Use of DSDApp in
Esthetic Direct Composite Veneers:

Case Report by: 
Dr. Ricardo Bertholdi, DDS
Case Report
A 22-year-old female patient who was unsatisfied with her previous orthodontic final treatment due to esthetic complaints was referred to Dr. Ricardo Bertholdi of BertholdiBastos Clinic, Espirito Santo State, Brazil. The initial smile displayed a maxillary gummy smile, with the irregular gingival architecture of the right upper central incisor, in addition to the length of the upper incisors being shortened (Fig. 1). No periodontal bleeding or secondary caries were detected after clinical and radiographic examinations. Moreover, facial structures, smile harmony, and the dental characteristics were evaluated. The Digital Smile Design App (DSDApp) dynamic documentation protocol was applied: Digital extraoral pictures (frontal facial smile, 12 o’clock and profile smile) (Fig. 2A,2B,2C) were taken to further analyze the patient’s aesthetic smile with her face structures.
A digital impression of the upper arch was made with an intraoral scanner in conjunction with three videos (a facial interview, an intraoral functional closeup, and a structural closeup) taken from various angles to assess an ideal development of the facial smile frame.

Fig 1: Initial Smile

Fig. 2A

Fig. 2B

Fig. 2C

Analysis & Diagnostics
The patient’s information was uploaded into DSDApp to reconcile the photos (frontal facial smile, 12 o’clock and profile smile) and the digital impression (scanner) with the goal of creating a 3D Smile Design. The facial guided smile frame was created by using the recurring aesthetic dental (RED) proportion, (width and length ratio proportion), arch curve, teeth proportion and design. (Fig. 5: video) The smile simulation design was then presented to the patient, with the goal of involving her to be a co-designer of her own digital smile; creating an emotional attachment to the design as well as the Wow-factor. (Fig 6).
Afterwards, the created smile simulation was converted to a 3D project, and later exported to a 3D printer; generating a physical model with the new teeth and gumline design (Fig.5: video).

Fig 5: Video: Smile Design

Before and After

To create the emotional mock-up, a silicone impression was made from the digital diagnostic wax-up to fabricate a matrix. The emotional mock-up was then placed in the patient’s mouth. The patient was not allowed to see themselves with the mockup. New pictures were taken from different angles and were then compiled into a case presentation. Mirrors were removed from the consultation room while the patient viewed the presentation. Once shown the transformation, she was immediately appreciative and instantly approved the case (Fig. 7A,7B, 7C).

Fig. 7A

Fig. 7B

Fig. 7C

A gingivoplasty was made at the gingival margin of the upper central right incisor where about 1.6mm was removed. After 30-40 days, teeth were prepped, and direct composite veneers were created using a palatal silicone index. The incisal edge of the central incisors and the left lateral incisor was lengthened by 1–1.2 mm while the mesial-incisal third length of the left upper canine was lengthened by 1.2mm. The right lateral and canine were also included in the treatment planning to create a harmonic smile. The occlusal bite and guidelines were checked to ensure the final results matched aesthetic and functional design (Fig. 8). The use of a digital tool such as DSDApp helps dental practitioners create faster and better outcomes, giving the dentist and patient confidence to a satisfying end-result.

Special thanks to Dr. Ricardo Bertholdi for sharing this case with us!

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