, who produced the mock-up directly without making a wax-up (Fig. 20). The STL ﬁle was sent to the 3D printer (SolFlex 170), which synthesised a resin mock-up within a few minutes (V-Print model). The char- acterisation was achieved with colour composite: green to imitate jade and blue for turquoise (Fig. 21). The mock-up was inserted into the mouth for presentation purposes in the context of this article. (During the writing of this article, this product was not speciﬁed for intra-oral application.) The result achieved was extraordinary, both in aesthetic as well as in technical terms (Fig. 22). It proved possible 28 cosmetic dentistry 1 2021

technique | 20 21 Fig. 20: Virtual Mayan mock-up. Fig. 21: Mayan mock-up printed in 3D after characterisation. by non-invasive means to produce a digitally designed Mayan mock-up from start to ﬁnish. nology has its place in everyday practice. It is up to the practitioner to ﬁnd the right dental technology to compete with the Mayan dental artists. Clinical applications This article presents an entertaining application of new dental technologies. Of course, there are many clinical ap- plications. Virtual simulation of a treatment is possible from beginning to end in craniofacial orthopaedics or in maxil- lofacial surgery. If the patient has a Class III malocclusion or requires Le Fort osteotomy, the specialist can simulate the therapeutic result on the computer and even print out the skull of the patient after treatment. This is a great way of checking the appropriateness of the treatment plan and obtaining the support of the patient. The dentist can also simulate treatment plans in general dentistry or even allow the patient to try out the end result. After scanning the dental arch, the dentist can simulta- neously display the digital wax-up using the digital smile design on the screen. After validation by the patient, a 3D printer can be used to print out the wax-up or, even better, the mock-up. Within minutes, we obtain a speciﬁc way for the patient to check and approve the therapeu- tic proposal. 22 Fig. 22: Trial of the Mayan mock-up after 3D printing. Conclusion Editorial note: This article was ﬁrst published in cosmetic dentistry—Magazin für innovative Zahnmedizin, Vol. 19, Issue 1/2021. To this day, the Maya have kept their capabilities and ex- pertise secret. In view of the longevity of their operations and their technical inventiveness, their dental aesthetic capabilities are breathtaking. Current dental technology has made it possible to design a smile with extremely demanding aesthetic criteria. contact Today, many dentists are looking for ways to meet their patients’ requirements. Digital dentistry provides tools that are affordable and accessible to everyone, enabling all requirements to be met. Whether in general dental practice, implant dentistry or orthodontics—digital tech- Dr Yassine Harichane graduated from the Paris Descartes University and conducted several research there. He is an author of numerous publications and a member of the Cosmetic Dentistry Study Group (CDSG) at the Paris Descartes University in Paris, France. He can be contacted at yassine.harichane@gmail.com. cosmetic 1 2021 dentistry 29

| trends & applications Bioactivity: Why should I care? Dr Fay Goldstep, Canada 1 2 Fig. 1: Giomers are based on a proprietary ﬁller particle with six ions that have distinct biological beneﬁts. Fig. 2: Giomers act as a reservoir to release and recharge ﬂuoride where it is needed. Introduction Dental clinicians are primary oral care providers focused on optimal health outcomes for their patients. The progression of oral disease is multifactorial and can present a downward spiral if left unchecked. This is not inevitable, however, if there is a conscious effort to proactively intervene, to slow or completely interrupt the process. All dental procedures must be performed with this in mind, through the practice of proactive intervention dentistry. Bioactive dental materials are the ideal candidates for the restoration of form and function of dental patients’ cari- ous and/or damaged dentition using a proactive approach. Bioactivity is deﬁned as having “any effect on, interaction with, or response from living tissue”.1 Bioactive materials are active, not passive, participants in the restorative process.2 They provide proactive beneﬁts for the patient that continue after they are placed, without any additional intervention on the part of the clinician. For a material to be tried and successfully incorporated into a dentist’s practice, it must exhibit superior physical and aesthetic properties and be user-friendly. Dental manufac- turers work hard in creating these products. Some prod- ucts have superior properties or are user-friendly, whereas the best have both attributes. Effective, successful bioac- tive materials must provide the same superior properties, be user-friendly and, of course, add the healing aspect of bioactivity. 3a 3b 4 Figs. 3a & b: Giomer ion release creates a protective ﬁlm layer which inhibits plaque formation. Plaque accumulation on a conventional composite placed in salivary solution (a). Almost no plaque accumulation on a giomer material placed in salivary solution (b). Fig. 4: The chemical and micromechanical (through resin tag formation) bond of FIT SA. 30 cosmetic dentistry 1 2021

trends & applications | 5a 5b 5c 5d Figs. 5a–g: The perimeter preparation using FIT SA. FIT SA (a). Stains and secondary decay around the defective margins (b). Stains and secondary decay around the defective margins are removed (c). Sound tooth and non- stained restoration formed the new cavity margins (d). FIT SA is placed (e). FIT SA is light-polymerised (f). FIT SA is plaque-resistant and remineralises the surrounding tooth structure without a bonding agent barrier, thereby preventing future perimeter breakdown and staining (g). Bioactivity in dental materials can be displayed by:2 1. the ability to remineralise and strengthen tooth structure through ﬂuoride release and/or release of other minerals; 2. the formation of an apatite-like layer on their surfaces when immersed in bodily ﬂuids; and 3. the regeneration of live tissue to promote vitality in the restored tooth. This article focuses on bioactive materials that heal by re- mineralising to strengthen remaining tooth structure and on other bioactive materials that regenerate live tissue to heal the pulp and keep the tooth alive. These are everyday restorative materials that are essential to the general dental practice. Remineralisation: The natural repair process for non-cavitated lesions Oral saliva is a miraculous solution that bathes the denti- tion with minerals that keep teeth strong and resistant to acid challenges. There is a constant state of deminerali- sation and remineralisation occurring which ﬂuctuates de- pending on food consumption, oral hygiene, oral pH and 5e 5f 5g other factors unique to each individual patient. Reminerali- sation is the natural repair process for tooth structure before it becomes cavitated. When remineralisation outperforms demineralisation, the tooth retains its mineral content and integrity. When this balance is disrupted, demineralisation prevails, minerals are lost and, with time, cavitation occurs. Oral hygiene products and techniques may improve the ini- tial situation, and today’s restorative materials are able to bioactively tip the balance to encourage remineralisation and to accomplish this in vulnerable, previously damaged areas which now require restoration or repair. Everyday bioactive clinical dentistry As mentioned, the ideal everyday go-to restorative material must exhibit superior physical and aesthetic properties and 6a 6b Figs. 6a & b: Before (a) and after (b) images of Class V restorations using FIT SA. (Images: © Dr Jack Grifﬁn) cosmetic 1 2021 dentistry 31

| trends & applications | trends & applications 7a 7b 7c 7d Figs.7a–g: Counter-top experiment to verify whether Biodentine achieves total set after being sealed with composite resin within a minute after placement and whether the two materials attain an adequate bond. Two cut straws were placed on a ﬂ at surface (a). Biodentine was mixed and inserted into the bottom of the straws (b). Beautiﬁ l Flow Plus 03 was bonded and inserted within a minute of Biodentine placement (c). Beautiﬁ l Flow Plus 03 is light-polymerised (d). easy handling. The addition of bioactive properties should in no way diminish these attributes. Giomers (SHOFU Dental) were developed to do just that: to be the everyday go-to bioactive restorative solution. This is the family of Beautiﬁl and Beautiﬁl Flow Plus materials. load-bearing indications. It is ideal in paediatric and geriatric cases, where speed and efﬁciency are of the essence. No etching, no rinsing, no mess. Defects and secondary decay around old crowns are speedily repaired with a material that delivers bioactive beneﬁts for many years after placement. Giomer materials have been clinically evaluated in a series of long-term clinical trials. A study of Beautiﬁl restorations placed at the University of Florida in the US found no post- operative sensitivity, no secondary decay and no marginal deterioration, 100% retention and maintenance of ana- tomical form with 95% of lustre retained after eight years.3 A 13-year recall study demonstrated that 95% of the resto- rations had no secondary decay.4 What about bioactivity? Studies show that dentine reminer- alisation occurs at the preparation surface adjacent to the giomer.5 Giomers are based on a proprietary ﬁller particle that contains ions that have distinct biological effects. These are ﬂuoride (remineralisation, acid resistance, antibacterial), strontium (acid resistance, decreased sensitivity, antibacterial), aluminium (decreased sensitivity, radiopacity), silicate (calciﬁ- cation), borate (antibacterial) and sodium (radiopacity; Fig. 1). Giomers take up additional ﬂuoride (after ﬂuoride toothpaste, rinse or varnish applications) and then act as a reservoir until the ﬂuoride is needed. This can be best described as a ﬂuo- ride bank from which ﬂuoride is released on demand during cariogenic challenges (to decrease demineralisation and enhance remineralisation) and then recharged during ﬂuoride application of toothpaste, varnish, etc. (Fig. 2).6, 7 The ion release around the giomer restoration creates a bio- active envelope (protective ﬁlm layer) which inhibits bacterial adhesion and plaque formation, thereby decreasing the risk of secondary decay and promoting periodontal health (Fig. 3). The ions in the protective ﬁlm layer neutralise oral acids, in effect cre- ating an acid-free zone around the restoration. The full range of bioactive actions of giomers thereby strengthens surrounding tooth structure and increases the longevity of the restoration. Most recently, SHOFU introduced FIT SA, a self-adhesive, ﬂowable, bioactive giomer restorative material, thereby eliminating the bonding layer, which may be a barrier to full ion transfer between the restoration and the tooth. There is no bonding layer to block the beneﬁcial action of giomer ions on the tooth. The bonding agent is within the material itself. This is chemical as well as micromechanical (through resin tag inﬁltration) bonding (Fig. 4). FIT SA is designed to be used as a liner, in small Class I, Class III and Class V restorations, and for any other non- Time and function may break down the margins of a resto- ration, at the interface between tooth structure and compos- ite resin. In many cases, although the margin exhibits local- ised or perimeter breakdown and secondary decay, the rest of the restoration remains intact. The dentist is then faced with the decision of replacing or repairing the restoration. This is not the time to watch and wait until the restoration becomes unsalvageable. A perimeter preparation is a pro- active treatment performed at an early stage before more extensive treatment is required. All stain and secondary decay around the defective margin must be removed. The ideal replacement material should integrate with the original restoration and the remaining tooth structure, be plaque- resistant and have remineralising properties in order to prevent future perimeter breakdown (Fig. 5).8 FIT SA is this material. Over the life of a restoration, the bonding layer may eventu- ally create a stain line at the margin. With no bonding layer, no stain line will develop. This is particularly beneﬁcial in Class III and Class V restorations (Fig. 6). The FIT SA resto- ration also blends easily with the surrounding dentition ow- ing to its unique ﬁller structure that combines the light trans- mission and diffusion properties of dentine and enamel. Glass ionomers, the original bioactive materials, should be used in challenging restorative areas where it is difﬁcult to achieve a dry ﬁeld. They are also indicated as protective seal- ants against caries during tooth eruption and development.9 Bioactive regeneration of pulpal tissue: Saving tooth vitality What is the protocol in cases of deep decay where a remineral- ising resin liner is just not enough to protect pulp vitality, where decay reaches dangerously close to the pulp, or even slightly into it? Biodentine (Septodont) is a calcium silicate material de- veloped to protect the pulp and to assist in regenerating pulpal tissue, without the physical limitations and handling challenges of earlier mineral trioxide aggregate (MTA) products. Biodentine provides a hermetic seal that protects the pulp from bacterial inﬁltration and provides an ideal environment for healing to take place. This seal is formed by Biodentine’s micromechanical retention into the dentinal tubules as well as by its stimulation of odontoblasts to deposit dentine.10 32 cosmetic 32 cosmetic dentistry 1 2021

trends & applications | trends & applications | 7e 7f 7g After 24 hours, the straw matrices were removed, demonstrating the total set of Biodentine under the composite resin. Biodentine is shown on top and Beautiﬁ l Flow Plus 03 on the bottom (e). An attempt is made to break the bond between the two materials (f). The bond was maintained. A cohesive fracture occurred within the Biodentine (g). Upon mixing, Biodentine produces calcium hydroxide, a known pulp regenerating agent.11 Calcium hydroxide on its own does not have long-term stability and with time turns into what can best be described as cottage cheese. The Biodentine formulation produces a gel-like material en- velope around the calcium hydroxide that is strong and not porous. This harnesses the regenerative powers of calcium hydroxide without its physical disadvantages. Biodentine, through the action of calcium hydroxide in this enhanced physical state, boosts the deposition of reparatory dentine by odontoblasts, creating a dense dentine barrier12, 13 that allows for isolation and healing of pulpal tissue.14 It should be noted that non-resin-based materials ( Biodentine) and ProRoot MTA (Dentsply Sirona) were more effective than a resin-based material (TheraCal, BISCO) in a partial pulpotomy study.15 In another study, TheraCal LC was shown to increase inﬂammatory cells and to decrease the regen- erative processes of the pulp, whereas Biodentine did not increase inﬂammation and supported pulpal regenera- tion.16 These studies suggest caution in using resin-based materials for vital pulp therapy.2 Biodentine can be used as a base in deep carious lesions, as a pulp capping agent in vital pulp therapy (both direct pulp capping and pulpotomy), for root repair (perforations, resorptions, apexiﬁcations, etc.), and for anywhere pulpal regeneration and tissue healing are needed.2 What about handling? Biodentine has been under-used in clin- ical practice owing to the assertion that complete set of the material is necessary prior to ﬁnishing the restoration with com- posite resin. Is this because the material does not completely set under the composite resin? Is the bond inadequate be- tween the unset Biodentine and the overlying composite resin? Instructions recommend bulk ﬁlling of Biodentine completely and using it as a temporary restoration while evaluating pul- pal response. The patient then returns in three to six months for replacement of the external layers with composite resin. A second option is to wait chairside for 12 minutes for the mate- rial to set completely before placement of the composite resin. The experiment The author undertook a simple counter-top experiment to test whether Biodentine would achieve total set after being sealed with composite resin within a minute after placement and whether the two materials would achieve a good bond. Biodentine was mixed and inserted into two cut straws, which were placed on a ﬂat surface (Figs. 7a & b). BeautiBond (SHOFU Dental) was applied and light-polymerised. (A seventh gen- eration no-etch bonding agent is preferred, as it eliminates the possibility of etching or rinsing interfering with the set or bond of the materials.) Beautiﬁl Flow Plus 03 was then applied (Fig. 7c) and light-polymerised (Fig. 7d). The straws with the two restorative materials and bonding agent were left for 24 hours. After 24 hours, the straw matrices were removed, and it was observed that the Biodentine had set rock-hard (Fig. 7e). An attempt was made to break the bond between the two materials (Fig. 7f). The result was a cohesive fracture (Fig. 7g) within the Biodentine (a therapeutic, regenerative material not designed to withstand shearing forces). This was not a bonding failure between the two materials. The takeaway: there is no reason to wait 12 minutes for the complete set of Biodentine before ﬁnishing the restoration with composite resin. Biodentine sets completely underneath composite resin, and the bond between them is strong. Conclusion The answer to the question of why we should care about bioactivity is clear. Whether it is the everyday go-to restor- ative giomer, or glass ionomer for challenging locations, or calcium silicate to save pulp, bioactive materials can help stop and reverse disease. They are better for the patient. They enhance clinical outcomes. They are easy to use. The time has come for bioactive dentistry! Editorial note: A list of references is available from the publisher. about Dr Fay Goldstep, DDS, is a clinician, author and educator. She has lectured nationally and internationally on proactive/minimal intervention dentistry, soft-tissue lasers, electronic caries detection, healing dentistry and innovations in hygiene. Dr Goldstep has been a member of the teaching staff of the postgraduate programmes in aesthetic dentistry at the State University of New York at Buffalo, the universities of Florida and Minnesota, and the University of Missouri–Kansas City in the US. She sits on several editorial boards, has contributed to four textbooks and has published more than 100 articles. She is a fellow of the American College of Dentists, International Academy for Dental-Facial Esthetics and American Society for Dental Aesthetics. Dr Goldstep is a consultant to a number of dental companies and practises in Toronto in Canada. cosmetic cosmetic 1 2021 dentistry 33 33

| case report Simple chords of shades for harmonious restorations Dr Wallid Boujemaa, France 1 4 7 11 2 3 5 6 Figs. 1 & 2: Case 1—initial situation. Fig. 3: Initial periapical radiograph. Figs. 4 & 5: Shade selection using the composite button technique, without (4) and with (5) polarising ﬁlters. Fig. 6: The wax-up allowing the creation of a palatal silicone key. Composite restorations set the rhythm of the daily life of our dental practices. Whether they are the ﬁnal goal of a re- habilitation or an intermediate stage of the treatment plan, their implementation must be easy and reproducible. In an- terior areas, the shape, colour and occlusal condition must be rigorously studied to achieve the desired aesthetic and functional requirements. In terms of posterior teeth, direct restorations have to fulﬁl two major goals, biological and functional. While aesthetics are not to be left behind, respect of cusp morphology will certainly be of greater importance. For more than a decade, composite resins have been used to fulﬁl these speciﬁcations. Their simplicity of appli- cation, their mechanical resistance, their polishing abilities and their optical properties allow them to integrate per- 8 12 9 13 10 14 Fig. 7: Tooth isolation with a dental dam. Fig. 8: Enamel etching using 37% orthophosphoric acid for 10 seconds. Fig. 9: Application of G-Premio BOND universal ad- hesive (GC). Figs. 10 & 11: Creation of the palatal enamel shell using the Junior Enamel shade (G-ænial A’CHORD, GC). Figs. 12 & 13: Elaboration of the mesial surface with an enamel shade using a proximal matrix (LumiContrast, Polydentia). Fig. 14: Modelling of the dentine core in opaque dentine Shade AO2 (G-ænial A’CHORD). 34 cosmetic dentistry 1 2021

15 19 23 27 30 16 20 17 21 18 22 24 25 26 Fig. 15: Modelling of dentine mamelons using the A2 shade (G-ænial A’CHORD). Fig. 16: Application of superﬁcial enamel, Shade JE. Fig. 17: The distal cavity is blocked with a core shade of medium opacity, A2. Fig. 18: Use of a brush impregnated with an unﬁlled resin (Modeling Liquid, GC), making it easier to sculpt and adjust the composite. Fig. 19: Macro-anatomy management with a red ﬂame bur. Fig. 20: Pre-polishing with the pink silicone disc Diacomp TwistPlus (EVE). Fig. 21: Polishing with the beige silicone disc Diacomp TwistPlus (EVE). Fig. 22: Surface condition after ﬁnishing and polishing. Figs. 23 & 24: Reduction of the black triangle with a shade of medium opacity, A2. Fig. 25: Immediate post-op situation. Fig. 26: Post-op radiograph. fectly with natural tissue over time. Among these materi- als, GC’s G-ænial range has proved itself for ten years. Its youngest member, the G-ænial A’CHORD, has just been launched and seems as promising as the former version. With a smaller number of shades, it can cover the same situations as its predecessor, but with a markedly im- proved consistency and surface condition after polishing. The two cases presented here are examples of the possi- ble applications of this material in a successful way. Case 1: Anterior restorations using monochromatic and multi-shade techniques A 40-year-old patient in general good health attended an emergency consultation. She had fallen on to her coffee table, causing a fracture from the mesial angle up to the middle third of tooth #21. The tooth responded positively to the pulp sensitivity test. Given the colour and textural characterisations to be reproduced, a stratiﬁcation ses- sion was scheduled. The patient also wanted to improve the aesthetics of her smile by having the apparent black triangles between tooth #21 and tooth #22 reduced. An impression for a wax-up and a provisional restoration using composite in a single-mass technique were carried out during the emergency consultation. Periodontal remediation and endodontic treatment of tooth #11, which was necrotised after the trauma, were performed prior to the composite stratiﬁcation session (Figs. 1–32). 28 31 Figs. 27–32: Post-op situation at one week. 29 32 cosmetic 1 2021 dentistry 35

| case report 33 34 35 36 37 Fig. 33: Case 2—initial situation. Fig. 34: Pre-op periapical radiograph. Fig. 35: Isolation of the tooth with a dental dam. Fig. 36: Composite removal. Fig. 37: The caries removal was carried out in a centripetal way. Case 2: Posterior restoration using a cusp-by-cusp approach A 15-year-old patient in good general health presented herself for a check-up. She reported that tooth #36 was sensitive to sweetness. The tooth responded pos- itively to the pulp sensitivity test and displayed an occlusal composite without morphology. Clinical and radiographic examinations revealed the presence of secondary caries under the composite, which showed 38 39 40 41 42 43 44 45 Fig. 38: Etching using 37% orthophosphoric acid for 10 seconds. This was removed with abundant rinsing. Fig. 39: Application of G-Premio BOND universal bonding. This was applied and rubbed vigorously on the dental surfaces and then dried thoroughly before light polymerisation. Figs. 40 & 41: Application of a 2 mm composite layer on the surface of the cavity using an injectable composite (G-ænial Universal Injectable A2, GC). Figs. 42 & 43: G-ænial A’CHORD com- posite A2 was easily shaped to create the cusps. Figs. 44 & 45: The other cusps were built cusp by cusp in the same manner, creating the occlusal anatomy. 36 cosmetic dentistry 1 2021

case report | 46 47 48 49 50 51 52 53 Fig. 46: The use of a composite stain (Brown Modiﬁer, Essentia Modiﬁer Kit, GC) makes it possible to assess the morphology and ensure that there are no gaps. Fig. 47: Forty-second photo-polymerization on each side under glycerin gel (AirBarrier, GC). Figs. 48 & 49: Polishing with silicone wheels (Sof-Lex, 3M). Fig. 50: Immediate post-op situation under dental dam isolation. Fig. 51: Post-op periapical radiograph. Fig. 52: Immediate post-op situation. Fig. 53: Post-op situation at one month. The sensitivity had been resolved. microleakage at the margins. A session was scheduled to remove the composite and determine whether a simple renewal of the composite with a direct technique was possible. At this stage, the cavity was disinfected with a 2% chlorhexidine solution to reduce the bacterial load during caries removal, which could have led to pulp exposure. After cleaning, the cavity was shaped. The pulpal wall appeared to be located away from the pulp cham- ber (0.5 mm). The thickness of the remaining walls enabled us to opt for a direct composite restoration (Figs. 33–53). Conclusion These two cases reﬂect the large scope of composite materials and the many facets with which they should be compliant. Whether used in a single-shade technique in the posterior and cervical areas or in multi-shade layering with different translucencies for more aesthetic restorations, a good composite material must raise to the main challenge: that of meeting the patient’s demands effectively and in a harmonious way. about Dr Wallid Boujemaa graduated as a dental surgeon in 2014 from the University of Bordeaux in France. He was a university hospital assistant in restorative dentistry and endodontics between 2015 and 2019 and has since then been a lecturer at the university. He is a full-time private practitioner. Dr Boujemaa has been involved in various research projects and conferences in the ﬁeld of restorative and aesthetic dentistry and won the aesthetic dentistry contest hosted by the French journal Réalités Cliniques and GC in 2018. cosmetic 1 2021 dentistry 37

| industry news “The perfect match between simplicity and aesthetics offers the clinician several beneﬁts” An interview with Dr Adham Elsayed By Brendan Day, Dental Tribune International In this interview, Dr Adham Elsayed, certiﬁed specialist in dental prosthodontics and implants and clinical and scientiﬁc manager at Kuraray Noritake Dental, details the beneﬁts of the company’s new CLEARFIL MAJESTY ES-2 Universal composite and explains its application in the daily dental workﬂow. Though dentists are becoming increasingly special- ised, there’s a growing demand for products that can be used for all indications. How does CLEARFIL MAJESTY ES-2 Universal ﬁt this model? First, we need to explain the meaning of the term “universal” in this context. Previously, there have been Dr Adham Elsayed 38 cosmetic dentistry 1 2021

industry news | product that can change the deﬁnition of the univer- sal composite. CLEARFIL MAJESTY ES-2 Universal incorporates several attributes from the well-established ES-2 and ES Flow, including Kuraray Noritake Dental’s light diffusion technology (LDT). Speaking of LDT—how does this technology beneﬁt the composite? LDT allows the material to scatter and reﬂect light rays at many different angles, which, in turn, allows the com- posite restoration to diffuse light in a similar way to the surrounding tooth structure. Hence, it eliminates aes- thetic problems like the visibility of restoration and prepa- ration borders. Thanks to innovative LDT, optimal particle ﬁllers and opacity, CLEARFIL MAJESTY ES-2 Universal blends seamlessly with the surrounding tooth struc- ture and emulates natural teeth, eliminating the need for shade selection. As you mentioned, CLEARFIL MAJESTY ES-2 Universal comes with one shade for posterior restorations and two for anterior restorations. Can such a reduced shade range still truly deliver aesthetic restorations? CLEARFIL MAJESTY ES-2 Universal is not the ﬁrst composite on the market with a reduced shade system. However, we can safely say that it is the ﬁrst to focus on aesthetics and not just on reducing the number of shades. two types of composites that differ according to the area of application: anterior composites, used in Class III, IV and V restorations where the aesthetic outcome is the priority, and posterior composites, in which the mechan- ical properties like strength and wear rate are more im- portant. Universal composites, then, are those that can be used for all types of restorations in the anterior as well as the posterior region. Another way in which “universal” can be considered is in relation to shade. In this case, the term is used to de- scribe a restorative composite system that exists in fewer shades, one that can adapt to the tooth structure inde- pendent of the colour of the tooth. A major beneﬁt of this type of composites is that it offers a simpliﬁed workﬂow. CLEARFIL MAJESTY ES-2 Universal is essentially univer- sal in both meanings: it is one system that can be used for posterior and anterior restorations, and it is also provided in only three shades—one for posterior, and two for anterior. Universal products, whether they are luting cements, bonding agents or composites, are attractive to dentists as long as they offer simpliﬁcation of the treatment procedure without compromising quality and durability. How does CLEARFIL MAJESTY ES-2 Universal build upon the success of the CLEARFIL MAJESTY range? The CLEARFIL MAJESTY family is very well established at this stage. It includes such products as CLEARFIL MAJESTY Posterior, one of the most popular posterior composites owing to its superior mechanical properties and minimal polymerisation shrinkage. CLEARFIL MAJESTY ES-2 is an extensive system that is highly beneﬁcial thanks to its outstanding optical properties and ability to produce high-end aesthetics in the anterior region using Kuraray Noritake Dental’s multilayering technique. The three ﬂow- able alternatives of CLEARFIL MAJESTY ES Flow, with different consistencies, are also other successful mem- bers of the family. Kuraray Noritake Dental now continues the success story of CLEARFIL MAJESTY with the latest innovative cosmetic 1 2021 dentistry 39

| industry news We know from experience that using one-shade com- posite systems in the anterior region mostly leads to unsatisfying aesthetic results, even with the use of an opaquer composite to reduce shade-matching interfer- ence. This is due to the fact that trying to provide one shade for all posterior and anterior restorations, and for all tooth shades, compromises the aesthetic to a high extent. In other words, using a highly translucent mate- rial to try to match all restorations and shades will result in the interference of other objects in the mouth, such as the tongue, gingivae and so on. “There is no need for exact shade selection (...), and there is also a reduced amount of material stock needed.” Kuraray Noritake understood this fact well and solved the problem by introducing three shades with trans- lucencies designed to match speciﬁc indications. It is important to note the simplicity of the workﬂow, since only one syringe per restoration is required. This makes CLEARFIL MAJESTY ES-2 Universal a true game-changer, as it provides the perfect match between simplicity and aesthetics. What other advantages does this new composite deliver? Other advantages include the superior mechanical prop- erties for which the CLEARFIL MAJESTY family is already known, such as favourable wear properties, low shrink- age stress and high strength. It can be polished easily and retains its gloss. Moreover, the handling of the mate- rial is a huge advantage: this includes a long working time of about 270 seconds under ambient light. It is non-sticky and can be sculpted easily. Which dental professionals would beneﬁt most from this product? The perfect match between simplicity and aesthetics offers the clinician several beneﬁts. It delivers a very straightforward time-saving procedure without com- promising aesthetic results. There is no need for exact shade selection, thereby excluding visible errors of non- matching shades, and there is also a reduced amount of material stock needed. Therefore, in my opinion, this should be the product of choice for most cases in every- day practice. Advances and developments in dental materials are rap- idly accelerating, and clinicians should integrate these innovations and make their daily practice more efﬁcient with simpliﬁed workﬂows, time-saving procedures, fewer material selections and, accordingly, less technique sen- sitivity and less need for dental practice personnel to become acquainted with an abundance of materials. 40 cosmetic dentistry 1 2021

industry news | Simpliﬁed posterior restoration— eliminating shade selection Dr Piotr Marchewka, Poland 1 4 2 5 3 6 Fig. 1: Initial situation. Carious lesions were detected on the occlusal and palatal surfaces of the ﬁrst molar, and on the distal aspect of the second premolar. A dental dam was placed for moisture control. Fig. 2: Appearance of the teeth after caries removal, selective etching of the enamel, and application of CLEARFIL SE BOND 2. Fig. 3: Sectional matrix in place. It is used to facilitate the creation of proper interproximal contact. Fig. 4: Occlusal view of the ﬁnal restorations produced with CLEARFIL MAJESTY ES-2 Universal. Fig. 5: Mesioocclusal view of the ﬁnal restorations. The surfaces were polished with Kuraray Noritake Dental polishing discs. Fig. 6: Distoocclusal view of the restored teeth. Efﬁciency is an important factor when it comes to restoring posterior cavities with resin composite. It may be achieved by selecting a material that eliminates the need for shade selection and by the use of simpliﬁed layering techniques, for example. In the clinical case depicted in this article, a maxillary ﬁrst molar and second premolar were restored with CLEARFIL MAJESTY ES-2 Universal (U) (Kuraray Noritake Dental) using the single-shade technique. contact Dr Piotr Marchewka STOMATOLOGIA PIOTR MARCHEWKA ul. Olszty ´nska 25 63-400 Ostrów Wielkopolski Poland 7 8 Fig. 7: Palatoocclusal view of the ﬁnal restorations. Fig. 8: Final situation after dental dam removal and occlusal adjustments. cosmetic 1 2021 dentistry 41

| feature | feature Sustainable dentistry is a philosophy that offers the best version of ourselves An interview with Dr Primitivo Roig By Monique Mehler, Dental Tribune International Dr Primitivo Roig from Spain is a dentist who combines his clinical practice with a great dedication to the dissem- ination of knowledge about management in dentistry and with the promotion of a vision of efﬁcient, science-driven and ethical dental management. His main objective is to im- prove the quality of service provided to patients. He is also very passionate when it comes to sustainability in the den- tal sector. In an interview with Dental Tribune International, Roig shared his opinion on where he thinks the profession stands when it comes to practising eco-friendly dentistry. Dr Roig, what do you think the position of dentistry is at the moment regarding eco-friendly dentistry? Is there more that needs to be done, or do you feel like a great deal has changed already? Undoubtedly, there is a growing awareness of the need for a more sustainable and environmentally friendly approach to dentistry. The current pandemic has provided an op- portunity for all of society to reﬂect on the way in which we live and work across all professions and settings. Dentistry has not been an exception, and increasingly more profes- sionals have realised the importance and critical need to continue doing what we love to do—but in a different way. In my opinion, the change is only just beginning, and there are other industries and professionals who are way ahead of us. Changing the mentality of the profession as a whole and of all its members is the ﬁrst step, and this has already begun. Of course, like in other professions, there will be professionals who are less interested in this change, and it will be the job of those who are more visionary and committed to motivate and convince the rest that it is possible and very beneﬁcial for everyone to prioritise more eco-friendly dentistry without having to sacriﬁce his or her professional growth, innova- tion and the proﬁtability of his or her professional practice. FDI World Dental Federation accounts sustainability as a core principle of dentistry which “must be practised ethi- cally, with high levels of quality and safety, in the pursuit of optimal oral health”. What do you think of this statement? This is a fundamental statement. Quality of care, patient safety, and professional and people-oriented values are the For Dr Primitivo Roig, management and leadership skills are the best complement to good clinical practice, an added value for patients and an ally for the success of all professionals. (All images: © Primitivo Roig) 42 cosmetic 42 cosmetic dentistry 1 2021

feature | feature | basis of excellence. In a world where the focus seems to be primarily on technology and technique, it is important to remember the fundamental pillars of dentistry and the service provided to each patient. Sometimes the glamour or attractiveness of new developments can take us away from the fundamentals. We need innovation, we need mar- keting, and we need technological evolution, but none of these contributions will be proﬁtable if they are not applied to sustainable, ethical, safe and quality dentistry. In other words, no icing on the cake will add value to our profession if we neglect our core business. What does sustainability in dentistry mean to you per- sonally? It means doing what I enjoy doing most in a way that is respectful not only to the environment but also to people. For me, that means taking care of the natural environment as well as the working environment of my clinic and taking care of my patients as well as my team and myself. For me, sustainable dentistry does not simply boil down to a green approach but to a whole philosophy that seeks to offer the best version of our services and ourselves over time, while also having a positive impact on everything around us. Excellence in dentistry should not only be limited to what we do within the oral cavity, nor should it be justiﬁed at any price. Excellence should also encompass everything that happens in the clinic and the impact our work has on soci- ety. Excellence must be accessible to the patient, proﬁtable for the professional and sustainable for the environment. If it is not accessible, we cannot provide patients with our high-quality care; if it is not proﬁtable, we will not be able to expand our service over time or continually re-invest in improvements; and if it is not sustainable, we will punish others and, in turn, ourselves with a more toxic and harm- ful world and work environment. What are the measures you have implemented in your practice that contribute to a greener future? I would like to clarify in my answer that, for me, the green aspect is just another pillar in a different way of practising dentistry. Sustainable dentistry must be more respectful to the environment as well as to people and their physical and mental well-being. In our clinic, we have implemented an entire philosophy and management model that includes several measures. In terms of the environment: use of recyclable and eco-friendly mate- rials in all possible processes; reduction of plastic as much as possible; recycling of waste; elimination of paper thanks to complete digitalisation in management and communication tools; and organisation of the agenda with a slow approach that reduces patient visits to the ofﬁce and therefore reduces environmental pollution and the use of resources. And in terms of personal care: work schedules that are compatible with work–life balance; organisational charts with deﬁned roles; individual professional development and support programmes; periodic networking and motivation sessions; thorough monitoring of patient and professional satisfaction through evaluation tools; and periodic produc- tivity, quality and proﬁtability analyses. In my opinion, a professional who does not know how to take care of his or her practice, his or her team or him- or herself will hardly be able to take care of the environment. That is why, in our model, we pay special attention to making the change towards a greener dentistry by changing our way of working and our style of living. “[Sustainability] means doing what I enjoy doing most in a way that is respectful not only to the environment but also to people.” How would you say your colleagues are adapting to such measures? And what advice would you give a colleague who is hesitant about implementing them or to someone who is not fully convinced of the effects of climate change? I like to think that, by now, there is no one who is not con- vinced of the effects of climate change. I think it is not a question of being convinced about the problem but rather about ﬁnding the solution and our role in it. There are many who know the problem and few who know the solution. This is not a problem for a few, and therefore, the solution is not reserved for the minority. I think the main challenge lies in the fact that we, as profes- sionals, must slow down the pace of our work and lifestyle so that we can take better control of our agendas and give ourselves the opportunity to be able to perform with much greater calmness and awareness. I like to say that we live in a very fast world, so living slower will help us to take better care of everything and everyone. Each person must know that his or her contribution, no matter how small, adds up to the common mission. I am totally convinced that there is a much brighter, much more enriching and much more beneﬁcial way of dentistry for everyone. Presently, there is no ofﬁcial body that governs what green dentistry really means. It is an optional step to take for dental professionals. Do you think there should be laws in this regard in order to enforce change? Any organisation or project aimed at improving dentistry should always be welcomed. However, in my personal cosmetic cosmetic 1 2021 dentistry 43 43

| feature Dr Primitivo Roig currently leads dentalDoctors, an organisation specialising in training related to clinical management and leadership. He is a guest lecturer at the Harvard School of Dental Medicine in Boston in the US and combines teaching with clinical practice at his own clinic. He is also the founder of Clínicas W, the ﬁrst network of dentists and dental clinics based on the Slow Dentistry method. opinion, I am not really convinced that green dentistry should be championed by a speciﬁc body. Although it would be a great contribution if it existed, I think that the change should rather be led by regulatory bodies, univer- sities and institutions already in existence. Undoubtedly, I think they are the ones who should motivate the change by regulating professional practice in order to facilitate a change that is certainly necessary and beneﬁcial. Dentistry and dental professionals should never be a problem for anyone or anything; on the contrary, we should set an example and be part of the solution. Why then do we not pay sufﬁcient attention to an aspect as important as the impact made by our profession? It is not easy, and one cannot always set an example, but trying “For some, it is not important to do more, but to do better, and that is the best motivation to continue channelling excellence towards a much more sustainable model.” to improve every day and striving to contribute increases the reward of practising dentistry. Is there anything else you can think of that I haven’t covered? We live in a fast-paced world, where multitasking, uncon- trolled speed, stress, the need to be in multiple places at once and the lack of time can be considered as some of the viruses that almost no one talks about. Slowing down the pace of work in search of a greater balance where calmness and control gain ground over stress and chaos is possibly the greatest challenge we are facing and the greatest need we have in order to achieve a more sustainable dentistry. There are many ways to refer to the model of dentistry which I call Slow Dentistry. We were global pioneers in developing a method inspired by the Slow movement and this has helped us channel excellence regarding the professional, the patient and the environment in a much more sustainable way. The Slow movement has been in motion for many years, and dentistry is, and should be, a participant in a global movement shared with such diverse industries as fashion, gastronomy, health, education, tourism and lifestyle. For some, it is not important to do more, but to do better, and that is the best motivation to continue channelling excellence towards a much more sustain- able model. 44 cosmetic dentistry 1 2021

| meetings FDI World Dental Congress 2021 will be held online By FDI World Dental Federation The Australian Dental Association and FDI have an- nounced that they will present a completely virtual special edition of the World Dental Congress (WDC) from 26 to 29 September. Owing to COVID-19 travel restrictions, the congress has been moved fully online for the ﬁrst time. This virtual congress, broadcast from International Con- vention Centre Sydney, will offer streamed live sessions as well as pre-recorded on-demand presentations. The latter will be available for 60 days after the congress. WDC 2021 programme and exhibition Congress participants will have more than 200 continuing education scientiﬁc sessions to choose from, and speak- ers will come from Africa, America, Asia, Australia, Europe, the Middle East and New Zealand. Participants will be able to interact with the speakers and ask questions in real time. The industry exhibition will be held through the same virtual event platform, ensuring a seamless experience that will enable participants to engage with exhibitors and view product demonstrations. All regular FDI business meetings and the General Assembly will also be held on this virtual platform. “This special edition of the FDI World Dental Congress 2021 Sydney offers us a unique opportunity to showcase the value of our wide-ranging list of speakers and unparal- leled continuing education offerings. Although this will be a 100% virtual event, the quality will reﬂect the high cal- ibre we expect from every FDI World Dental Congress. Attendees will be able to navigate between scientiﬁc sessions and the industry exhibition with ease and con- nect with colleagues in real time. Because the event is no longer limited to a strict time schedule, participants will have the ﬂexibility to attend as many sessions as they would like,” the organisation stated. Abstract submissions The time window for abstract submission is scheduled to run for a slightly shorter period this year and will only be open until 15 April. Authors are advised to carefully review the submission guidelines (available online) and may sub- mit abstracts for oral presentations and posters in the fol- lowing categories: general dentistry; preventive dentistry; dental treatment and restorative dentistry; and oral surgery, medicine and cancer. Info: www.world-dental-congress.org 46 cosmetic dentistry 1 2021 © Rudy Balasko/Shutterstock.com

| submission guidelines m o c . k c o t s r e t t u h S / s l i e x p 2 3 © How to send us your work? Please note that all the textual compo- nents of your submission must be com- bined into one MS Word document. Please do not submit multiple ﬁles for each of these items: the complete article; · · all the image (tables, charts, photo- · · graphs, etc.) captions; the complete list of sources consulted and the author or contact information (bi- ographical sketch, mailing address, e-mail address, etc.). In addition, images must not be embed- ded into the MS Word document. All im- ages must be submitted separately, and details about such submission follow be- low under image requirements. Text length Article lengths can vary greatly—from 1,500 to 5,500 words—depending on the subject matter. Our approach is that if you need more or fewer words to do the topic justice, then please make the article as long or as short as necessary. We can run an unusually long article in multiple parts, but this usually entails a topic for which each part can stand alone because it contains so much in- formation. In short, we do not want to limit you in terms of article length, so please use the word count above as a general guideline and if you have speciﬁc questions, please do not hesitate to contact us. Text formatting Please use single spacing and make sure that the text is left justiﬁed. Please do not centre text on the page. Do not indent paragraphs, rather place a blank line be- tween paragraphs. Please do not add tab stops. Should you require a special layout, please let the word processing pro- gramme you are using help you do this formatting automatically. Similarly, should you need to make a list, or add footnotes or endnotes, please let the word process- ing programme do it for you automatically. There are menus in every programme that will enable you to do so. The fact is that no matter how carefully done, errors can creep in when you try to number footnotes yourself. Any formatting contrary to stated above will require us to remove such formatting before layout, which is very time-consum- ing. Please consider this when formatting your document. Image requirements Please number images consecutively throughout the article by using a new number for each image. If it is imperative that certain images are grouped together, then use lowercase letters to designate these in a group (for example, 2a, 2b, 2c). Please place image references in your article wherever they are appropriate, whether in the middle or at the end of a sentence. If you do not directly refer to the image, place the reference at the end of the sentence to which it relates enclosed within brackets and before the period. In addition, please note: We also ask that you forego any special formatting beyond the use of italics and boldface. If you would like to emphasise certain words within the text, please only use italics (do not use underlining or a larger font size). Boldface is reserved for article headers. Please do not use un- derlining. · We require images in TIF or JPEG for- · · mat. These images must be no smaller than 6 x 6 cm in size at 300 DPI. These image ﬁles must be no smaller than 80 KB in size (or they will print the size of a postage stamp!). Larger image ﬁles are always better, and those approximately the size of 1 MB are best. Thus, do not size large image ﬁles down to meet our requirements but send us the largest ﬁles available. (The larger the starting image is in terms of bytes, the more leeway the designer has for resizing the image in order to ﬁll up more space should there be room available.) Also, please remember that images must not be embedded into the body of the article submitted. Images must be submitted separately to the textual sub- mission. You may submit images via e-mail, via our FTP server or post a CD contain- ing your images directly to us (please contact us for the mailing address, as this will depend upon the country from which you will be mailing). Please also send us a head shot of your- self that is in accordance with the re- quirements stated above so that it can be printed with your article. Abstracts An abstract of your article is not re- quired. Author or contact information The author’s contact information and a head shot of the author are included at the end of every article. Please note the exact information you would like to ap- pear in this section and format it accord- ing to the requirements stated above. A short biographical sketch may precede the contact information if you provide us with the necessary information (60 words or less). Questions? Magda Wojtkiewicz (Managing Editor) m.wojtkiewicz@dental-tribune.com 48 cosmetic dentistry 1 2021

| international imprint Imprint Publisher and Chief Executive Ofﬁcer Torsten R. Oemus t.oemus@dental-tribune.com Editor-in-Chief Dr Sushil Koirala drsushilkoirala@gmail.com Managing Editor Magda Wojtkiewicz m.wojtkiewicz@dental-tribune.com Designer Franziska Schmid Copy Editors Sabrina Raaff Ann-Katrin Paulick Editorial Board Dr Valerio Bini (Italy) Asst. Prof. Pavinee P. Didron (Thailand) Dr Dinos Kountouras (Greece) Dr Florin Lazarescu (Romania) Dr José Roberto Moura (Brazil) Prof. Akira Senda (Japan) International Administration International Headquarters Chief Financial Ofﬁcer Dan Wunderlich Chief Content Ofﬁcer Claudia Duschek Clinical Editors Nathalie Schüller Magda Wojtkiewicz Editors Franziska Beier Jeremy Booth Brendan Day Monique Mehler Iveta Ramonaite Executive Producer Gernot Meyer Advertising Disposition Marius Mezger Art Director Alexander Jahn Dental Tribune International GmbH Holbeinstr. 29, 04229 Leipzig, Germany Tel.: +49 341 48474-302 Fax: +49 341 48474-173 General requests: info@dental-tribune.com Sales requests: mediasales@dental-tribune.com www.dental-tribune.com Ofﬁcial publication of: Printed by Löhnert Druck Handelsstraße 12 04420 Markranstädt, Germany Copyright Regulations All rights reserved. © 2021 Dental Tribune International GmbH. Reproduction in any manner in any language, in whole or in part, without the prior written permission of Dental Tribune International GmbH is expressly prohibited. Dental Tribune International GmbH makes every effort to report clinical information and manufacturers’ product news accurately but cannot assume responsibility for the validity of product claims or for typographical errors. The publisher also does not assume responsibility for product names, claims or statements made by advertisers. Opinions expressed by authors are their own and may not reﬂect those of Dental Tribune International GmbH. 50 cosmetic dentistry 1 2021

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