DeNtal tribuNe | January-March, 2010 and desires of the patient are explored. The primary goal of this first step is a better patient– dentist understanding. As the aesthetic perceptions of the dentist and the patient may differ, it is imperative to understand the subjective aesthetic perception of the patient. Various types of questions, personal interviews and visual aids can be used as supporting tools. In this step, the practitioner should Fig 2 trends & applications 17 health, function and aesthetics as follows: Grade A: The established parameters of oral health, function and aesthetics are within normal limits and aesthetic enhancement is required only to fulfil the patient’s cosmetic desires. Grade B: The established parameters of oral health and function are within normal limits; however, the aesthetic parameters are below the accepted level. Aesthetic enhancement can further improve the aesthetic parameters. Grade C: The established parameters of oral health or Next, diseases, force elements and aesthetic defects of smile are explored. Information on the medical and dental history, general health and specific health (oral-facial) of the patient is collected and complete dental and periodontal charting is performed. In order to understand the force elements, the existing occlusion, comfort, muscular activity, speech and phonetics are thoroughly examined with the evaluation of para-functional and other oral habits, comfort during mastication and deglutition, and temporo-mandibular joints (TMJ) movements. The necessary diagnostic tests, photographic documentation and the diagnostic study models are prepared during this step for the further exploration of existing diseases, force elements and aesthetic defects. The patient’s PHFA factors are the four fundamental compoIn the following step, the data collected is analysed in relation to the accepted normal values of a patient’s sex, race and age (SRA) factors. The aesthetic components of the smile are analysed in detail grouped into macro-(facial and dental midline relation, facial profile, symmetry of the facial thirds and hemi-faces), mini(visibility of upper anterior teeth, smile arc, smile symmetry, buccal corridor, display zone, smile index and lip line) and micro-aesthetics (dental: central dominance, teeth proportion, axial inclination, incisal embrasure, contact-point progression, shade progression, surface texture; gingival: shape, contour, embrasure and zenith height). The practitioner can now grade the smile in terms of the patient’s nents of aesthetic dentistry 18 cations, treatment limitation, and tentative costs should be established during this step. For easy application, the aesthetic treatments in MICD are categorised as follows: Type I: Micro-aesthetic components; Type II: Mini-aesthetic components; and Type III: Macro-aesthetic components: facial and dental midline relation, facial profile, symmetry of facial thirds and hemi-faces. As the treatment modality depends on the professional capability and experience of the practitioner, simple and practical methods are used to ask the patient to complete the MICD self smile-evaluation 3. reduction of treatment fear and increased patient confidence; 4. promotion of trust and enhancement of professional image. form. The information obtained will help estimate the perceived smile aesthetic score (a-score) and will be used as the base-line data in the evaluation step. to be adequately addressed during aesthetic treatment.17 MICD deals both with subjective and objective issues. Therefore, in this article I define MICD as “a holistic approach that explores the smile defects and aesthetic desires of a patient at an early stage and treats them using the least intervention options in diagnosis and treatment technology by considering the psychology, health, function and aesthetics of the patient.”18 The core MICD principles are: 1. application of the-soonerthe-better approach and exploration of the patient’s smile defects and aesthetics desires at an early stage in order to minimise invasive treatments in the future; 2. smile design in consideration of the psychology, health, function and aesthetics (Smile Design Wheel18) of the patient; 3. adoption of the do-no-harm strategy in the selection of treatment procedures and the maximum possible preservation of healthy oral tissues; 4. selection of dental materials and equipment that support MI treatment options in an evidence-based approach; 5. encouragement of the keepin-touch relationship with the patient to facilitate regular maintenance, timely repair and strict evaluation of the aesthetic work performed. The main MICD benefits include: 1. promotion of health, function and aesthetics of the oral tissues and positive impact on the quality of life of the patient; 2. preservation of sound tooth structures (banking the tooth structure), while achieving the desired aesthetic result; The MICD treatment protocol In my experience, the TPs that are currently in use in aesthetic dentistry are mostly based on more invasive techniques and procedures. With the use of such protocols, cosmetic dentists are knowingly, or unknowingly, heading towards the overutilisation of invasive technologies in their practices, which is becoming a professional and ethical concern. The basic aim of the MICD TP is to guide practitioners in achieving optimum results with as little intervention as possible. The intervention level of the treatment in MICD depends on the type of smile defects and the aesthetic needs (objective measurement and subjective perception) of the patient. The basic framework and pathway of the MICD TP are illustrated in Figures 2 and 3. It is to be noted that the TP in medical and dental sciences must be dynamic in nature and should be flexible to incorporate evidence-based facts. I have therefore outlined the MICD core principles that are required to achieve the optimum result in terms of health, function and aesthetics with minimum intervention and optimal patient satisfaction. However, it is the practitioner’s duty to incorporate all the necessary guidelines, protocols and regulations of the authority concerned (state or affiliated professional organisations) into the MICD TP. Phase I: Understand In the first step of Phase I, the perception, lifestyle, personality, function or both are below the normal limits. An Fig 3 establishment treatment is mandatory prior to aesthetic enhancement. categorise the MICD treatment complexity: Grade I: Treatment that may require consultation with a specialist (preventive, simple oral surgery/endodontics/periodontics/implants, short orthodontics); Grade II: Treatment that requires the procedural involvement of other dental specialists (complex endodontics/periodontics/orthodontics) but not oral and maxillofacial surgery or plastic surgery; and Grade III: Treatment that requires the procedural involvement of oral and maxillofacial surgery or plastic surgery. With the aid of this simple grading system, any practitioner can determine the complexity of the treatment involved for the accomplishment of a new smile design for an individual patient and can plan for the necessary multidisciplinary support. The last step of this phase is the most important in MICD TP because in this step the patient is presented with an image of his or her future smile. Visual aids, such as a smile catalogue, aesthetic mock-ups, manual From the above, the practitioner will obtain a smile aesthetic grading in terms of the patient’s health, function and aesthetics, as well as a complete overview over the smile aesthetic problems and the macro-, mini- and micro-smile defects. and must be respected to achieve healthy, harmonious and beautiful smiles. The design step depends on the information obtained from exploration and analysis. The information on psychology is subjective in nature; however, health, function and aesthetic analysis provides the objective information that will guide the design with the various established and basic principles of smile aesthetics and also the feasible & practical extent of the aesthetic desires of the patient. The aesthetic mock-up, manual tracing, digital makeover and smile catalogues are some of the popular tools used in this step. A new smile, alternative designs, types of treatments involved, complexity, possible risk factors and compli-