Available from Clark Dental, the Orthophos S 3D combines the advantages of a Csl sensor with an innovative autofocus function to generate striking radiographs at the lowest possible dose.

Clinicians can take advantage of sophisticated diagnostic options for a wide range of indications, including endodontics, periodontics, orthodontics and dental implantology. Moreover, the unit’s intuitive EasyPad control panel and occlusal bite block simplifies patient positioning to prevent incorrect exposures and streamline workflows.

The Orthophos S 3D also provides the flexibility for you to retrofit a cephalometric arm, enabling you to expand your practice offerings and future-proof your business.

For more information call Clark Dental on 01268 733 146, email info@clarkdental.co.uk or visit www.clarkdental.co.uk

When approaching periodontology, we often think about the health of the gingiva and the treatment or management of disease. While this is the priority, it is also often necessary to consider aesthetics too. The soft tissue is integral to the appearance and function of the teeth, so optimising every aspect of it is beneficial in achieving the best possible outcomes for patients. 

Soft tissue impact on treatment

The soft tissue fulfils several roles within the mouth, including protection of the tooth roots and/or dental implants, prevention of infection and improving smile aesthetics.

When assessing the gingiva either visually or with a periodontal probe, it is commonly characterised according to its biotype. Typically, it is referred to as ‘thick’ or ‘thin’ – more specifically ‘scalloped and thin’ or ‘flat and thick’ – which relate to gingival thicknesses of ≥1 mm or <1.0mm respectively.[i]

It has been proposed that gingival biotype is one of the main factors influencing the success of root coverage procedures or restorative dental treatments. Patients with a thinner gingiva are more likely to experience recession following non-surgical periodontal therapy and mucogingival problems as a result of orthodontic treatment.[ii] Tissue biotype can also affect site preparation and surgical outcomes with regards to dental implant planning and placement.[iii] All of these have the potential to impact final aesthetics, so careful consideration should be given to minimising potential soft tissue complications when working with thinner biotypes.

However, tissue thickness is not the only aspect to think about – the position of the gingiva in relation to the teeth and smile line is also important. We would typically categorise a ‘high’, ‘average’ or ‘low’ smile line, which is generally determined by how much cervico-incisal length of the maxillary anterior teeth and adjoining gingiva is visible when smiling. A high smile line reveals the entire length of the teeth with a band of the adjoining gingiva, an average smile line 75-100% of the teeth with interproximal gingiva and a low smile line less than 75% of the anterior teeth with no gingiva visible.[iv] Though not an exact science, there is evidence to suggest that high smile lines (or ‘gummy smiles’) are generally perceived to be less aesthetic. [v]

Crown lengthening indications and contra-indications

According to the American Academy of Periodontology,[vi] crown lengthening is “a surgical procedure designed to increase the extent of supragingival tooth structure, primarily for restorative purposes, by apically positioning the gingival margins with or without the removal of supporting bone”. Indications for treatment include:[vii]

• Restorative needs
• To increase clinical crown height lost due to caries, fracture or wear
• To access subgingival caries
• To produce a ‘ferrule’ for the provision of a post crown
• To access a perforation in the coronal third of the root
• To relocate the margin of restorations that are impinging on biological width
• Aesthetics
• Short teeth
• Uneven gingival contour
• Gummy smile

Contra-indications include:

• Inadequate crown-to-root ratio
• Non restorable caries or root fracture
• Aesthetic compromise
• High furcation
• Inadequate predictability
• Tooth arch relationship inadequacy
• Compromising of adjacent periodontium or aesthetics
• Insufficient restorative space

Essentially, crown lengthening can be utilised to improve smile aesthetics by increasing the amount of tooth length visible and reducing the amount of gingiva in the smile line. The most important consideration is to ensure that surgery doesn’t make the appearance of the teeth and gums worse – the crown-to-root ratio is a crucial aspect of the treatment planning process!

Another vital factor to asses and plan for is the biological width – which is the dimension of soft tissue that is attached to the part of the tooth that is coronal to the crest of the alveolar bone. This is important for periodontal health and poor management of the biological width during any treatment, including crown lengthening, can result in increased risk of periodontitis. Other possible signs of biological width violation are chronic progressive gingival inflammation, bleeding on probing, localised gingival hyperplasia, clinical attachment loss and alveolar bone loss.[viii] For a thin biotype, there is also an increased risk of gingival recession and bone resorption, while a thick biotype is associated with vertical osseous defects around the tooth and pocket formation.

Planning for success

For all these reasons and more, pre-surgical evaluation for crown lengthening must consider periodontal health and gingival biotype, root anatomy, crown-to-root ratio, the presence of caries and endodontic prognosis. This requires radiographic assessment and bone sounding to ensure that the bone is of sufficient height, width and density to facilitate the change in gingival volume. This involves taking a 1mm probe and pushing down from the gingival margin as far as it goes under local anaesthetic.

Of course, this is just the beginning of successful crown lengthening treatment for the aesthetic improvement of patients’ smiles. The Surgical Crown Lengthening Hands-on course with BPI Dental & Education is a great option for any clinicians looking to significantly develop their knowledge and skills in the field. The comprehensive training covers everything discussed here and more, including the surgical procedures themselves, which we will look at in more detail in the next article.

Images

Dr Boota Singh Ubhi

Speciality: Specialist Periodontist & Implant Surgeon

Qualifications: 1992 University of Liverpool BDS, FDS RCS (Edinburgh) MDentSci (Liverpool) MRD RCS (England)

About Me: Leading a select team of experts, Boota has a reputation for routinely surpassing patients’ expectations.

For more details or to book your place on the next Surgical Crown Lengthening course with Dr Boota Singh Ubhi, please visit https://bpieducation.co.uk/dental-courses/surgical-crown-lengthening/

[i] Kan JYK, Morimoto T, Runcharassaeng K, Roe P. Gingival biotype assessment in the esthetic zone: Visual versus direct measurement. The International journal of periodontics & restorative dentistry. June 2010. 30(3); 237-43.

[ii] Manjunath RG, Rana A, Sarkar A. Gingival Biotype Assessment in a Healthy Periodontium: Transgingival Probing Method. J Clin Diagn Res. 2015;9(5):ZC66-ZC69. doi:10.7860/JCDR/2015/13759.5956

[iii] Kao RT, Fagan MC, Conte GJ. Thick vs. thin gingival biotypes: a key determinant in treatment planning for dental implants. J Calif Dent Assoc. 2008 Mar;36(3):193-8. PMID: 18444430.

[iv] Al-Juboori MJ, Al0Juboori AJ, Wan TM, Ting J, Chui LS, Hoe TM, Al-Wakeel HA. The relationship between the lip length and smile line in a Malaysian population: A cross-sectional study. Dental, Oral and Craniofacial Research. 2017. 3(4); 1-5. doi: 10.15761/DOCR.1000208

[v] Sybaite J, Sharma P, Fine P, Blizard R, Leung A. The Influence of Varying Gingival Display of Maxillary Anterior Teeth on the Perceptions of Smile Aesthetics. J Dent. 2020 Dec;103:103504. doi: 10.1016/j.jdent.2020.103504. Epub 2020 Oct 28. PMID: 33129999.

[vi] AAP Connect. Crown Lengthening. Glossary of Periodontal Terms. American Academy of Periodontology. https://members.perio.org/libraries/glossary?ssopc=1 [Accessed August 2021]

[vii] Camargo PM, Melnick PR, Camargo LM. Clinical Crown Lengthening in Esthetic Zone. C D A Journal 2007;3 5,Number7:487-498

[viii] Nugala B, Kumar BS, Sahitya S, Krishna PM. Biologic width and its importance in periodontal and restorative dentistry. J Conserv Dent. 2012;15(1):12-17. doi:10.4103/0972-0707.92599

The ADI is delighted to launch a new ADI script for implant consultations on Kiroku – the script is now available to members for free. The digital note-taking platform is designed to help clinicians ensure the quality and efficiency of their notes, saving them time, reducing stress and helping to protect them from potential litigation.

Eimear O’Connell, ADI President, reiterates the importance of quality record keeping in today’s profession:

“Fear of medicolegal litigation has increased over the past few years. In order to help our membership make contemporaneous notes in a comprehensive but more simplified way, the ADI is delighted to announce this latest member benefit. We have partnered with Kiroku because we believe the digital note-taking platform will provide valuable support for all our clinicians in this area. This is true both for its practical implementation and in its ability to reduce stress levels. As such, it is yet another great reason to become an ADI member.”

This is just one of many valuable benefits available to ADI members – find out more today!

For more information about the ADI, or to join, please visit the website www.adi.org.uk

As he reaches the end of his year as President of the British Academy of Cosmetic Dentistry (BACD), Dr Paul Abrahams reflects on what the past 12 months have meant for dentistry and for the organisation:

“It has, without a doubt, been a difficult year for everyone in dentistry. Our aim was to support our members in any way we could, so one of the first things we did was freeze membership fees for three months to help alleviate potential financial strains. Though already in the pipeline, the pandemic also accelerated plans to present webinars, which the BACD now provides free to members to support remote learning.

“Though education has always been the primary focus of the BACD, we really thrive on social contact. The lack of face-to-face interaction meant we had to find new ways of engaging with members, which I think we did very successfully with virtual events such as a gin and whiskey tasting, which was brilliant! It was great to see so many people get involved.

“When we were able to present live events again, we knew our first had to be special. The BACD Drive In Cinema was a fantastic affair – a beautiful day and an idyllic setting, with a bar, street food van and the amazing Christian Coachman speaking on the big screen live from Madrid. The brain child of Shameek Popat, it was such a clever and unique event and we were delighted to see so many cars join us!

“With regards to the internal workings of the BACD, many of our committees have met virtually during the pandemic and this will likely stay where appropriate – the increased accessibility of meetings enables more people to get involved, which is what we’re all about. We have also been able to strengthen partnerships with other associations, sponsors and trade members, to further enhance the benefits provided to members. There is now a huge list of benefits available that I would encourage everyone to browse on the website.”

Clearly, the BACD did not sit back and rest during the pandemic, but rather remained focused on its members and how it could support them. Paul comments on what he is most proud of from his term as President:

“It’s been great to see that the BACD didn’t lose any members despite everything this year and that we have developed our support of members even further. Perhaps what I’m most proud of is our affiliation with charity Confidental. Their work in supporting dentists who are struggling has been incredibly important this past year, when so many have faced hardships. Our backing has enabled them to train more volunteers so that more phone calls could be answered and more individuals given the advice and life-changing support they needed. I’m very proud that we have been able to help our members and the wider profession by broadening the charity’s reach and capabilities.” 

Looking ahead, Paul is nothing but positive about the future of the BACD, with various events in the making. He continues:

“We will be continuing to combine live education with social aspects where we can moving forward. The 2021 sell-out Annual Conference aside, we can look forward to the Anoop Maini memorial lecture in June 2022 and a day of lectures by an amazing all-female speaker line-up, championing and promoting the diversity and equality already present across the Academy.

“Our prestigious BACD Accreditation programme will also be reformed to make it more accessible and enable more clinicians to be recognised for their skill and dedication. It will also be updated to reflects some of the latest techniques in dentistry.”

With all this and more yet to come, the BACD remains a dynamic, inclusive and thriving organisation for all dental professionals with an interest in clinical excellence. Paul’s final words are to encourage more people to get involved:

“It’s important that every organisation welcomes new people and fresh blood to stay relevant and move with the times, so we’re always keen to invite new professionals to join. The BACD is proud to be a progressive and supportive community, which should not be underestimated. We’ve seen dentists join early in their careers, grow and truly excel – some of the work they’re doing now is phenomenal. We share a passion for what we do and this is evident during every event, every course and every virtual interaction. It’s what the BACD is built on.

“On that note, I would like to thank everyone who has supported my term as President. We have a very strong Board and strong committees, which is only made possible by the people who selflessly give up their time. Your hard work is so appreciated and the BACD wouldn’t be what it is today without you! In addition, having preceded me as President, Nishan Dixit has been incredibly supportive during my term, so many thanks to you also.

For further enquiries about the British Academy of Cosmetic Dentistry, visit www.bacd.com

Looking to utilise zygomatic implants to further improve your treatment outcomes?

The Zygoma Anatomy-Guided Approach (ZAGA) is a patient-centric treatment concept that uses an evidenced-based understanding of anatomical variations to drive treatment planning decisions. You can now either refer your patients to a trusted ZAGA Centre, or you can learn to do it yourself.

The Centre for Oral-Maxillofacial and Dental Implant Reconstruction is a ZAGA Centre based in Manchester and is accepting referrals for zygomatic implants. The talented team is led by Specialist Oral Surgeon, Professor Cemal Ucer, who also joins Dr Carlos Aparicio (creator of the ZAGA method) and Dr Rubén Davó (one of the foremost zygomatic implant experts in the world) in presenting training and mentorship on the topic as well.

To find out more about referring to the international ZAGA Centre in Manchester, or developing your own skills with the ZAGA concept, contact the team today.

Please contact Professor Ucer at ucer@icedental.institute or Mel Hay at mel@mdic.co

01612 371842

 www.ucer-clinic.dental

The hugely popular Align, Bleach & Bond (ABB) training courses with IAS Academy have proven as popular as ever since live events returned this year. So much so that places remain on only one programme date for 2021 – in December.

Presented by highly experienced clinicians, the two-day course explores the philosophy, mechanics and approach to treatment with removable aligners. The second day focuses on ortho-restorative aspects, covering simple edge bonding and polishing, envelope of function and orthodontics, the Dahl Principle, treatment of tooth wear and advanced retention management.

The programme helps GDPs to integrate restorative dentistry within their orthodontics for a minimally invasive treatment approach. Mentoring from experts in the field is also readily available to ensure delegates can apply what they learn into practice safely and effectively.

Remaining course date:

• 10-11 December 2021 – Surrey

Book today!

For more information on upcoming IAS Academy training courses, please visit www.iasortho.com or call 01932 336470 (Press 1)

After such a turbulent year, both the dental profession and the general population is slowly starting to resume some normality. This should eventually see the return of full UDAs in England, where NHS dental contracts will likely soon be required to complete in their entirety by providers. Aside from the challenges that the pandemic continues to inflict upon us all, this poses more interesting questions. For example, is the ratio of NHS and private dentistry the same in mixed practices as it was pre-COVID? If not, how has it changed? What impact would this change have on the goodwill of the business? Though we are yet to find the answers, we can speculate what the future has in store based on what we know so far.

The UDA story so far

Traditionally, the size of the NHS dental contract and the UDA value contracted directly correlate with its goodwill value. Dental practice valuations are largely based on multiples of EBITDA (Earnings Before Interest, Tax, Depreciation and Amortisation) or Adjusted Net Profit before Principal Drawings – influenced by not just revenue but also the costs of delivery e.g. average associate fees and staffing costs. Where a practice is contracted with higher UDA values, this more often than not will lead to a higher valuation than another business of similar size and performance, but which has a lower UDA value.

As you’ll know, all UK practices were required to deliver 45% of their contracts from 1 January 2021 until 1 April 2021, at which point the target increased to 60% of their contract – with a cliff-edge drop in funding at 36% for dentistry and 56% for orthodontics. At time of writing, the profession expects to deliver an increasing proportion of their contract delivery in the coming months. The question is, will this dip in income have impacted the medium-term profitability and therefore value of businesses?

A shift on the horizon

Though our own data differed from NASDAL’s recent findings, the general trends demonstrated are interesting to consider. They found that goodwill as a percentage of fee income across all dental practices dropped by just over 10% between January and April 2021, with NHS goodwill falling from 191% to 146% during the same timeframe. The same report stated that private practice values remained steady, though only at 110% of gross fees. 

Fundamentally, the overall conclusions from this data do not appear to reflect the reality of what is happening on the ground, but this is not to say the conclusions are inaccurate. They are just too simplistic to draw a valid conclusion; large private practices are indisputably the ‘crown jewels’ of the dental practice sales market at the moment and competition for these kinds of practice has never been more fierce.

Comparatively for smaller private practices that appeal more to the owner-led market the market, demand is still variable with the hangover of apprehension from the COVID pandemic. A wide difference in appetite for these practices also exists, depending on their aesthetic appeal, type of work performed and geography.

Conversely, the opposite is true for larger NHS practices where there is still a busy market of corporate acquirers seeking to purchase these kinds of practice. However, the market is slightly smaller than it was in early 2019, albeit the owner-led acquirers compete more aggressively for this stock than they did in 2019.

Impact on valuations

We have seen relatively little impact on valuations for all types of practices, with a continued appetite and a steady flow of new businesses coming to market. While banks have remained confident in the dental profession with regards to lending, consistency and sustainability of accounts are more important than ever. Many practices have recovered to almost pre-pandemic levels and buyers are very much looking for this in any business they view.

Where some businesses have increased the proportion of private dentistry they provide, this could have two potential outcomes. If they are aiming to maintain their full NHS dental contract alongside the growing private work, this would increase turnover overall and therefore have a very positive impact on the value of the business. Where private dentistry is replacing some of the NHS contract, this might cause a slight reduction in goodwill value if the gross contribution from the private work is less than that afforded by the NHS contract – although a much higher gross income than pre-pandemic could have the opposite effect.

What is meant by a decrease in gross contribution is that if the practice is afforded £28 per UDA and pays the associate £12 per UDA, then for £28 of income the associate is effectively paid 42.85% less shared costs. Traditionally, private practice may have paid the associate 50% of private work, which means the ‘UDA replacement’ private treatment priced at £28 would effectively see a fall in the profit for the practice of £2. To maintain EBITDA and profit, the NHS replacement income would need to equal £32 rather than £28 or the associate percentage is re-configured in order to maintain the status quo.

Still got questions?

The very nature of dentistry means that practice valuations can be an intricate and complex process, so getting expert advice and support is essential. Whether the return of the UDA has taken you back to pre-pandemic operational levels or caused a shift in how you work, getting an up-to-date valuation is always useful. The team from Dental Elite would be more than happy to help, offering valuations and a free practice health check to identify any areas where you could improve the value of your business for the most successful sale.

Luke Moore is one of the Founders and Directors of Dental Elite and has overseen well in excess of 750 practice sales and valuations. With over 11 years working in the dental industry, Luke has extensive knowledge in both dental practice transfers and recruitment and understands the complexities of NHS and Private practices.

For more information contact Dental Elite. Visit www.dentalelite.co.uk, email info@dentalelite.co.uk or call 01788 545 900