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Ryan Hungate DDS
One of the biggest challenges we have in clinical dentistry is to meet the expectations of esthetically demanding patients, for which it becomes imperative for the aesthetic dentist to understand his patient’s needs as well as desires. Also, we need tools that enhance our diagnostic vision and make it easier for us to communicate the treatment steps with our team objectively and clearly. The need is to employ user-friendly systems & create standardized workflows that can guide the team through the aesthetic rehabilitation process. The ultimate aim is to address the functional and biological issues therapeutically and generate aesthetic outcomes that are predictable & consistent.
Digital Smile Design (DSD), a novel concept designed by Dr Christian Coachman, collects digital images of the patient’s smile and provides essential tools to create a 3D diagnostic wax-up. High-quality digital images - static and dynamic, make the foundation of DSD for the documentation, communication and analysis of data - the most critical components of contemporary esthetic rehabilitation. Moreover, they create a set of standardised templates and guidelines for diagnosis and treatment planning. We also need good videos documenting the patient's phonetics.
The DSD protocol is also a fantastic communication tool to enable the patients to see the treatment outcomes beforehand. Test drive – a powerful DSD tool enables the patients not only to see and compare the end result with the pre-op situation but also experience it in real life. A test drive adds transparency, builds trust and increases the treatment acceptance rate.
Another concept that we describe here is called the ‘New SKIN’ designed by Paulo Kano. The New SKIN concept uses natural anatomical shapes of the teeth to give a natural appearance. Originally it was a combination of digital and manual workflows. Later it was completely digitized by Florin Cofar et al through the ‘RAW’ concept. Now, all these workflows are clinically known as Natural Restoration workflows.
This case shows how we create two test drives (mock-ups), both of which have DSD planning in common, but differ in their morphology based on the tooth shapes selected from the 3Shape digital library.
A 27-year-old male presented with a short and small upper right lateral incisor (12), and worn-out central incisors (11/21). Below is a 6- step workflow that covers the digital planning and clinical execution until he gets a test drive to wear.
Step 1: Photographs and Treatment Planning using the DSD Software (Fig 1 - 6).
First, we need a full set of high-resolution photographs to analyse and diagnose the smile. Also, good videos documenting the patient's phonetics.
We use these images to plan the treatment and also to guide the team through all the subsequent steps of smile design and esthetic rehabilitation.
Next, we start with the Digital Smile Design process to create a treatment plan. Out of all the images taken above, three photographs viz. frontal, 12 o'clock position, and occlusal – are essential for this step. We have to verify the harmony among these three images as shown in Fig. 7.
We do the DSD 2D planning using the keynote on a Mac/ powerpoint/ DSD app or any similar app. This 2D planning creates the foundation for the subsequent 3D steps.
Step 2: Intraoral Scanner and Digital Wax-ups using the New SKIN / RAW concepts
The second step is to collect the intraoral data using a 3Shape Trios intraoral scanner. (Fig 8)
Use the scanned data and design a digital wax-up using the new SKIN concept, introduced by Paulo Kano. (As mentioned earlier, this process has been completely digitized by Florin Cofar et al through the ‘RAW’ concept.)
Use the 3Shape Software to create two sets of digital wax-ups – one for the upper 6 anteriors and another for the upper 10 teeth till the second premolars using the tooth shapes available in the 3Shape library. (Fig 9- 12). The 3 D wax-up can also be done using the exocad software.
Step 3: 3D Printing of the Digital Wax-up.
Next, we 3-D print the digital wax-ups (Anycubic Photon 3D Printer). (Fig 13-14)
3 D printing can be done, besides Photon, in any DLP /SLA printer.
Step 4: Create a Silicone Index using 3D printed models.
Next, you create a silicone index - an impression of a wax-up. If you have created a digital wax-up, as done in this case, then 3D print the digital wax-up first and then take its impression. A silicone index is designed for transferring the information of a wax-up into the mouth during treatment.
The silicone index prepared from the 3D printed models (Fig 14- 15) carries the provisionalization material (Luxatemp) into the patient’s mouth to create two sets of mock-ups.
Step 5: Carry a provisionalization material intraorally in the Silicone Index.
One silicone index carries the provisionalization (Luxatemp) material (A2 shade) for the upper 6 anterior teeth, whereas the other carries Luxatemp (A1 shade) for the upper 10 teeth till the second premolars.
We create two mock-ups (Fig 16-17) and the patient gets to compare them with the baseline situation (pre-op images).
Step 6: Test-drive the mockup in the patient’s mouth
Allow the patient to wear and experience the test-drive. Evaluate his satisfaction with the new appearance, function, and speech with the intraoral test-drive. (Fig 18- 23)
Take your patient's approval for the subsequent steps of smile design.
In Digital Aesthetic Dentistry, the right mix and the optimum use of advanced technologies – DSD, New SKIN concept, RAW, Intraoral scanner, Digital library, 3D wax-up software, 3D printer - can give excellent results in esthetic rehabilitations.
1. The Anatomical Shell Technique: An Approach to Improve the Esthetic Predictability of CAD/CAM Restorations. Paulo Kano et al. Quintessence of Dental Technology 2013: Vol 362.
2. Improving aesthetics in CAD/CAM dentistry – Anatomic Shell Technique (AST) Paulo Kano, Cristiano Xavier, Jonathan Ferencz et al. Cosmetic Dentistry International, 2013 Issue 4, Volume 7: 18- 21.
3. Coachman C, Calamita MA, Sesma N. Dynamic Documentation of the Smile and the 2D/3D Digital Smile Design Process. Int J Periodontics Restorative Dent. 2017;37(2):183-193.
4. The Anatomical Shell Technique: Mimicking Nature— Paulo Kano; Luiz Narciso Baratieri et al. Quintessence of Dental Technology 2014: Vol 37