CASE REPORT

Year : 2014  |  Volume : 4  |  Issue : 3  |  Page : 144-147

Evaluation of function and esthetics for creating a beautiful smile in dental practice using digital smile designing

Prafulla Thumati
Department of Prosthodontics, Dayananda Sagar Dental College and Research Centre, Rajiv Gandhi University of Health Sciences, Kumarswamy Layout, Bengaluru, Karnataka, India

Correspondence Address:
Prafulla Thumati
Department of Prosthodontics, Dayananda Sagar Dental College and Research Centre, Rajiv Gandhi University of Health Sciences, Kumarswamy Layout, Bengaluru, Karnataka
India

Source of Support: None, Conflict of Interest: None

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DOI: 10.4103/2229-5194.147335

Abstract

Appropriate application of principles of smile designing for any restorative work can drastically improve the esthetics of the patients. This case report describes the treatment for the hypoplastic teeth with generalized wear out facets using digital smile designing (DSD) technique rather the conventional approach. Much Literature is available on conventional smile designing, but discussion on DSD is sparse. The treatment plan included DSD and measurements using digital ruler, diagnostic wax-up and fabrication of crowns. DSD is a promising treatment option for good esthetic outcomes.
Clinical Relevance To Interdisciplinary Dentistry

• Aesthetic value and Functional efficiency to be provided in any restorative dentistry case, can be diagnosed and assed in advance by using digital gadgets.
• How far can we integrate such protocol like DSD-Digital Smile Designing in our routine practice-a case demonstration?

Keywords: Computerized smile analysis, digital smile designing, smile proportion




How to cite this article: Thumati P. Evaluation of function and esthetics for creating a beautiful smile in dental practice using digital smile designing. J Interdiscip Dentistry 2014;4:144-7




How to cite this URL: Thumati P. Evaluation of function and esthetics for creating a beautiful smile in dental practice using digital smile designing. J Interdiscip Dentistry [serial online] 2014 [cited 2023 Mar 30];4:144-7. Available from: https://www.jidonline.com/text.asp?2014/4/3/144/147335





Introduction



Coloring is the sunshine of art that clothes poverty in smiles, while it heightens the interest and doubles the charm of beauty. The science of aesthetics literally means, "The science of beauty in nature and arts." Beauty itself is a combination of reality and personal perception. Esthetics denotes concern about beauty or appreciation of beauty. The perception of esthetics varies from person to person and is influenced by personal experiences and social environments. ^[1] The esthetic dentist should have a thorough knowledge and appreciation of the artistic principles that can be applied to the dentofacial complex and should combine artistic creativity with scientific discretion to effect an appreciable change in the dentition. The science of aesthetic dentistry cannot be called a perfect science due to its inherent variations with respect to evolution, geographic locations, social and racial factors.

The smile we create should be esthetically appealing and functionally sound requires a comprehensive approach to patient care. The digital smile design (DSD) is an esthetic treatment designing tool that can strengthen diagnostic vision, improve communication between the interdisciplinary dental team as well as a laboratory technician, and enhance the treatment outcomes.

The present case report describes the interdisciplinary DSD approach to restore function and smile designing.




Case report



A 31-year-old, male presented himself with the need for smile correction. After knowing the history and examination findings, it was analyzed that the patient has hypoplastic teeth with generalized wear out facets.

Digital smile designing technique

After going through the details of the case, decision was taken to treat the case by DSD method that helps analysis of both facial and dental composition of smile. Dental evaluation involves teeth and their relation to gingival tissues. Facial evaluation includes hard and soft tissues of the face. ^[2] There are two facial features which do play a major role in the smile design. These are the interpupillary line and lips. The interpupillary line should be perpendicular to the midline of the face and parallel to the occlusal plane. Lips are important since they create the boundaries of smile design. Any abnormalities in this facial composition should be corrected before correcting the dental composition. ^[3]

Digital smile designing

Sketches can be performed in presentation software such as keynote or Microsoft PowerPoint (Microsoft Office, USA). Three basic photographic views are necessary:


• Full face with a wide smile and the teeth apart,
• Full face at rest, and
• Retracted view of the full maxillary arch with teeth apart.


The photographs and videos were downloaded and inserted into the slide presentation. For designing, a series of photographs were taken. In the power point presentation series of windows, a photo was inserted. Two lines must be placed on the center of the slide, forming a cross, and the photograph is placed behind these lines. A line was drawn between the pupils, and the cant was adjusted by rotating the photograph. The interpupillary line was the first reference line to establish a horizontal reference plane. Then a vertical line was drawn to represent the midline on the face, thus both the horizontal and vertical reference lines forming a cross. The facial photograph with a wide smile and the teeth apart was moved behind the cross to determine the ideal horizontal plane and vertical midline [bold white lines in [Figure 1]a.

Now this photograph was cropped to show only the intraoral view and three reference lines were marked on the teeth for replacement with another intraoral photograph of the patient [Figure 1]b; a straight line is drawn from canine tip to canine tip, one more line on the incisal edges of central incisors and another line passing through the dental midline (passing through the interdental papillae). This assists in duplicating the cross, that is, the reference interpupillary and facial midline on the face onto the intraoral view. Smile arc is determined for the patient that is, the relationship between the curvature of the incisal edges of the maxillary anterior teeth and the curvature of the upper border of the lower lip. ^[4],[5],[6] The ideal relationship desired is parallelism between both [yellow line in [Figure 2] shows the curvature of incisal edges].

Incisal edge position acts as a reference for establishing the tooth proportions. The midline refers to the vertical contact interface between two maxillary centrals. It should be perpendicular to the incisal plane and parallel to the midline of the face. Minor discrepancies between facial and dental midlines are acceptable and in many instances, not noticeable. ^[7] The center of the philtrum is the center of the cupids bow, and it should match the papilla between the central incisors. Thereafter midline and occlusal plane shifting and canting can be easily detected.

With these lines being the orientation landmarks (indexing or tripoding), the current photo was replaced with a new photograph showing the full gum posture. The photo was oriented to the first photo using landmarks or lines and then the designing was done [Figure 1]c.

Now, rectangles were placed over the incisors to mimic the required length and width of the incisors in accordance with the golden proportion grid (1.618:1 i.e. the smaller tooth is about 62% of the size of larger tooth) superimposed below the maxillary anterior teeth. Premade tooth size and shapes based on patient's desire as well as face shape were also superimposed to see how much difference in width and length is to be achieved [Figure 1]d.

Digital ruler can be calibrated on the photograph by measuring the width of the central incisors in the study model. The proportions of central incisors were compared with the ideal proportions described in dental literature. Here the width of the central incisor was 8.5 mm. This measurement when transferred to the computer helps in the calibration of a digital ruler, photograph of ruler that can be positioned on the slide as necessary. Measurements were made as to how much length and width had to be increased [Figure 1]e.

Figure 1: (a) Photograph is moved behind the cross formed by the interpupillary and the midline of face to determine the Ideal horizontal plane and midline. (b and c) Three reference lines marked on the cropped photograph for replacing it with intraoral photograph and intra-oral photograph is being replaced. (d) The selection of tooth shape and size superimposed with the golden proportion. (e) Measurement of the distance between the lines superimposed above the gingival margins with a calibrated digital ruler Click here to view



Desired morphology of the tooth was filled with a particular shade selected for the patient and the laboratory was communicated with the soft copy of the photo showing the details of size, morphology and shade for which patient had agreed [Figure 2]a and b. All the above measurements could also be transferred to the cast for a diagnostic wax-up. In this particular case, the new incisal length was measured on the computer and transferred to the provisional restorations with a caliper. Once the laboratory technician developed the mock-ups in resin, they were tried in the patient's mouth and then sent back for the final work. Then the metal free E-max (lithium di silicate) crowns and laminates are bonded using the resin reinforced luting material (Panavia F, Khurarray Company, Japan).

Treatment procedure


• Irreversible hydrocolloid impressions were made for the diagnostic cast
• Diagnostic wax-up was done using white Ivory Wax to evaluate the smile line and to explain the treatment protocol to the patient
• Oral prophylaxis was done
• The patient was recalled after 2 weeks for review. After tooth preparation, gingival retraction was done, followed by impression with polyvinyl siloxanes (ivaclar using type II) using putty wash impression technique
• Provisional restoration fabricated from Silicon Index prepared from the wax-up model using Ivoclar systems C and B II was bonded with light cured flowable composite in one point [Figure 2]c

  Figure 2: (a and b) The size and shape of teeth decided is being filled with shade selection color. This is used for communication to lab. (c and d). Digital smile designing based provisional restorations luted and postoperative metal free E-max crowns cemented in patient's mouth. (e and f) Pre-and post-treatment photos Click here to view

• Bite registration was done to record the maxillo-mandibular relationship using vinyl polysiloxane bite registration material. Casts were mounted on a semi-adjustable articulator using a face bow transfer
• The E-max crowns and laminates (IPS e.max Press, LT, Ivoclar Vivadent) were luted with resin reinforced luting agent (Panavia F, Khuraray Company, Japan) [Figure 2]d.





Discussion



According to Pincus, "Aesthetics is the physiologic 4 ^th dimension in oral rehabilitation." The goal of an esthetic makeover is to develop a peaceful and stable masticatory system, where the teeth, tissues, muscles, skeletal structures and joints all function in harmony (Peter Dawson). ^[8]

A dental examination is complete if it allows identification of all active factors that are capable of causing deterioration of oral health and function. Both the causes and effects must be analyzed to provide better optimal oral health anatomic and functional harmony, comfort and esthetic.

Form and esthetics go hand in hand. One of the most important goals in aesthetic dentistry is to provide harmonious proportions of the maxillary anterior teeth. The use of a proportional ratio is important when restoring or replacing maxillary anterior teeth. ^[9] One particular ratio that has been widely discussed in aesthetic dentistry is the golden proportion ratio given by Keppler. If one chooses to use this particular ratio, from a facial view tooth proportions are guided by the golden proportion. ^[10] These guidelines state that if the lateral incisor has a width value of 1, then the central incisor width is 1.618, and the canine should be 0.618. ^{[11],[12],[13]}

Goldstein affirms the importance of using computerized analyses, enabling the professional to study and discuss the patient's expectations with the dental professional, since there are no analyses or studies showing what should be applied in clinical practice. ^[14]

A comparative analysis was also performed by specialists between the results obtained by computerized analyses of the "smile" with subjective analyses of the different levels of factors of the "smile" under study. The McNemar test was used for to compare the results. A study showed significant differences between smile line (P < 0.0001), golden proportion (P = 0.0170), labial line (P = 0.0122) and line between commissures (P < 0.0001). This study emphasizes the importance of computerized analysis, even for professionals with experience in dental esthetics. The visualization of tracings greatly facilitates analysis when compared with analysis using imaginary lines. ^[15]

This valuable tool can be used to initiate a dialogue with the patient concerning his or her interest in cosmetic dentistry. The patient can take home a printed copy of his or her smile with the golden proportion grid superimposed and share it with family and friends. DSD is a powerful communication tool between technician dentists and the patients. It can improve the acceptance as well as the results of esthetic dental treatment.




Conclusion



The smile that we create should be esthetically appealing and functionally sound. Proper treatment planning is very essential in managing cases. Proper computerized smile designing as well as communication with the laboratory technician made the diagnostic wax-up easier as well helped in further education of the patients. Use of all ceramic laminates and veneers enhanced the overall esthetic outcome. Thus, we have provided a comprehensive esthetic treatment to the patient as you see in the pre- and post-treatment photos [Figure 2]e and f. This technique of DSD is an extremely useful tool for patient motivation and interdisciplinary as well as laboratory communication. It is a valuable tool for future treatment planning to achieve a desirable esthetic smile.

 

References




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Figures


  [Figure 1], [Figure 2]