A 26 year-old male patient sought dental treatment at ISO Angra Dental Clinic, located in Angra dos Reis, Brazil complaining about his dissatisfaction with the harmony of his smile and incisal edge fractures. Due to the nature of his profession the patient sought a treatment option that was quick and effective.
To visually communicate with the patient, a frontal facial smiling photo of the patient was taken using the patient documentation tool to simulate a facially-driven motivational smile with DSDApp. (Fig. 1) The Artificial lntelligence(AI) automatically calibrated the patient picture following the facial flow* (Fig. 2) to analyze facial structures and smile harmony with the face. A smile (selected from one of the natural smile donor libraries [Jan Hajto F07] by the doctor and the patient) was then superimposed on the patient’s picture (Fig. 3). The patient was shown the smile simulation case presentation with before and after photos using DSDApp and was immediately appreciative of the big difference and instantly approved the case (Fig.4).
*The Facial Flow Feature is based on the Clinical Report ”The Facial Flow Concept: An organic orofacial analysis – the vertical component” Published in The Journal of Prosthetic Dentistry by Bruno Pereira, DDS, PhD, Eduardo Mahn, DDS, PhD, Kyle Stanley, DDS, Christian Coachman, DDS, CDT
Fig. 4: 2D Before and After
To initiate the backward treatment plan, an examination and full-mouth radiographs revealed no cavities and no evidence of any endodontic or periodontal pathology. Moreover, attritions involving enamel and dentin tissues at the incisal edges of maxillary and mandibular anterior teeth were notes due to a possible bruxism problem, but there were no signs or symptoms of temporomandibular joint disorder. The buccal cusps edges of premolars were also slightly outwards giving it disharmony in the buccal corridor. Correct oral hygiene was performed followed by an in-office teeth whitening session during the patient’s first appointment.
The Digital Smile Design App (DSDApp) dynamic documentation protocol (photographs: frontal facial smile, 12 o’clock and profile smile; digital impression of the upper and lower arch made with an intraoral scanner in conjunction with a video interview to assess an ideal development of the facial smile frame) were uploaded to reconcile the initial frontal facial smile (Fig. SA, SB). After a clinical and digital esthetic evaluation, an in-office teeth whitening procedure followed by a direct composite veneers restoration and a dental night guard was proposed and accepted by the patient as a conservative and affordable treatment option that aided predictable esthetic results.
To begin the ideal minimally-invasive preparation guide (IMIPG) using DSDAPP a 3D Design project was created. An upper intraoral scan file .STL was calibrated into the App. To determine the arch form, an occlusal curve line was placed on the edge of the buccal cusps of the posterior teeth and incisal edge of the incisors with the goal of decreasing the axial inclination of the buccal segments to give harmony to the buccal corridor area. (Fig. 6) To visually validate the adjustments made, the .STL file was then superimposed on a frontal facial smiling photo, a 12 o’ Clock photo, and a profile photo (Fig.7 A,7B,7C). The facial guided smile frame was designed by using the recurring esthetic dental
(RED) proportion and arch curve based on the smile simulation approved by the patient. This was then converted to a 3D project for digital teeth mounting (Fig. 8) and saved on the app’s case management file for the patient.
The same 3D project was used to design the motivational mock-up where the 3D teeth were brought outward to cover the existing teeth (Fig. 9). To fine-tune the project, digital waxing was applied to improve the accuracy of the future smile (Fig. 10). The motivational 3D design project was then saved as a new case in the patient’s management file.
The 3D ideal minimally invasive preparation guide (IMIPG) project was open once again. The original intraoral scan was modified to reduce on substrative areas creating the final composite veneers guide (Fig.11 A, 11 B) and then saved as a new case in the patient’s management file.
All 3D Smile Design cases ( ideal minimally invasive preparation guide (JMIPG), Motivational mock up and final composite veneers guide) were then exported from the app (as a 3D project which is an .STL file) and imported to a CAM software to create and 3D print mock-up.
An impression of the mock-up was done using addition silicone. The mold was then filled with bysacryl resin and placed onto the patient’s teeth where no adjustment on the mock-up was needed (Fig 12). When shown to the patient, he instantly made an emotional connection as he saw a natural smile that complemented his facial structure. It was his “wow” factor. ( Fig. 13)
To create ten minimally invasive composite veneers going from the upper-left second premolar to the upper-right second premolar, the motivational mock-up was removed and a silicon index of the ideal minimally-invasive preparation guide (IMIPG) was done using addition silicone. The mold was then filled with bysacryl resin and placed onto the patient’s teeth with the goal of reducing the enamel in order to be as minimally invasive and precise during the preparation. A depth cutter diamond bur was used to facilitate the exact depth in order to accommodate the future restoration. ( Fig. 14).
The horizontal preparation lines were marked with a pencil ( Fig. 15). The residual mock-up (IMIPG) was removed with a scaler and selective preparation was performed based on the marked areas to guarantee an even and harmonious dental arch.
The cervical margins consequently stayed in the enamel at the CEJ using the biologically oriented preparation technique (BOPT). The minimal preparations remained on the buccal sides of the interproximal contact points without loosening the proximal contact surfaces.
To create a transparent index of the composite veneers guide model, a 2mm thermoforming dental tray was used. Tape for dental isolation was used to protect teeth. Non-isolated teeth were etched, washed, adhered, and light-cured (Fig. 16). Flowable resin composite in the shade A 1 was injected in the inside buccal area of the transparent index, placed onto the patient’s teeth, and light-cured with the index in place (Fig. 17).
The transparent index was taken out and the excess flash was removed with a bladed instrument while a fine metal finishing strip was used to create space in the interproximal areas. The same procedure was conducted to the originally isolated teeth. No adjustments were made on the buccal anatomy. The occlusal bite and guidelines were checked to ensure that the final result was functional, harmonic, and aesthetically pleasing. (Fig. 18A,18B, 18C).
The method of conducting a minimally invasive flowable composite veneers treatment is an easy and cost-effective solution that practitioners can implement speedily and efficiently into their daily practice. Using digital tools such as DSDApp allows dental practitioners to supplement their dental knowledge and know-how and not only create smile simulations but also 3D motivational mock-ups and treatment guides to give dentists and patients confidence in a satisfying end result.
Dr. Diogo Alves, DDS -DSDApp
Clinical Content Lead
Specialization in Surgical lmplantology and Prosthesis over Implants – UFPR
MBA in Strategic Business Management – FGV
Project Management and Marketing – NYU School of Professional Studies
Partner at ISO ANGRA Dental Clinic – Brazil
Dr. Omar Castro, DDS
Member of the Fluminense Education Association (since 1984)
Member of the Brazilian Society of Aesthetic Dentistry
Specialization in Surgical lmplantology and Prosthesis over Implants – ABO-RJ
Owner of ISO ANGRA Dental Clinic – Brazil
Dr. Lucas Andrade, DDS
Specialization in Endodontics – PUCRIO
Partner at ISO ANGRA Dental Clinic – Brazil