Digital treatment planning for multidisciplinary approach: Going from aesthetic to functional rehabilitation of the smile
(Fully digital versus traditional protocol)
As digital dentistry continues to evolve, multidisciplinary dental treatment (periodontal-occlusal-restorative) can now be planned digitally, allowing for the patient to give their input on the final aesthetic result even before starting the treatment itself.
Digital Smile Design App has been presented as a tool to strengthen the diagnostic view and improve communication and predictability during treatment. With a simplified photographic protocol, the digital planning presents simple steps to evaluate the size, shape, and position of the teeth, as well as the gingival and incisal contours. Digital smile planning has been shown to be efficient, especially when the treatment involves an increase in length in the gingival region, a procedure that generates much fear, as well as many doubts and disappointments in patients.
A young female patient came to the clinic to report dissatisfaction with the shape and size of her teeth, fractures in composite resin restorations of the upper anterior teeth, and the right canine presenting a gingival difference in relation to the left canine. Initially, photos were taken of the smiling face with a digital camera, and then the photos were inserted into the digital smile planning program (DSD App).
Fig. 1 ( initial photo)
Observation of facial references to guide the patient’s new smile design were made using the facial analysis tool of the application. The app’s artificial intelligence (AI) technology automatically calibrated the frontal facial picture which allowed the doctor to draw a line connecting the glabella, nose bridge, philtrum, and chin to determine the patient’s facial midline and to create harmony and balance between the facial structures and current dental midline. Additionally, the interpupillary line was determined for parallelism analysis in conjunction with the intercommissural line to guide the practitioner on the current position of the patient’s occlusal plane.
Fig 2. ( facial flow pic)
Next, in order to determine the teeth height and width ratio lines, the doctor was guided by the distal central incisors and the smile line of the upper and lower lips. The gingival recontouring was carried out to accompany the upper lip line of the smile, thus, the format itself can be changed freely in the app to visualize other options with respect to the gingival contour to determine whether or not a gingival intervention needs to be performed.
Fig. 3 ( smile frame )
To choose the teeth shapes, DSDApp offers an extensive selection of natural teeth formats which allow the dentist to choose the right tooth shape that would best fit the patient’s unique facial features. The teeth shapes [F07– Jan Hajto] were selected by the doctor and the patient.
Fig. 4 ( teeth shapes)
To finish customizing the smile, the natural shaped teeth were then adjusted in the app to perfect the positioning and contouring of the selected teeth.
(Fig 5 ( adjust shape )
A side by side visual was used to present the before and after pictures of the smile simulation created with DSDApp. (Fig. 6A, 6B before and after) Once the digital design was reviewed and approved by the patient and the professionals involved, DSDApp’s measurement tool was used to aid the clinical planning to identify measurements from the area between the preoperative location of the patient’s current cervical gingival margins and the new ideal cervical postoperative location to reshape and contour the gingival tissues.
(Fig 7 – measurements)
The case was saved and shared with the dentists involved in the treatment as well as the lab technician for visual aid.
(Fig 8A,8B – shared + send to email )
A digital waxing and evaluation with the virtual articulator was used with a CAD software to collaborate fundamentally for the evaluation of the anterior and lateral disocclusion guides, favoring the longevity of the restorative treatment. Additionally, the mock-up and provisional prosthesis were sent to a CAM software and machined presenting an evolution in relation to the adaptation as it’s capable of machining exactly the same size and shape as previously demonstrated to the patient, thus avoiding problems of aesthetic or occlusal differences as well as decreases in time when compared to the traditional method.
The machined mock-up was tested in the patient to evaluate the proposal to gain permission for continuation of the treatment. After small adjustments of the mockup in mouth, the patient was re-scanned one last time, now with the functional, esthetic ideal mock-up before sending the ceramics for fabrication. The patient kept the mockup in the mouth throughout the time leading to her procedure. ( Fig. 9A,9B,9C)
The laminates were made with machined ceramic with a lithium silicate reinforcement base, following the same design as previously approved by the patient. Afterward, the restorations were individualized by the pigmentation technique (Fig 10).
After cementation, the occlusal contacts were checked and adjusted, and proximal excesses were removed. The final appearance can be seen in figure 11A,11B,11C.
Function, esthetic results, and overall patient satisfaction were monitored for 18 months and were remarkable. By adding DSDApp into the digital treatment planning we are able to eliminate errors at all stages. The digital protocol for integrated treatments is predictable and efficient, allowing easy diagnosis, improved communication with the patient, clinical and prosthetic work safety, and treatment longevity.
Authors: Ubiracy Gaião DDS, MSc, PhD, A Talyta Duarte DDS, MSc, B Patrícia Ferronato Araújo DDS, MSc, C Leonardo Fernandes da Cunha DDS, MSc, PhD D
A Professor, Department of Dentistry; Positivo University, Curitiba, PR, Brazil.
B Professor, Department of Dentistry; Positivo University, Curitiba, PR, Brazil.
C Master student, Department of Dentistry; School of Health Sciences, University of Brasília (UnB), Brasília, DF, Brazil.
D Professor, Department of Dentistry; School of Health Sciences, University of Brasília (UnB), Brasília, DF, Brazil.
Leonardo Fernandes da Cunha firstname.lastname@example.org
School of Health Sciences, University of Brasília
Case report review with Dr. Ubiracy Gaiao and Dr. Diogo Alves