18 trends & applications methods are given, as well as protective devices. Selfcare should focus on regular tooth brushing, flossing, the use of prescribed protective devices and other pertiFig. 4a: Gummy smile with lack of upper central dominance. Fig. 4b: Harmonised smile with proper central dominance. Treated with MI approach. DeNtal tribuNe | January-March, 2010 Table 1: MICD treatment options NI treatment options Smile training Tooth whitening Re-mineralisation of white spots Short orthodontics (sectional) MI treatmet options Micro- and macro-abrasion Selective contouring (gums/teeth) Direct restorations with minimal tooth preparation Minimal Preparation Adhesive Brigdes Non-preparation veneers Enamel augmentation Adhesive pontic (long-term temporary restoration) Oral appliance Veneers, inlays and onlays MI implants nent professional advice for maintaining general health. Professional care: The oral habits, health of the oral tissues, and the functional and aesthetic status of the work preformed are well documented during each follow-up visit, and neces– Professional factors: existing knowledge and skills, and attitude towards developing these. Detailed clinical documen- sively in every field of the dentistry. For this reason, I have explained the MICD concept and its TP, which integrates the evidence-based MI philosophy into aesthetic dentistry, in the hope that it will help practitioners achieve optimum results in terms of health, function and aesthetics with minimum treatment intervention and optimum patient satisfaction. Fig. 5a: Smile after establishment treatment. Fig. 5b: Smile aesthetic enhancement with non-invasive veneers treatment. sary maintenance repair jobs are carried out. sketches, modified digital pictures, computer-designed make overs or animations can be used as presentation tools. The results of the design step are systematically presented to the patient with professional honesty and ethics. All pertinent queries of the patient related to the proposed smile need to be addressed during presentation. The treatment complexity, its limitations, the risks involved, possible complications, treatment cost estimation and maintenance responsibility must properly be explained to the patient. The patient is thus involved in finalising the treatment plan and will sign the written informed consent form before proceeding to Phase II. Phase II: Achieve As per the TP, which is finalised during the presentation step, all necessary preventive interceptive and restorative (curative) dental treatments are conducted in order to establish the proper health and function of the oral tissues. Owing to the complexity of the treatment, a multidisciplinary approach may be necessary for a good result. Once the case is stable in terms of health (controlled disease) and function (balanced force elements) with good oral habits, the patient is requested to re-evaluate his or her smile in terms of aesthetics with the help of the MICD self smile re-evaluation form. This is important, because in some cases the patient is fully satisfied with the results of the establishment step alone and may modify his or her idea of further aesthetic enhancement. In MICD TP it is considered unethical should the practitioner not collect self smile re-evaluation information from the patient. The enhancement step of MICD is focused on the fulfilment of the patient’s aesthetic desires, which can be grouped into two categories based on the patient’s needs and wants. Even though it is sometimes difficult to draw a clear line between the two & their related treatment, in MICD they are categorised as follows: needs: objective restorative needs of the patient in harmony with the SRA factors and due emphasis on health and function of oral tissues (naturo-mimetic smile enhancement) wants: subjective desires of the patient, which may not be in harmony with the SRA factors (cosmetic smile enhancement) During aesthetic any want-based where Evaluation is the final step of MICD TP. Any ‘completed’ treatment without a proper evaluation is considered incomplete in MICD protocol. The following components need to be evaluated: Global patient satisfaction: After receiving aesthetic dental treatment, the patient is requested to complete the MICD exit form, in which the patient evaluates his or her new smile, gives a second perceived smile aesthetic score (b-score), and indicates his or her global satisfaction score. The b-score is compared with the previous a-score. This process helps determine the patient’s actual satisfaction status. In MICD, this is the main parameter for evaluating a patient’s aesthetic satisfaction. Clinical success: Clinical success is a multifactorial issue. Selection of proper cases (the patient), restorative materials, TPs and their correct and skilful application are the key factors for clinical success. Therefore, MICD TP suggests selfevaluation of the following four factors (4Ps) using the Phase III: Keep in touch Regular maintenance, compliance and timely repair play a crucial role in the long-term success of aesthetic enhancement procedures. Hence, MICD emphasises the keep-in-touch concept and encourages patients to go for regular follow-up visits. Responsibility for maintenance is grouped into two categories: Self-care: Patients are advised to continue their normal oral hygiene procedures. If necessary, special care and precautionary – – – MICD clinical evaluation form: Patient factors: regular maintenance status, compliance issues and attitude of the patient towards aesthetic treatment; Product factors: bio-compatibility, mechanical and aesthetic quality of the products treatment; Protocol factors: TP used in terms of its simplicity, predictability & its evidencebased nature; used for the treatment, tation of the case during maintenance and evaluation can provide various cues to the practitioner in the evaluation of his or her clinical success in terms of case planning, material and protocol selection, as well as his or her existing restorative skills. I believe that a thorough evaluation can support any practitioner in initiating practice-based research and keeping up-to-date with the recent trend of evidence-based dentistry (Figs. 4a–5b). Acknowledgements In formulating the MICD TP, I discussed the concept with several national and international colleagues in order to ensure that it is simple, practical and comprehensive. I would like to extend my gratitude to Dr Akira Senda (Japan), Dr Didier Dietschi (Switzerland), Dr Hisashi Hisamitsu (Japan), Dr Oliver Hennedige (Singapore), Dr Dinos Kountouras (Greece), Dr Mabi L. Singh (USA), Dr Ryuichi Kondo (Japan), Dr SoRan Kwon (Korea), Dr Prafulla Thumati (India), Dr Vijayaratnam Vijayakumaran (Sri Lanka), as well as Dr Suhit R. Adhikari, Dr Rabindra Man Shrestha, Dr Binod Acharya and Dr Dinesh Bhusal valuable of Nepal, for their advice comments, MICD treatment modalities Various MICD. types are Their of treatment in use modalities available effective depends on the level of smile defects, type of smile design, proposed treatment type and the treatment complexity grade. There is only one principle in selecting treatment modalities in MICD: always select the least invasive procedure as the choice of the treatment. The two categories of MICD treatment are NI and MI treatment (Table 1). However, conventional invasive treatment modalities may also be required, depending on the complexity of the case. healthy oral tissue is treated with no direct benefit to health or function, the treatment modalities should be within the scope of non-invasive (NI) or MI procedures.19 The patient’s cosmetic desires alone should not be the rational for the treatment. 20 and feedback. DT References available on request. Do no harm! should always be the credo pertinent to all dental treatment procedures. About the author Conclusion MI dentistry was developed over a decade ago by restorative experts and founded on sound evidence-based principles.21–30 In dentistry, it has focused mainly on prevention, re-mineralisation and minimal dental intervention in caries management and not given sufficient attention to other oral health problems. I believe that the MI philosophy should be the mantra adopted comprehenDr. Sushil Koirala is the founding president of the Vedic Institute of Smile Aesthetics and maintains a private practice focusing primarily on MI cosmetic dentistry (MICD). He can be contacted at skoirala@wlink.com.np.