Smile Design Research Articles

Complex Full-Arch Treatment with Zygomatic Implants, Fully Digital Protocol with Scan Flag Intraoral Scanning, and 3D-Printed Temporary Reconstructions in a Periodontal Patient—A Case Report

Background: The following case report presents the treatment of a patient with severe maxillary atrophy and failing residual dentition. The patient has been diagnosed with stage IV grade C periodontitis, making this case challenging from the very beginning. Methods: The treatment plan was based on collecting and merging digital data: CBCT, a face scan, and an intraoral scan. Due to the advancement of the periodontal disease, the treatment was divided into three stages. The entire process was conducted in a digital manner, based on the concept of prosthetically driven implantology. Additionally, all prosthetic temporaries were planned via digital smile design. Stage I included extracting the residual dentition, placing four implants in the mandible, and the delivery of a 3D-printed upper removable denture. Stage II included placing two zygomatic implants, two anchored piriform rims, and one midline implant. Both arches were immediately loaded with the intraoral welding of abutments screwed to multiunit abutments and 3D-printed shells. Subsequently, in stage III, two milled ceramic superstructures combined with a titanium milled bar were delivered as a final screw-retained restoration with the application of scan flags (horizontal scan bodies) for intraoral scanning. Results: The aforementioned technologies can all be implemented and merged into one complex treatment plan combining high predictability, successful esthetics, and a reliable and accurate end result. Even though the concept of scan flags is relatively new, this case shows its potential and merit. Conclusions: This case represents the power of the digital approach as a helpful tool in the recreation of functional and esthetic smiles in compromised conditions in periodontal patients.

Digital Smile Design Software: An Overview

Digital Smile Design (DSD) software have revolutionized the field of aesthetic dentistry by enabling clinicians to design and visualize patient-specific treatment outcomes. This software integrates digital tools like 2D and 3D imaging, CAD/CAM technology, and simulation algorithms to create comprehensive and highly accurate treatment plans. It facilitates communication between dentists, technicians, and patients by providing a visual representation of potential results, enhancing patient understanding and confidence. This article presents an overview of digital smile design software currently available.

Smile design with periodontal-restorative treatment: A case report

Smile design with periodontal-restorative treatment: A case report

The "Smile Design and Space" Concept for Altering Vertical Dimension of Occlusion and Esthetic Restorative Material Selection.

This article introduces the smile design and space (SDS) concept for managing the vertical dimension of occlusion (VDO) in full-mouth reconstructions and its influence on the selection of esthetic restorative materials. Limitations of traditional VDO adjustment methods are being addressed through a facially driven treatment approach that enhances esthetics improves function and minimizes invasiveness. The SDS concept involves detailed evaluations of the incisal edges of the maxillary central incisors in relation to the upper lip at rest and at full smile. This includes analyzing variations in incisal exposure due to differing lip mobility, which can significantly impact gingival esthetics, particularly in cases with gingival exposure during smiling. The concept employs a strategic formula to determine the necessary alterations in VDO based on specific dental relationships and wear patterns. The SDS concept provides guidelines for full-mouth reconstructions, emphasizing minimal invasiveness and the integration of esthetics with functional dynamics to enhance the predictability of clinical outcomes and reduce complications associated with traditional restoration techniques. The SDS concept enhances the precision of full-mouth reconstructions through individualized adjustment of the VDO, tailored to the esthetic and functional requirements of each patient.

Triple digital guides for implant-supported restorations with alveoloplasty procedure in the esthetic zone.

The principal aim of this report is to address the challenge of integrating prosthetic crowns with natural dentition in the esthetic zone. It highlights the utilization of a prosthetically driven treatment plan, designed to ensure predictable esthetic outcomes. This report details a technique that utilizes three digital guides, all derived from a 3-dimensional digital smile design. The integration of a restoration guide, an implant drilling guide, and an alveoloplasty guide is described. These tools collectively facilitate the precise execution of both surgical and prosthetic procedures, enhancing treatment accuracy and esthetic integration. This technique considers the esthetic prosthetic crowns, implant positions, and alveoloplasty collectively. It enhances the predictability of esthetic outcomes in oral implantology and potentially provides an integrated prosthetically driven workflow in cosmetic dental treatments. The application of multiple digital guides derived from the same prosthetically driven treatment significantly enhances the predictability of esthetic outcomes in oral implantology.

Esthetic crown lengthening treatment on the maxillary anterior teeth

Background: Asymmetrical smile design due to uneven gingival margin heights of the anterior upper teeth can lead to aesthetic issues and inadequate crown restorations, necessitating crown lengthening treatment. Purpose: The objective of this case report is to demonstrate the outcomes of crown lengthening to achieve improved aesthetics and symmetric gingival margin heights. Case: A 16-year-old female patient sought treatment for decayed left maxillary anterior teeth. Clinical examination revealed a non-vital tooth (tooth 21) with decay and excessively low gingival margins, along with asymmetrical gingival heights between the incisors and canines. Radiographs indicated radiolucent mass in the pulp chamber. Case Management: Crown lengthening was performed on teeth 12, 11, 21, and 22, and apexification was conducted on tooth 21 using a customized fiber post and lithium disilicate crown. Follow-up evaluations showed no complaints, well-maintained crowns, and healthy gingiva. Conclusion: Crown lengthening is feasible for anterior teeth with low gingival margins, enhancing clinical crown length to support aesthetic and final restorations in maxillary anterior teeth.

An interdisciplinary treatment to reshape upper anterior displaced teeth by using dynamic occlusal recording with an intraoral scanner.

This article describes an interdisciplinary treatment that helped a patient with displaced upper anterior teeth. A gingivectomy, root canal therapies, digital smile design, digital wax-up, and guided tooth preparations were applied. A patient with pathologically migrated teeth asked for treatment without orthodontic involvement due to a primary failed orthodontic treatment history. A smile photo was taken and superimposed with the dentition in a CAD software to accomplish a digital smile design. The jaw movements were recorded with two different methods, a mechanical articulator and an intraoral scanner with Patient-Specific-Motion function. The occlusal contacts during protrusive and lateral movements were compared and the digital wax-up was designed according to the later occlusal data. An aesthetic crown lengthening and pre-op root canal treatment were carried out in advance accordingly. After guided tooth preparation with a silicone index, the final fixed restorations were manufactured and cemented. A 2-year follow-up showed that our prosthesis functions well. This clinical report revealed that an intraoral scanner with Patient-Specific-Motion function can effectively record individual dynamic occlusal patterns and these data can be integrated into the CAD/CAM process to enhance the fulfillment of clinical requirements. This clinical procedure with a 2-year follow-up demonstrated that a prosthodontic-based interdisciplinary treatment of pathologically migrated teeth using dynamic occlusal recording with an intraoral scanner could achieve satisfactory esthetics in a relatively short treatment period. The Patient Specific Motion module may be used to record a personalized functional movement and the data can be integrated into the design process of the final restorations.

Occlusal Cant-A Narrative Review

Occlusal cant, indeed, plays a significant role in smile aesthetics. It refers to the asymmetry or tilt of the occlusal plane, which can affect the balance and harmony of the smile. The dynamic display zone, which includes lateral, vertical, and anteroposterior characteristics, as well as the cant of the occlusal plane, are important factors to take into account when creating a smile or designing mechanotherapy (treatment utilizing mechanical devices). Ensuring an aesthetic plane of occlusion involves aligning the teeth and jaws in a way that enhances the overall appearance of the smile. This may involve orthodontic treatment, dental restorations, or other interventions aimed at achieving symmetry and balance in the occlusal plane. By addressing occlusal cant as part of smile design and mechanotherapy, orthodontists can help patients achieve optimal smile aesthetics and function This review article decribes diagnosis ,etiology, methods of detecting occlusal cant and treatment alternatives.

The Recent Use, Patient Satisfaction, and Advancement in Digital Smile Designing: A Systematic Review.

Digital smile designing (DSD) is a concept of dentistry which combines the old and the new and becomes a different world in the world of smile aesthetics and functionality. Dental aesthetics is not just a cosmetic issue but a multidimensional part of oral health that has a great impact on psychological well-being, social life, functional capabilities, and, hence, the quality of life. To put it simply, the recognition of its significance stresses the necessity of complete dental care which is the one that combines beauty and function as well as health. This systematic review aims to analyze the recent use and patient satisfaction of DSD and to show the recent advances in DSD. A thorough literature search was conducted across the online databases for articles about the implementation of digital smile analysis in dentistry. The articles that were published between 2013 and 2023 on DSD were selected which included randomized and non-randomized trials and observational studies covering the effectiveness, advantages, and patients' opinions about the treatment. The National Institutes of Health tool was applied for bias assessment. Ten studies were selected to address the use of DSD in dentistry based on the inclusion criteria. The findings from these studies suggest that DSD is useful in improving communication, reducing working time, minimizing errors, enhancing patient satisfaction, and providing clinical adequacy for final prosthetic pieces, indicating the usefulness of this approach in dental procedures.Smile designing using digital technologies has the potential to improve dental aesthetics and treatment procedures while showcasing their reliability and clinical effectiveness.

Using Artificial Intelligence-Based 3D Smile Design: REBEL in Prosthetic Rehabilitation with Patient's Personal Preferences. Case-2

Looks are becoming a major concern in dentistry. Patients want beautiful smiles, no matter how complex their case. Dentists and lab technicians have relied on established esthetic principles for smile design, aiming for a pleasing patient outcome. Ideally, a well-designed smile brings happiness to the dentist and the patient, exceeding expectations beyond straight teeth. However, sometimes the final results fall short. This can happen when the smile design clashes with the patient's unique characteristics. Patient desires and the need for better information are forcing dentists to rethink how customized smile design should be. Ignoring this customization can lead to disappointment, even if all the standard esthetic rules were followed.

Using Artificial Intelligence-Based 3D Smile Design: REBEL in Prosthetic Rehabilitation with Patient's Personal Preferences. Case-1

Each smile is unique, and smiles reflect the different shapes, textures, and colors of the teeth and their combinations. When creating a new smile design dentists need to consider the biology, structure, function, and esthetics to create the fifth dimension of the smile. This approach is completely different from the conventional one. A smile reflects the personality and emotional state of the patient, and the translation of this into a new smile design occurs either by analog methods or digitally. A smile is a person's ability to express a wide range of emotions with the movement and structure of the teeth, dentofacial, esthetic lips, social and psychological (Rambabu et al, 2018) it also determines how well a person functions in society. When a person has a harmonious smile. it is always assumed that it increases self-esteem and their ability to interact properly and more confidently in their surroundings.

Artificial intelligence and smile design: An e-Delphi consensus statement of ethical challenges.

Smile design software increasingly relies on artificial intelligence (AI). However, using AI for smile design raises numerous technical and ethical concerns. This study aimed to evaluate these ethical issues. An international consortium of experts specialized in AI, dentistry, and smile design was engaged to emulate and assess the ethical challenges raised by the use of AI for smile design. An e-Delphi protocol was used to seek the agreement of the ITU-WHO group on well-established ethical principles regarding the use of AI (wellness, respect for autonomy, privacy protection, solidarity, governance, equity, diversity, expertise/prudence, accountability/responsibility, sustainability, and transparency). Each principle included examples of ethical challenges that users might encounter when using AI for smile design. On the first round of the e-Delphi exercise, participants agreed that seven items should be considered in smile design (diversity, transparency, wellness, privacy protection, prudence, law and governance, and sustainable development), but the remaining four items (equity, accountability and responsibility, solidarity, and respect of autonomy) were rejected and had to be reformulated. After a second round, participants agreed to all items that should be considered while using AI for smile design. AI development and deployment for smile design should abide by the ethical principles of wellness, respect for autonomy, privacy protection, solidarity, governance, equity, diversity, expertise/prudence, accountability/responsibility, sustainability, and transparency.

Perceptions in Digital Smile Design: Assessing Laypeople and Dental Professionals' Preferences Using an Artificial-Intelligence-Based Application.

Digital Smile Design (DSD) is used in many fields of dentistry. This prospective observational study assessed laypeople's and dental professionals' perceptions of a DSD application. SmileCloud, an online DSD platform, was used to create two different designs for three patients; after that, the participants, in a 30-question online illustrated survey, were asked about the most attractive design and other features of the smile. Dentists' and laypeople's perceptions about specific DSD features were assessed. The Kolmogorov-Smirnov normality test was used. Descriptive and crosstab analyses compared the respondents' opinions for each statement. Chi-square tests were used to determine the relationship between the questions and any association with age, gender, and profession. The test results were rated as significant at a p-value < 0.05. A total of 520 participants (dental professionals, students, dental technicians, and laypeople) were enrolled. The statistically significant features were self-esteem related to appearance (p = 0.05), facial and smile symmetry (p = 0.42, p < 0.0001), tooth color (p = 0.012), and symmetry of gums (p < 0.001). For each patient, the design with dominant round upper incisors and perfect symmetry was preferred (p < 0.001). Digital pre-visualization benefits diagnosis and enriches treatment planning. The dentist-dental technician-patient team should be involved in the decision-making process of pre-visualization.

Fully digital workflow of occlusal reconstruction treatment in a patient with congenital dentition defects.

Occlusal reconstruction is a critical intervention for patients with dental hard tissue defects, temporomandibular joint (TMJ) disorders, and jaw position abnormalities. Clinical efficiency and outcomes of these procedures have improved with advances in digital technologies. This case report aims to illustrate a comprehensive digital workflow for occlusal reconstruction in a patient with congenital dentition defects, emphasizing the application of digital technologies to enhance treatment outcomes. A 28-year-old woman with previously installed porcelain-fused-to-metal bridge restorations presented with a fractured prosthesis and TMJ symptoms. A multidisciplinary approach was adopted involving the use of digital facebow, intraoral scanners, digital smile design, and CAD/CAM technologies. The process included the extraction of defective restorations, temporary restorations to refine jaw position, and final permanent restorations. The digital workflow facilitated precise diagnostics and treatment, culminating in the successful installation of permanent restorations. Regular follow-ups at one- and three-months post-treatment confirmed stable occlusal function and high patient satisfaction. This case report showcases the potential of multiple digital technologies to streamline complex dental treatments and achieve high-quality results. The integration of digital technologies in occlusal reconstruction treatments offers significant benefits in terms of precision, patient comfort, and esthetic outcomes.

Digitally planned surgical crown lengthening: a novel bone reduction strategy to correct a gummy smile.

This report describes the bone reduction guide which was digitally obtained to improve diagnosis, treatment outcome and follow-up. Treatment of gingival smiles due to altered passive eruption should include interdisciplinary planning and smile design to facilitate the prediction of treatment outcome. Crown lengthening surgery can be supported by digital tools to improve surgical planning and follow-up. A 30-year-old female patient was referred to a private dental clinic seeking solutions for her gingival smile. Based on the anatomical crown length, a smile design was created, and the patient was presented with a simulated smile before treatment. In the surgical phase, a full-thickness flap was raised in the upper jaw to achieve the desired outcome. Using cone-beam computed tomography to determine cementoenamel junction for smile design and treatment planning brings many benefits. Patients and clinicians can foresee treatment results. From there, appropriate changes can be made. The bone reduction guide is designed to rest on the bone to help the clinician cut the bone accurately and thoroughly follow the established plan.

A Systematic Review of the Use of Intraoral Scanning for Human Identification Based on Palatal Morphology.

A common application for intraoral scanners is the digitization of the morphology of teeth and palatal rugae. Palatal scans are most commonly required to fabricate complete dentures and immediate transitional dentures and serve as a reference point for assessing orthodontic results. However, they are also frequently included by accident, even though the main purpose of intraoral scanning is to reconstruct dentition using computer-aided manufacturing (CAM). The literature shows that the identification of disaster victims has frequently involved palatal rugae impressions. As the skull provides sound insulation, the rugae are resistant to heat, chemicals, and stress. Antemortem data might be difficult to find during a forensic inquiry, particularly in disaster victim identification cases. In contrast with DNA and fingerprints, there is a greater likelihood of having a dental record that contains palatal scans. With specialized software, the scans can be exported as open stereolithography (STL) files. Considering that a full case consumes up to about 100 MB of hard drive space, long-term storage should not be an issue compared to a plaster model. Additionally, dentists widely use online databases to exchange data for smile design, implant registration, and orthodontic purposes. This will produce a digital database that grows quickly and is readily usable for forensic investigations. The uniqueness of forensic features is frequently challenged; however, palatal morphology's unique trait could make it possible as it is characteristic of individuals as well as the most distinguishing factor. This review will highlight how rugae, palatal morphology, mirroring, superimposition, and geometrics can serve in forensic identification.

The Scalloped Surgical Guide as an Alternative to Flat Bone Reduction Guide in Full-arch Implant Restoration.

The goal of this clinical report was to present an alternative to traditional flat bone reduction guides, using a custom-designed 3D printed guide according to the future gingival margin of the planned dentition. A 61-year-old female with concerns regarding her smile appearance was presented. The initial examination revealed excessive gingival show accompanied by excessive overjet. The dentition was in a failing situation. The proposed treatment plan, relying on the sufficient amount of bone and keratinized tissue, consisted of re-contouring of the alveolar ridge and gingiva and placement of six implants and a FP-1 prosthesis after extraction of all remaining maxillary teeth. Digital smile design was completed, and a fully-digitally-guided surgery was planned. This consisted of utilizing three surgical guides. Starting with the fixation pin guide and continuing with the scalloped hard and soft tissue reduction guide and finally, the implant placement template. Following the surgery, the patient received a temporary restoration and on the 4-month follow-up, a new poly-methyl meta-acrylate temporary prosthesis was delivered. The patient's 7-month follow-up is presented in the paper. The report of this triple-template guided surgery indicated that digital 3D planning is a considerably predictable tool to properly establish and evaluate future occlusal plane, smile line, and lip support. Scalloped guides seem to be an excellent alternative to conventional bone reduction guides since they require less bone removal and improve patient comfort during surgery.

Facially driven guided crown lengthening using a complete digital workflow: A dental technique

A facially driven digital guided crown lengthening method using the virtual smile design approach supplemented with a static 3-dimensional face scan that demonstrates the digital data of extraoral soft tissue is presented. The technique enables the practitioner to virtually design the new smile and surgically plan the crown lengthening procedure.

Evaluation metric of smile classification by peri-oral tissue segmentation for the automation of digital smile design

ObjectivesThis study aimed to develop and validate evaluation metric for an automated smile classification model termed the “smile index.” This innovative model uses computational methods to numerically classify and analyze conventional smile types. MethodsThe datasets used in this study consisted of 300 images to verify, 150 images to validate, and 9 images to test the evaluation metric. Images were annotated using Labelme. Computational techniques were used to calculate smile index values for the study datasets, and the resulting values were evaluated in three stages. ResultsThe smile index successfully classified smile types using cutoff values of 0.0285 and 0.193. High accuracy (0.933) was achieved, along with an F1 score greater than 0.09. The smile index successfully reclassified smiles into six types (low, low-to-medium, medium, medium-to-high, high, and extremely high smiles), thereby providing a clear distinction among different smile characteristics. ConclusionThe smile index is a novel dimensionless parameter for classifying smile types. The index acts as a robust evaluation tool for artificial intelligence models that automatically classify smile types, thereby providing a scientific basis for largely subjective aesthetic elements. Clinical significanceThe computational approach employed by the smile index enables quantitative numerical classification of smile types. This fosters the application of computerized methods in quantifying and analyzing real smile characteristics observed in clinical practice, paving the way for a more objective evidence-based approach to aesthetic dentistry.

Alignment of Maxillary and Mandibular Midlines in Dentate Individuals: A Cross-sectional Analysis

Introduction: The dental midline is a vital element in smile design. The maxillary and mandibular central incisors midline should ideally be positioned coinciding with each other, Incorrect placement of midlines would lead to instability in dental composition. The dental literature fails to disclose the data as to how nature positions the midline of anterior teeth. Aim: To evaluate the relation between the midlines of maxillary and mandibular dental arches in the dentate population using standardised digital photographs. Materials and Methods: This in-vitro cross-sectional study was carried out in the Department of Prosthodontics, Maharishi Markandeshwar College of Dental Sciences and Research, Mullana, Ambala, Haryana, India between June 2021 to December 2022. A total of 155 dentate subjects (102 females and 53 males) of this demographic area, all within the age group 18-45 years of age were selected for present study. Full-face standardised photographs of the subject’s frontal profile of occluding teeth in a retracted mouth were captured with a Digital Camera (Nikon D3200 DSLR). The collected samples of intraoral images were analysed in image analysing software (Digimiser version 6.0). Lines were constructed in the software to record the maxillary midline and mandibular midline to assess the coincidence or deviation between them. Direct measurements were also obtained within these constructed lines to record the distance of deviation. Direction (right/left) and distance of deviation were recorded. The collected data were subjected to appropriate statistical testing. The statistical analysis was done using the Chi-square test, t-test, etc., and performed in the statistical software International Bussiness Machine (IBM) Statisical Packages of Social Sciences (SPSS) statistics version 25 (Armonk, USA). Results: The mandibular midline did not coincide with the maxillary midline in 134 (86%) of the tested population and within both genders and showed a significant (p-value-0.00) deviation of 1.88 mm after application of the t-test. Although 78 (50%) deviations were towards the left-side and 56 (36%) toward the right-side of the maxillary midline within both genders, the results were statistically insignificant with the Chi-square test. Conclusion: Mandibular and maxillary dental midline fails to coincide in more than four-fifths of the subjects.