The patient, a 32-year-old woman in good general health, was referred to a dental clinic specifically for esthetic rehabilitation. (Fig.1). She was dissatisfied with her smile, specifically with the size and cant of the teeth and the gingival smile. She requested ceramic veneers. A complete examination was performed including radiographic, clinical, videos, and photographic documentation following the DSD protocol. All the documentation was uploaded into DSDApp’s smile design platform to create the virtual patient. (Fig.2A,2B).
After a thorough examination by all team members, observation of facial references to guide the patient’s new smile design, and taking the patient’s good periodontal status into consideration, the team identified the need for an interdisciplinary approach that included orthodontic and periodontal (crown lengthening) treatments and prosthetic rehabilitation. As part of the treatment, orthognathic surgery was also proposed; however, the patient did not consent to this or to having conventional orthodontic treatment performed, which led to the team changing the plan.
To increase treatment predictability of the final esthetics, DSDApp’s digital workflow was used to create a 2D advanced smile simulation using a frontal facial smile picture and the intraoral scan of the patient. This allowed for better communication and managed expectations between the patient and other members of the team.
To begin the project, the patient’s upper intraoral scan file (.STL) was imported and calibrated into the app (fig.3). Then, the app’s artificial intelligence (AI) technology automatically calibrated the frontal facial picture which allowed the doctors involved in the case to draw a line connecting the glabella, nose bridge, philtrum, and chin to determine the patient’s facial flow (an evaluation of the face in relation to harmony and balance between the facial structures and smile)* (Fig. 4A, 4B). The calibrated .STL file was then superimposed on the frontal facial smiling photo (Fig. 5) and using the recurring esthetic dental (RED) proportion, the facial guided smile frame was designed Fig. 6. To assert that the final result would follow the facially-driven guidelines, tooth shapes from one of the natural smile donor libraries [F08 – Jan Hajto] were selected by the doctor and the patient (Fig. 7A,7B). The doctor showed the patient the smile design using the before and after feature of the app and she was instantly pleased which led to her initial approval of the treatment (Fig.8).
Finally, to give the patient a visual of the final outcome of the proposed treatment, the smile design project was sent to the planning center (DSD Planning Center) to create a digital wax-up guided by the 2D advanced smile design. They transformed the 2D smile design into a 3D digital model and sent it for 3D printing. (fig. 9A, 9B) . For this model, a silicone barrier was fabricated to make a motivational mock-up out of bis-acryl resin. The mock-up was placed onto the patient’s teeth and when shown to her she expressed how satisfied she was with the aesthetics as it fulfilled her desires. (fig.10).
A total of 22 aligners were used to complete the orthodontic treatment. After the orthodontic treatment, since there was no bleeding despite a maximum probing depth of 3mm, the periodontal treatment began.
A crown lengthening guide was created by the DSD Planning Center based on the patient’s CBCT and based on the facially-guided digital design The bone level was defined from the future gingival level for the purpose of maintaining the biological space; thus, a digital guide for the dual technique was created for use during surgery. This guide provided references for the gingival (bottom of the guide) and bone (top of the guide) levels and thus provided an acceptable reference for maintaining the biological space. (fig11).
Gingivectomy and bone reduction for crown lengthening were performed (Fig. 12A, 12B, 12C). Even with the increase in the clinical crown length, the patient still presented a gingival smile as foreseen in the esthetic planning. The patient was presented with the possibility of using botulinum toxin to paralyze the muscles; however, the results of this treatment last for a maximum of six months, and the patient would need to have applications at least two times per year to maintain the results. The patient agreed to this treatment and a controlled quantity was then used to minimize the mobility of the upper lip elevator muscles, consequently minimizing gingival exposure in the broad smile. (Fig. 13).
After the 90-day period of gingival stabilization after surgery, 21 restorative treatment began. For precise and predictable execution, the planning center forwarded the motivational mock-up STL file and two other STL files for two different situations. One of these two files guided the dental preparations, called the ideal pre-treatment STL, and the other guided the final rehabilitation, called the ideal post-treatment or technical STL, which could be used for the provisional and the final prosthesis. Thus, a model was printed, and a silicone index was made from the ideal pre-treatment STL. A mock-up was made of bis-acryl resin to guide the dental wear. Thus, a minimally invasive preparation that preserved tooth enamel was performed (Figs 14A, 14B).
After this, a digital scan (iTERO, Align Technology) of the preparations was performed and sent to the planning center to CAD production the laminated veneers (Fig. 15). The units and the teeth were prepared in accordance with the manufacturer’s instructions and cementation was performed. The occlusion was evaluated, and polishing was performed. (Fig. 16A, 16B)
The case was completed, and the patient was satisfied with the results (Figs 17A, 17B, 17C). The patient received necessary postoperative instructions and follow-up assessments were made for the following week, the following month, and at least once a year thereafter.
PhD in implantology – UMC Utrecht
Specialization in prosthodontics – ULBRA
Master in prosthodontics – ULBRA
Professor and coordinator at AVANTIS prosthodontics post graduation school
ITI Member & speaker
Dr. Alvaro Antonio De Freitas Arteche, DDS
MASTERS IN ORTHODONTICS – PUC-RS
Specialization in orthodontics and functional orthopedics – UFPR
Dr. Tatiane Caldeira Ulzefer
Specialization in Periodontics – UFRGS
Member of European Association for Osseointegration
Member of American Academy of Periodontology