01-12 FDI 2015 Annual World Dental Congress, Bangkok

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Skillful treatment planning key to successful Implant practice:Experts

SEPTEMBER, 2015 - Issue No. 05 Vol.2

Smile analysis and photoshop smile design technique Page 4

IMPLANT CONFERENCE

4 sessions of Implantology course held in Karachi

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CLINICAL PRACTICE

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‘DENTISTRY IN THE 21ST CENTURY’

PMDC REWARDS

FDI 2015 Annual World Dental Congress, Bangkok

Students to pay more after PM&DC rewards private colleges for their good performance

DT Pakistan Report ANGKOK - Bangkok is all set to host the 2015 FDI Annual World Dental Congress from 22-25 September 2015 at the Bangkok International

scientific session exceeding 90, scientific posters reaching 500 mark and with 150 high profile speakers from around the globe this event is the largest FDI in

event here in Pakistan as FDI media partner. It is also a proven platform for global education, communication and development. FDI 2015 in

dentists, about 5,800 per head of population. This represents a rapid increase in supply from the 2007 ratio of 7,300 php, quoted in FDI's Oral Health Atlas (2009).

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SLAMABAD - The recent notice for grading of institutions by Pakistan Medical and Dental Council (PM&DC) reference PID (1) 775/15 has graded colleges as category A and B. The category A colleges have been prompted to

“PM&DC's Good performance reward to be paid by medical Students” Trade & Exhibition Center (BITEC) a highly acclaimed exhibition venue, accessible from Bangkok itself by the renowned Skytrain. The theme of the congress this year is 'Dentistry in the 21st Century'. With 12000 visitors expected to attend the forthcoming event, more than 255 exhibitors,

terms of speakers in the past 5 years. Approximately 200 participants are travelling from Pakistan to attend this mega event including the President and office bearers of Pakistan Dental Association. As always Dental News played a pivotal role in registering of participants and promoting the

Bangkok aims to provide all its visitors with the facilities and support to make this a truly productive and memorable experience. With ever growing market in Thailand, the wisdom of the venue choice is visible as according to recent estimates, today the country has a workforce of some 12,000

The FDI President T.C. Wong in her message said that "after our 100th anniversary Hong Kong in 2012, this is the second time in three years that our Federation has demonstrated its confidence in the Asia Pacific region as an area of growth and development in the field of dentistry and the dental sector". Continued on page 04

ORAL HEALTHCARE MARKET SALES DOUBLED DURING 5 YEARS PAST

Market to grow up to 30.4 Billion by 2019 in Pakistan DT Pakistan Report

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ARACHI - Oral care value sales grew by 14 per cent in current value terms to spike its sales to PKR21.2 billion in 2014. Moreover, oral care is likely to grow by a CAGR of 8pc at constant 2014 prices during the forecast period to reach sales of PKR30.4bn in 2019 The reason for its quick rise and attaining a high value is being attributed to huge investments made by multinational and local companies in television and billboard advertisements for creating oral hygiene awareness among consumers. Moreover, urban consumers have also played a significant role in the growth of oral care as they have more education and awareness about

oral hygiene. One of the reasons cited for the growth of oral care by 14pc in current value terms was that oral care companies have been continuously focusing on making doctors and dentists their brand ambassadors. Market research reported that the market expanded by a staggering 117% in the last 5 years. In addition to this, consumers have a vast variety of toothpaste in terms of price and benefits. Another salient feature of the briefing was that Colgate-Palmolive Ltd maintained its lead in oral care with a value share of 49pc in 2014-

2015 followed by Close-Up holding 10% and Sensodyne holding 7% of the market share. The market survey finding articulates that the oral healthcare market has vast potential in the Pakistani market. While the importance of oral health care is being recognized by the public in general due to awareness campaigns being implemented, Dr. Ayyaz Ali Khan - a veteran dentist and head of Institute of Continued on page 12

“PM&DC grading puts private medical & dental colleges out of reach of a common man” increase annual tuition fees by seven per cent for the students getting admission to private medical and dental colleges, thus making it beyond the reach of a common man. These decisions were taken in the 139th session of the council held recently. In a public notice PMDC set mandatory grading requirements. They decided to categorize the recognized Medical & Dental Colleges as A & B. Medical Colleges who have made the list are the ones with 500 bedded own Teaching Hospital, latest treatment facility including MRI & CT Scan and a Nursing College. All others who lack the aforementioned facilities are placed in category B. The meeting also decided that to let category A Private Sector Medical and Dental colleges raise their fees to Rs. 700.000. As for the standalone Dental Colleges the ones with 60 bedded own teaching hospital have been graded as category A with liberty to increase the fee. The council after reviewing its 2013 regulations Continued on page 12

INTERNATIONAL NEWS

2 DENTAL TRIBUNE Pakistan Edition September 2015

Fake Medicines on Sale in Pakistan, Claims US Media -It' s A Crime Against Humanity, Says PMA DT Pakistan Report

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ARACHI - A meeting of Pakistan Medical Association held here at the PMA House took serious notice of the news of an American broadcast in which it was claimed that 45 per cent fake medicines, containing brick powder, paints and insecticide, are being sold in the Pakistani market.These drugs, according the report, are being manufactured allegedly by 4,000 licensed drug manufacturers. It further pointed out that former Interior Minister Rehman Malik has also testified this claim. Taking a strong notice of the news, the PMA meeting said that the people involved in this business are committing a crime against humanity. "These criminals are not only playing with the lives of the people, but also fleecing them by supplying harmful material in the name of drug," it added. The meeting demanded a stern action and exemplary punishment against all those involved in the heinous crime.PMA also

requested the superior judiciary to take a suo motu action against the criminals. The meeting was attended by PMA's (Centre) former president Prof S. Tipu Sultan, secretary general Dr Mirza Ali Azhar, treasurer Dr S.M. Qaisar Sajjad, PMA Karachi chapter president Prof M. Idrees Adhi, general secretary Dr Qazi M. Wasiq, Dr Naseer Baloch, Dr Ahmed Bhimani, Dr Hamid Manzoor, Dr Khalil Mukkadam, Dr Abdul Ghafoor Shoro, Dr Usman Ghani, Dr Najum Feroz Mehmudi.Those who participated in the meeting through video link from different parts of the country included PMA's (Centre)

Publisher/CEO Syed Hashim A. Hasan [email protected] Editor Clinical Research: Dr. Inayatullah Padhiar Editors Research & Public Health Prof. Dr. Ayyaz Ali Khan Editor - Online Haseeb Uddin Designing & Layouting Sh. M. Sadiq Ali

Dental Tribune Pakistan 3rd floor, Mahmood Centre, BC-11, Block-9 Clifton, Karachi, Pakistan. Tel.: +92 21 35378440-2 | Fax: +92 21 35836940 www.dental-tribune.com.pk [email protected] Dental Tribune Pakistan cannot assume responsibility for the validity of product claims or for typographical errors. The publisher also does not assume responsibility for product names or statements made by advertisers. Opinions expressed by authors are their own and may not reflect of Dental Tribune Pakistan.

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president Dr Aziz Ahmed Lehri, president-elect Dr M. Ashraf Nizami, Dr Talha Sherwani, Dr Bashir Ahmed Channa, Dr Izhar Ahmed Chaudhry, Dr Tanveer Anwar, Dr Shahid Malik, Dr Mehr Muhammad Iqbal, Dr Saeed Memon and Dr Pir Manzoor Ali.

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IADSR 2015

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Patient focus treatment need of the hour: Experts

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AHORE - The IADSR conference 2015 began in Lahore with great fanfare. The conference exceeded its targets for both speakers and participants. The conference theme is "Evidence Based Dental Practice; Choosing the best treatment for your patients", is something which is of interest to everybody specially the general dentist. The venue of this academic masterpiece is

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Christiane Ferret Marketing & Sales Services

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Matthias Diessner (Key Accounts) Melissa Brown (International) Antje Kahnt (International) Peter Witteczek (Asia Pacific) Weridiana Mageswki (Latin America) Maria Kaiser (North America) Hélène Carpentier (Europe) Barbora Solarova(Eastern Europe) Executive Producer Gernot Meyer Advertising Disposition Marius Mezger

University of Health Sciences Lahore The highlight of the conference includes routine clinical practice issues from prevention of dental disease to use of antibiotics, recent root canal medicaments to decision between partial dentures and bridges, effectiveness of functional appliances & patient, career counseling backed by pre and post

conference workshops. The conference also features best clinical case Awards named after our legendary dentists which is a laudable beginning for others to follow. The awards are Prof. Dr. B. A Ya z d a n i e Award (Prosthodontics), Prof. Dr. M. S a l e e m C h e e m a Aw a r d (OMFS), Prof. Dr. Haider Tirmazi Award (Orthodontics), Prof. Dr. Mazhar-ul-Haq Award

(Operative Dentistry), and Dr. R i a z S h a f i Q a z i Aw a r d (Comprehensive Dental Care). Prof Ayyaz Ali Khan is the man behind this highly successful academic conference and together with his team including Saima ch, Sumair Farooq, Dr Faisal, Sharea Ijaz, Mohsin Dewan, Nauman Khan , Faiza Awais, Haris Iqbal, Muhammad Suleman Tahir , Arsalan Malik,

Arshad Taqi and shoaib farooq put together this excellent conference. The participants are very impressed and gave positive feedback about the event and the topics it covered. They also appreciated the speakers. The event media partner is Dental News with PM&DC Certified CPD hours for General Dental Practitioners and Specialists attending it.

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IMPLANT CONFERENCE

September 2015 Pakistan Edition DENTAL TRIBUNE 4

Skillful treatment planning key to successful implant practice:Experts DT Pakistan Report ARACHI - The Implant congress Pakistan 2015 organized by Dental News with Baqai Medical University and supported by Pakistan Dental Association and the Oral Diseases Commission of the Asia Pacific Dental Federation concluded at Pearl Continental Hotel Karachi. The congress started with the recitation from the Holy Quran followed by the National Anthem. Earlier the conference started with pre-conference workshop at the AIC Center Karachi conducted by International and renowned Dr Erdem Ozdemir from Turkey.

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Turkey. The jam packed audience were treated to excellent lectures by the learned speakers including Dr Erdem Ozdemir, Prof Navid Rashid, Prof Kashif Ikram, Dr Nadeem Pasha, Dr Sameer Quraeshi, Dr Irfan Qureshi, Dr Khurram Ataullah, Dr Noorul Wahab and Dr Murtaza Kazmi. The congress offered CDE hours by Baqai Medical University and was sponsored by M&C Dental the leading implant company in Pakistan, Helix Pharma

Both the workshop and congress got an overwhelming response and the registration had to be closed beforehand. The congress attracted a galaxy of renowned and distinguished National Speakers from Karachi and Lahore besides an international speaker from

and Chughtai Dental Supplies. The Scientific Committee head and principal Baqai Dental College Prof Dr Kashif Ikram, appreciated Dental News’ efforts for the Implants Conference and also thanked all the speakers for their

valuable contribution. Overall the event provided valuable insight to the dental

Mouth cancer cases on the rise in Sindh DT Pakistan Report

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ARACHI - Civil Hospital Karachi (CHK) Cancer Unit's in charge Dr Naoor Muhammad Soomro said here that mouth cancer cases are on the rise in Sindh, particularly in urban areas, merely because of excessive use of tobacco products. "In fact, mouth cancer cases are more common in the province due to rising trend of chewing chalia, pan, gutka, sheesha, smoking and other tobaccos substance," he added. About breast cancer among women, he said that hormonal imbalance was a major contributing factor in incidents of breast cancer. He said that the CHK's Cancer Unit had provided services to 100,062 cancer patients from 2004 to June 2015, besides registering 8,733 new cancer patients. Giving break-up of the cancer patients registered between 2004 and June 2015, he said that 687 cancer patients were registered in 2004, 630 in 2005, 594 in 2006, 689 in 2007, 750 in 2008, 738 in 2009, 724 in 2010, 692 in 2011, 1,172 in 2012, 829 in 2013, 795 and 433 till June 2015.

fraternity about various aspects of implant dentistry in Pakistan. This international event will be

PM&DC cabinet dissolved by presidential notification Monitoring Desk

Dr Soomro said that of the total 8,733 new cancer patients registered during the period, 5,952 were reported from Karachi, 280 from Hyderabad, 169 Khairpur, 151 from Lasbella, 125 from Larkana, 98 from Mirpurkhas, 95 from Badin, 59 from Dadu, 80 from Nawabshah and 74 from Ghokti. Giving community-wise details of the cancer patients reported at the health facility, he said that 2,747 cancer cases belonged to Sindhi community, 2,395 (Urdu-speaking), 751 (Baloch), 605 (Pashto), 553 (Punjabi), 275 (Memonai), 178 (Hindko), 193 (Gujrati), 164 (Katchi) and 147 Saraiki-speaking community. He said that the CHK's Cancer Unit offers all sorts of cancer treatment facilities free of cost. According to a report, around 0.2 million people become victim of cancer in Pakistan every year and of them between 25,000 and 30,000 are reported from Sindh.

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SLAMABAD - According to media reports, through a presidential ordinance the Pakistan Medical & Dental Council's existing cabinet has been dissolved. It also further states that new elections will be held within 120 days electing a new cabinet to govern the PMDC. The outgoing PM&DC President, Dr Masood Hameed was re-elected in April 2013, and had been much discussed for his cabinet's controversial decisions by the medical and healthcare fraternity. According to the notification, fresh elections are due to take place in the next 120 days to elect the new cabinet for the Pakistan Medical & Dental Council. This had prompted the health ministry to urge the government to issue an ordinance for dissolving the council. PMDC registrar Dr Shaista Faisal confirmed that the council had been dissolved and a new council would be formed through proper procedure.

an annual event for the benefit of the dental fraternity across Pakistan.

FDI 2015 Annual World Dental Congress Continued from front page With ever growing technology around the world, FDI has also introduced an app, called FDI2015, is available to download for free to smartphones and tablets from Apple Store and Play Store The participants can create their own congress programme and itinerary, as well as news, alerts and messaging capabilities, the app features a congress centre floor plan and information on sessions, by type, speaker and subject. The FDI World Dental Federation represents approximately 200 national dental associations and specialist groups. Our vision is to lead the world to optimal oral health and acknowledging oral health as a fundamental part of general health and well-being. Our vision is brought to life by being the global voice for oral health, and delivering excellence in oral health policy and promotion; continuing professional education; and access to care. The FDI's Annual World Dental Congress has always been a unique opportunity to meet leaders of the dental profession from more than one hundred countries, as well as top personalities of the international and national trade and industry. The Annual World Dental Congress and Exhibition is fully supported by the International Dental Manufacturers Association (IDM), the FDI's natural counterpart and partner at the global level."

CLINICAL PRACTICE

6 DENTAL TRIBUNE Pakistan Edition September 2015

Smile analysis and photoshop smile design technique By Prof. Edward A. McLaren, Lee Culp Lee Culp

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Fig. 1: Three altered views of the same THE ROLE OF 42.2 called dento-facial aestheics patient enable analysis of what can be accomplished to enhance facial and smile minus 3 mm gingival dispaly aesthetics. -Fig. 2: Sagittal views best demonstrate which specialists should be involved in tr eatment, whether orthodontists or maxillo facial surgeons, to best aesthetically alter the facial aesthetics.-Fig. 3: Drawing a line along the glabella, subnasale, and pogonion 1 mm dispaly at rest enables a quick evaluation of aesthetics 5 4 without the need for radio graphs to determine alignment of ideal facial elements.-Fig. 4: Evaluating the maxillary incisal edge position is the starting point for establishing oral aesthetics.-Fig. 5:According to the 4.2.2 rule, this patient' s smile is deficient in aesthetic elements, having only 1mm of tooth display at rest (left), minus 3mm of gingival display, and 4 mm of space between the incisal edge and the lower lip (right) ORAL-ESTHETICS(dento-liabial-gingival)- has been

Introduction: Smile analysis and aesthetic design Dental facial aesthetics can be defined in three ways. Traditionally, dental and facial aesthetics have been defined in terms of macro- and micro-elements. Macro-aesthetics encompasses the interrelationships between the face, lips, gingiva, and teeth and the perception that these relationships are pleasing. Micro-aesthetics involves the aesthetics of an individual tooth and the perception that the colour and form are pleasing. Historically, accepted smile design concepts and smile parameters have helped to design aesthetic treatments. These specific measurements of form, colour, and tooth/aesthetic elements aid in transferring smile design information between the dentist, ceramist, and patient. Aesthetics in dentistry can encompass a broad area— known as the aesthetic zone1. Rufenacht delineated smile analysis into facial aesthetics, dentofacial aesthetics, and dental aesthetics, encompassing the macroand micro-elements described in the first definition above2. Further classification

Table I: Components of smile analysis and aesthetic design.

identifies five levels of aesthetics: facial, orofacial, oral, dentogingival, and dental (Table 1)1,3. Initiating smile analysis: Evaluating facial and orofacial aesthetics The smile analysis/design process begins at the macro level, examining the patient’s face first, progressing to an evaluation of the individual teeth, and finally moving to material selection considerations. Multiple photographic views (e.g., facial and sagittal) facilitate this analysis.

At the macro level, facial elements are evaluated for form and balance, with an emphasis on how they may be affected by dental treatment 3,4 . During the macroanalysis, the balance of the facial thirds is examined (Fig. 1). If something appears unbalanced in any one of those zones, the face and/or smile will appear unaesthetic. Such evaluations help determine the extent and type of treatment necessary to affect the aesthetic changes desired. Depending on the complexity and uniqueness of a given case, orthodontics could be considered when restorative treatment alone would not produce the desired results (Fig. 2), such as when facial height is an issue and the lower third is affected. In other cases—but not all— restorative treatment could alter the vertical

dimension of occlusion to open the bite and enhance aesthetics when a patient presents with relatively even facial thirds (Fig. 3). Evaluating oral aesthetics The dentolabial gingival relationship, which is considered oral aesthetics, has traditionally been the starting point for treatment planning. This process begins by determining the ideal maxillary incisal edge placement (Fig. 4). This is accomplished by understanding the incisal edge position relative to several different landmarks. The following questions can be used to determine the ideal incisal edge position: . Where in the face should the maxillary incisal edges be placed? . What is the proper tooth display, both statically and dynamically? . What is the proper intra- and inter- tooth relationship (e.g., length and size of teeth, arch form)? . Can the ideal position be achieved with restorative dentistry alone, or is orthodontics needed? In order to facilitate smile evaluation based on these landmarks, the rule of 4.2.2—which refers to the amount of maxillary central display when the lips are at rest, the amount of gingival tissue revealed, and the proximity of the incisal line to the lower lip—is helpful (Fig. 5). At a time when patients perceive fuller and brighter smiles as most aesthetic, 4mm of maxillary central incisor display while the lips are at rest maybe ideal2,5. In an aesthetic

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Fig. 6: Gingival symmetry in relation to the central incisors, lateral incisors and canines is essential to aesthetics. Optimal aesthetics is achieved when the gingival line is relatively horizontal and symmetrical on both sides of the midline in relation to the central incisors and lateral incisors.—Fig. 7: The aesthetic ideal from the gingival scallop to the tip of the papilla is 4–5mm.—Figs. 8–10: Acceptable width-tolength ratios fall between 70 % and 85 %, with the ideal range between 80 % and 85 %.—Fig. 11: An acceptable starting point for central incisors is 11mm in length, with lateral incisors 1–2mm shorter than the central incisors, and canines 0.5–1mm shorter than the central incisors for an aesthetic smile display.—Fig. 12: The canines and other teeth distally located are visually perceived as occupying less space in an aesthetically pleasing smile.—Fig. 13: A general rule for achieving proportionate smile design is that lateral incisors should measure two-thirds of the central incisors and canines four-fifths of the lateral incisors.—Fig. 14: If feasible, the contact areas can be restoratively moved up to the root of the adjacent tooth.—Fig. 15: Photoshop provides an effective and inexpensive way to design a digital smile with proper patient input. To start creating custom tooth grids, open an image of an attractive smile in Photoshop and create a separate transparent layer.—Fig. 16: The polygonal lasso tool is an effective way to select the teeth.—Fig. 17: Click “edit > stroke,” then use a two-pixel stroke line (with colour set to black) to trace your selection. Make sure the transparent layer is the active working layer.

CLINICAL PRACTICE

September 2015 Pakistan Edition DENTAL TRIBUNE 7

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Fig. 18: Image of the central incisor with a two-pixel black stroke (tracing).—Fig. 19: Image of the teeth traced up to the second premolar to create a tooth grid.—Fig. 20: Size the image in Photoshop.— Fig. 21: Save the grid as a .png or .psd file type and name it appropriately. Create other dimension grids using the same technique.—Fig. 22: To determine the digital tooth size, a conversion factor is created by dividing the proposed length by the existing length of the tooth.—Fig. 23: Select the ruler tool in Photoshop.—Fig. 24: Measure the digital length of the central incisor using the ruler tool.—Fig. 25: Measure the new digital length using the conversion factor created earlier.—Fig. 26: Create a new transparent layer and mark the new proposed length with the pencil tool.—Fig. 27: Open the image of the chosen tooth grid in Photoshop and drag the grid on to the image of teeth to be smile designed. This will create a new layer in the image to be smile designed.

smile, seeing no more than 2mm of gingiva when the patient is fully smiling is ideal6. Finally, the incisal line should come very close to and almost touch the lower lip, being no more than 2mm away2. These guidelines are somewhat subjective and should be used as a starting point for determining proper incisal edge position. Dentogingival aesthetics Gingival margin placement and the scalloped shape, in particular, are well discussed in the literature. As gingival heights are measured, heights relative to the central incisor, lateral incisor, and canine in an up/down/up relationship are considered aesthetic (Fig. 6). However, this may create a false perception that the lateral gingival line is incisal to the central incisor. Rather, in most aesthetic tooth relationships, the gingival line of the four incisors is approximately the same line (Fig. 6), with the lateral incisor perhaps being slightly incisal.[7] The gingival line should be relatively parallel to the horizon for the

being most important. . The midline only should be moved restoratively up to the root of the adjacent tooth. If the midline is within 4mm of the centre of the face, it will be aesthetically pleasing. . The midline should be vertical when the head is in the postural rest position Evaluating dental aesthetics Part of evaluating dental aesthetics for smile design is choosing tooth shapes for patients based on their facial characteristics (e.g., long and dolichocephalic, or squarish and brachycephalic). When patients present with a longer face, a more rectangular tooth within the aesthetic range is appropriate. For someone with a square face, a tooth with an 80% width-to-length ratio would be more appropriate. The width-to-length ratio most often discussed in the literature is between 75% and 80%, but aesthetic smiles could demonstrate ratios between 70% and 75% or between 80% and 85% (Figs. 8–10)1.

proportions. Natural portions demonstrate a lateral incisor between 60% and 70% of the width of the central incisor, and this is larger than the golden proportion 11 . However, a rule guiding proportions is that the canine and all teeth distal should be perceived to occupy less visual space (Fig. 12). Another rule to help maintain proportions throughout the arch is 1-2-34-5; the lateral incisor is two-thirds of the central incisor and the canine is four-fifths of the lateral incisor, with some latitude within those paces (Fig. 13). Finally, contact areas can be moved restoratively up to the root of the adjacent tooth. Beyond that, orthodontics is required (Fig. 14). Creating a digital smile designed in Photoshop Although there are digital smile design services available to dentists for a fee, it is possible to use Photoshop CS5 software (Adobe Systems) to create and demonstrate for patients the proposed smile design treatments. It starts by creating tooth grids—

of the teeth (Fig. 15). This transparent layer will enable the image to be outlined without the work being embedded into the image. . Name the layer appropriately and, when prompted to identify your choice of fill, choose “no fill,” since the layer will be transparent, except for the tracing of the tooth grid. . To begin tracing the tooth grid, activate a selection tool, move to the tool palette, and select either the polygonal lasso tool or the magnetic lasso tool. In the authors’ opinion, the polygonal works best. Once activated, zoom in (Fig. 16) and trace the teeth with the lasso tool. . To create a pencil outline of the tooth, with the transparent layer active, click on the edit menu in the menu bar; in the edit drop-down menu, select “stroke”; choose black for colour, and select a twopixel stroke pencil line (Fig. 17), which will create a perfect tracing of your selection. Click “OK” to stroke the selection. Select (trace with the lasso selection tool) one tooth at

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Fig. 28: Adjust the grid as required while maintaining proper proportions by using the free transform tool from the edit menu.—Fig. 29: Modify the grid shape as necessary using the liquify tool.— Fig. 30: Select all of the teeth in the grid by activating the magic wand selection tool and then clicking on each tooth with the grid layer activated (highlighted) in the layers palette.—Fig. 31: Use the selection modify tool to expand the selection to better fit the grid shape.—Fig. 32: Activate the layer of the teeth by clicking on it. Blue-coloured layers are active.—Fig. 33: With the layer of the teeth highlighted, choose“liquify”; a new window will appear with a red background called a “mask”.—Fig. 34: Shape one tooth at a time as needed by selecting “wand”.—Fig. 35: Once all of the teeth have been shaped, use the liquify tool. —Fig. 36: Tooth brightness is adjusted using commands from the dodge tool menu or image adjustments menu. —Fig. 37: Image of all the teeth whitened with the dodge tool.

central incisors and the lateral incisors and symmetric on each side of the midline2,8. The gingival contours (i.e., gingival scallop) should follow a radiating arch similar to the incisal line. The gingival scallop shapes the teeth and should be between 4mm and 5mm (Fig. 7)9. Related to normal gingival form is midline placement. Although usually the first issue addressed in smile design, it is not as significant as tooth form, gingival form, tooth shape, or smile line. Several rules can be applied when considering modifying the midline to create an aesthetic smile design: . The midline only should be moved to establish an aesthetic intra- and inter-tooth relationship, with the two central incisors

The length of teeth also affects aesthetics. Maxillary central incisors average between 10mm and 11mm in length. According to Magne, the average length of an unworn maxillary central to the cementoenamel junction is slightly over 11mm 10 . The aesthetic zone for central incisor length, according to the authors, is between 10.5mm and 12mm, with 11mm being a good starting point. Lateral incisors are between 1mm and a maximum of 2mm shorter than the central incisors, with the canines slightly shorter than the central incisors by between 0.5mm and 1mm (Fig. 11). The inter-tooth relationship, or arch form, involves the golden proportion and position of tooth width. Although it is a good beginning, it does not reflect natural tooth

predesigned tooth templates in different width-tolength ratios (e.g., 75% central, 80% central) that can be incorporated into a custom smile design based on patient characteristics. You can create as many different tooth grids as you like with different tooth proportions in the aesthetic zone. Once completed, you will not have to do this step again, since you will save the created tooth grids and use them to create a new desired outline form for the desired teeth. Follow these recommended steps: . To begin creating a tooth grid, use a cheekretracted image of an attractive smile as a basis (e.g., one with a 75% width-to-length ratio). Open the image in Photoshop and create a new clear transparent layer on top

a time and then stroke it (Fig. 18). Select and stroke (trace) the teeth up to the second premolar (the first molar is acceptable; Fig. 19). . The image should be sized now for easy future use in a smile design. In the authors’ experience, it is best to adjust the size of the image to a height of 720 pixels (Fig. 20) by opening up the image size menu and selecting 720 pixels for the height. The width will adjust proportionately. . At this time, the tooth grid tracing can be saved, without the image of the teeth, by double-clicking on the layer of the tooth image. A dialog box reading “new layer” will appear; click “OK.” This process unlocks the layer of the teeth so it can be Continued on page 11

10 DENTAL TRIBUNE Pakistan Edition September 2015 HEC-USAID SCHOLARSHIPS

Thailand' s first dental museum opens 24 partner varsities in Bangkok attend training session

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ANGKOK, THAILAND With the newly opened Sirindhorn Dental Museum, the Faculty of Dentistry at Mahidol University in Bangkok has introduced the first dental museum of its kind in Asia. By highlighting the history of dentistry and oral hygiene across Asia through fun and interactive exhibits, the museum hopes to raise awareness in the country about the importance of proper oral care. The 620 m2 museum, which is sponsored by the royal family, features five main exhibits, each aimed at improving understanding of the importance of good dental health. "We want to ensure that Thais will have a healthy smile in our 'Land of Smiles' for as long as possible," Dr Phira Sithiamnuai, assistant professor and Deputy Dean for Collaboration and Networking at the faculty, told the Bangkok Post last week. "Our goal for the museum is to encourage Thai children to understand the

importance of oral health in an entertaining way. We hope that learning with fun will inspire people to make healthy choices about their oral health." A highlight for children is the giant model of a mouth. Assisted by the staff, visitors are encouraged to practise their toothbrushing skills on the huge teeth with equally giant toothbrushes. Other interactive items are a 3-D human model that shows how oral health can affect the overall well-being, as well as several multimedia displays on dental science. Furthermore, the exhibition takes a closer look at the history of dentistry throughout China, India and Thailand, including collections of dental materials and tools, as well as information on dental statistics, and even a prehistoric human skeleton that features traces of unnaturally modified teeth.

DT Pakistan Report

I Many Thais, especially people in remote areas, lack access to basic oral health care. As reported online by the Bangkok Post, Sithiamnuai remarked that the dentist per capita ratio in the capital is 14 times higher than in the north-east of the country, for example. According to figures from the Bureau of Dental Health, Thailand has just 11,607 dentists. This translates to a dentist-population ratio of approximately 1:5,533, compared with an average of 1:2,000 in most developed countries. The Sirindhorn Dental Museum is located at the HRH Princess Maha Chakri Sirindhorn 50th Anniversary Building at the university's Phayathai campus and is free of admission.

SLAMABAD - Higher Education Commission (HEC) in collaboration with the United States Agency for International Development (USAID) organised a twoday training session on 'Effective Financial Aid Offices for USAID' - both for merit and need-based scholarship programme. Over 35 representatives of the financial aid offices of 24 partner universities of the USAID attended the training, which was aimed at improving effectiveness and efficiency of these offices in various facets such as communication skills, coordination and interaction with aspiring students regarding scholarships and procedure involving execution of the programme. USAID Merit and Needs-Based Scholarship Programme (MNBSP) is a $37 million scholarship programme, offering graduate and undergraduate degrees in 31 public and private universities in Pakistan. Fifty per cent of scholarships are reserved for meritorious and deserving female students. Speaking at the concluding ceremony, HEC executive director Dr G Raza Bhatti highlighted local and overseas scholarship projects, faculty and infrastructure development Continued on page 13

Continued from page 05 removed. Drag the layer of the teeth to the trash, leaving only the layer with the tracing of the teeth (Fig. 21). In the file menu, click “save as” and choose “.png” or “.psd” (Photoshop) as the file type. This will preserve the transparency. You do not want to save it as a JPEG, since this would create a white background around the tracing. Name the file appropriately (e.g., 75% W/L central). . By tracing several patients’ teeth that have tooth size and proportion in the aesthetic zone and saving them, you can create a library of tooth grids to custom design new teeth for your patients who require smile designs. The Photoshop smile design technique The Photoshop Smile Design (PSD) technique can be done on any image, and images can be combined to show the full face or the lower third with lips on or lips off. This article demonstrates how to perform the technique on the cheek-retracted view. The first step in the PSD technique is to create a digital conversion of the actual tooth length and width, and then digitally determine the proposed new length and proportion of the teeth. Determining digital tooth size To determine digital tooth size, follow these steps: . Create a conversion factor by dividing the proposed length (developed from the smile analysis) by the existing length of the tooth. . The patient’s tooth can be measured in the mouth or on the cast (Fig. 22). If the length measures 8.5mm but needs to be at 11 mm for an aesthetic smile, divide 11 by 8.5. The conversion factor equals 1.29, a 29% digital increase lengthwise. . Open the full-arch cheek-retracted view in Photoshop, and zoom in on the central incisor. Select the eyedropper palette. A new menu will appear. Select the ruler tool (Fig. 23).

. Click and drag the ruler tool from the top to the bottom of the tooth to generate a vertical number, in this case 170 pixels (Fig. 24). Multiply the number of pixels by the conversion factor. In this case, 170 x 1.29 = 219 pixels; 219 pixels is digitally equivalent to 11 mm (Fig. 25). Determine the digital tooth width using the same formula. . Create a new layer, leave it transparent, and mark the measurement with the pencil tool (Fig. 26). Applying a new proposed tooth form Next, follow these steps: . After performing the smile analysis and digital measurements, choose a custom tooth grid appropriate for the patient. Select a tooth grid based on the width-to-length ratio of the planned teeth (e.g., 80/70/90 or 80/65/80). Open the image of the chosen tooth grid in Photoshop and drag the grid on to the image of teeth to be smile designed (Fig. 27). . If the shape or length is deemed inappropriate, press the command button (control button for PCs) and “z” to delete and select a suitable choice. . Depending on the original image size, the tooth grid may be proportionally too big or too small. To enlarge or shrink the tooth grid created (with the layer activated), press command (or control) and “t” to bring up the free transform function. While holding the shift key (holding the shift key allows you to transform the object proportionally), click and drag a corner left or right to expand or contract the custom tooth grid. . Adjust the size of the grid so that the outlines of the central incisors have the new proposed length. Move the grid as necessary using the move tool so that the incisal edge of the tooth grid lines up with the new proposed length (Fig. 28). . Areas of the grid can be individually altered using the liquify tool (Fig. 29). Digitally creating new aesthetic teeth Next, follow these suggested steps:

. With the new tooth grid layer and the magic wand tool both activated, click on each tooth to select all of the teeth in the grid (Fig. 30). . Expand the selection by two pixels in the expand menu; click “select > modify > expand” (Fig. 31). Note that the selection better approximates the grid. You can expand the selection or contract as necessary using the same menu. Activate the layer of the teeth (cheekretracted view) by clicking on it (Fig. 32). . Next, activate the liquify filter (you will see a red mask around the shapes of the proposed teeth). The mask creates a digital limit that the teeth cannot be altered beyond. This is similar to creating a mask with tape for painting a shape (Fig. 33). . Use the forward warp tool by clicking on an area of the existing tooth and dragging to mold/shape the tooth into the shape of the new proposed outline form (Fig. 34). Repeat this for each tooth. If you make a mistake or do not like something, click command (or control) and “z” to go back to the previous edit (Fig. 35). Adjusting tooth brightness The following steps are recommended next: . Select the whitening tool (dodge tool) to brighten the teeth. In the dodge tool palate, click on “midtones” and set the exposure to approximately 20%. Click on the areas of the tooth you want brightened (Figs. 36 & 37). . Alternatively, with the teeth selected, you can use the brightness adjustment in the brightness/contrast menu; click “image > adjustments > brightness/ contrast”. Performing the changes on only one side of the mouth allows the patient to compare the new smile design to his/her original teeth before agreeing to treatment. Create a copy To save the information you have created for presentation to the patient, follow these tips:

. Go to “file” and select “save as.” . When the menu appears, click on the “copy” box. . Name the file at that step. Save it as a JPEG file type. . Designate where you want it saved. . Click “save.” A file of the current state of the image will be created in the designated area. You can now continue working on the image and save again at any point you want. Conclusion Knowledge of smile design, coupled with new and innovative dental technologies, allows dentists to diagnose, plan, create, and deliver aesthetically pleasing new smiles. Simultaneously, digital dentistry is enabling dentists to provide what patients demand: quick, comfortable, and predictable dental restorations that satisfy their aesthetic needs. Editorial note: A complete list of references is available from the publisher. This article was originally published in the Journal of Cosmetic Dentistry, spring issue, No 1/2013, Vol. 29, and the Clinical Masters Magazine No 1/2015.

Authors Info Prof. EdwardA. McLaren is the dir ector ofthe University ofCalifornia, Los Angeles Center for Esthetic Dentistry. He can be contacted at [email protected] .edu. Lee Culp, CDT, is an adjunct faculty member at the University of North Carolina at Chapel Hill School of Dentistry. He can be contacted at lee_culp@microdental. com.

12 DENTAL TRIBUNE Pakistan Edition September 2015

Maxillary Sinus Grafting course DT Pakistan Report

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ARACHI - After the success of first Implantology course by renowned maxillofacial surgeon Dr. Noor ul Wahab, the course is being offered for the

the hands-on session, where all the participants successfully placed implants on patients under the supervision of Dr. Noor ul Wahab. The fourth session was held on 29th and 30th August 2015. The main

second time this year for those who seek to enhance their skills and knowledge. The course began in May 2015 and already four successful sessions have been conducted. Each session consists of lecture and hands on work shop. The third session was held on 25th and 26th July 2015. It was dedicated to Maxillary Sinus

Grafting. There were lectures by Dr. Noor ul Wahab on Anatomy of maxillary sinus, vertical and horizontal sinus lift techniques - both with and without implant placements. This was followed by a lunch break, after which the participants gathered again for a hands-on session comprising of Vertical and Horizontal sinus lifting and Sinus grafting on models. One whole day was dedicated to

focus of the session was Guided Bone Regeneration. Dr. Noor ul wahab spoke on; Classification of ridge defects. GBR materials and bone augmentation techniques for various ridge defects. After the lunch break, the hands-on workshop was dedicated to bone augmentation and various types of suturing techniques, after the placement of artificial bone and implant. Dr. Naveed Rasheed was invited to share his valuable knowledge and some of his cases with the participants, highlighting various techniques in sinus lift as well as the Dos and Don'ts while placing implants. He also shed some light on bone augmentation and regeneration.

Market to grow up to 30.4 Billion.... Continued from front page Advancement in Dental Studies & Research (IADSR) said that the rise in oral health care awareness in Pakistan due to FMCG and toothpaste & tooth brush manufactures is no more than 10% - 15%. He further commented that the rise in GNP in Pakistan along with Education and international exposure of a common individual in Pakistan are the major reasons for rise in Oral care awareness. He said that it is a known and established phenomena globally that the rise oral health care awareness is directly proportional to the Secondary and Tertiary education in any country. He said that marketing campaign executed by the toothpaste manufactures and marketers have surely raised the awareness on brushing habits however, the rise of oral health care awareness cannot be complimented alone to the advertising activities. Students to pay more after PM&DC.... Continued from front page directed the colleges to implement the new fees from 2015-16 sessions onwards. This will affect more than 6000 students across Pakistan but who cares. "No medical and dental institution training for MBBS/BDS in the private sector shall charge tuition fee more than 600,000 per annum per student," the 2013 regulations read. Interestingly one of the oldest private dental college in Sindh which until recently was marked in red with admissions stopped has now been graded as category A. Sources told Dental News that the letter issued to them by PM&DC has also been retracted stating that it was sent inadvertently. With this decision it is expected that the tuition fees to the tune of Rs100,000will be increased per student for category 'A' private colleges. Similarly, category 'B' colleges would charge each student Rs42,000 as incremental annual tuition fees.

Students reacted to the development with anger and shock, in a recent statement by the Pakistan Medical Student Council (PMSC) they referred to PM&DC as "private medical and dental council". PM&DC is silent on payments other than tuition fee like students pay university examination fees, taxes, hostel fees, transport fees and the onetime admission fee under the PM&DC regulations. Some private colleges are charging Rs 200,000 as non-refundable admission fees and there is no stopping. PM&DC Registrar has categorically said that the council had increased the tuition fees to facilitate those medical and dental colleges which showed good performance. It seems no Public sector medical or dental college came upto the standards of PM&DC as none of them were rewarded. 24 partner varsities attend training session Continued from page 10 conducted by the HEC. He appreciated support from the US government and partner universities in promoting higher education in Pakistan and emphasized that focal persons attending the training must implement the techniques and tools for efficient functioning of the financial aid offices. USAID Education Office's deputy director Dr Garth Willis was also present at the event. Speaking on the occasion, he said that this training is a useful activity to create better understanding of the programme's objectives among partner universities so that it can be implemented according to the criteria of merit and need. He said that the US government has invested in many education projects in Pakistan and USAID-Merit and Need-based Scholarship Programme is one of its key programmes which is dedicated to cater to the needs of talented students who, due to financial barriers, are deprived of higher education. Later, Dr Willis and Dr Bhatti gave away certificates among representatives of the financial-aid offices.

PLAGIARISM AT UNIVERSITIES

SHC Suspends HEC notification DT Pakistan Report

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YDERABAD - The Sindh High Court has recently suspended the implementation of an earlier notification from the Higher Education Commission, which had blacklisted the former Vice president of the Federation of All Pakistan Universities Academic Staff Association, on charges of Plagiarism. According to recent media reports; Dr Azhar Ali Shah- an associate professor in Sindh University, was among the 20

teachers of seven universities in Pakistan who were blacklisted and stripped of all benefits and allowances in March 2015. The news report further stated that; All of them were charged with plagiarism and were accused of re-publishing, in Pakistani journals, two of his articles that were earlier published in foreign journals, without modifying his research. The act amounts to selfplagiarism in the academic parlance. The court restrained the SU's

syndicate, which was scheduled to meet in the end of August, from implementing the HEC's notification until the next hearing. The petitioner informed the court that; decision over the issue is on the meeting's agenda. In his petition before the Hyderabad Circuit Bench, Shah maintained that; this decision by the HEC's Plagiarism Standing Committee violated the commission's plagiarism policy. He was not even heard before

facing the HEC's action, he added. Shah claimed that before publishing his articles in the SU's Research Journal in 2011, the varsity's focal person for antiplagiarism - Dr M Saleem Chandio had cleared it for publication. He argued that; the committee took action on a fake complaint against him. "The [then] acting SU's VC Dr Parveen Shah who is

VC in Khairpur's Shah Abdul Latif University (SALU)] and former SALU professor Ghulam Raza Bhatti [one of the 13-member Plagiarism Standing Committee] used their influence [against me]," he had said in his initial reaction to his blacklisting. Shah hoped the court would declare the notification illegal and order the HEC to restore his benefits.