Article_5_4_3
AESTETHIC DENTISTRY
CURRENT PERSPECTIVES ON DIGITAL SMILE DESIGN
Review Article
Luca Levrini1a* , Silvia Croceb, Sanda Mihaela Popescu2c , Marian-Vladimir Constantinescu3d ,
Riccardo Bottab, Francesca Cattoni4e
1
Department of Medicine and Surgery, University of Insubria, Varese Como, Italy
2
Dental Reabilitation and Medical Surgery Emergencies Department, Faculty of Dental Medicine, University of Medicine and Pharmacy of Craiova, Dolj, Romania
3
Holistic Dental & Medical Institute – ROPOSTURO, Bucharest, Romania
4
Department of Dentistry, Vita-Salute San Raffaele University, Milano, Italy
a
MD, PhD, Associate Professor; University of Insubria, Varese, Italy; Assistant Medical Director, Dental Clinic, Fondazione Macchi Hospital, Varese, Italy
b
DDS, private practice
c
DDS, PhD, Professor, Head
d
DDS, MSc, PhD, Professor, President
e
MD, PhD, Adjunct Professor
These authors contributed equally to this work
ABSTRACT DOI: 10.25241/stomaeduj.2018.5(4).art.3
Background: Digital Smile Design (DSD) is a method that helps predict digitally the OPEN ACCESS This is an
outcome of a smile based on the use of both static or dynamic images, in order to Open Access article under the CC
plan simple or complex rehabilitation cases, to “draw a smile”. It is a valuable resource BY-NC 4.0 license.
Peer-Reviewed Article
used to show the outcome of the treatment, to evaluate the aesthetic rehabilitation, to
complete the diagnosis and improve communication with patients, laboratories and Citation: Levrini L, Croce S, Popescu
SM, Constantinescu M-V, Botta R, Cattoni
interdisciplinary clinicians. JPEG photos and STL files are forwarded to the laboratory F. Current perspectives on digital smile
and imported in CAD-CAM to make a mock-up and a provisional restoration. Thus, it is design. Stoma Edu J. 2018;5(4):229-235.
possible to check each step of the planning and make any corrections necessary. Academic Editor:
Objective: The present article is a comprehensive review on DSD, including every field Constantinus Politis, MD, DDS, MM, MHA,
PhD, Professor & Chairperson, University of
in which it extends. Leuven, Leuven, Belgium.
Data sources: The research includes articles featuring the keywords: digital smile Received: November 14, 2018
design, prosthodontic, surgery, digital flow, orthodontics and was conducted in two Revised: November 30, 2018
different databases, PubMed and Google Scholar. Accepted: December 10, 2018
Published: December 11, 2018
Study Selection: After screening and removing the duplicates, 22 articles from Pubmed
and 11 from Google Scholar were selected. *Corresponding author:
Associate Professor Luca Levrini, DDS,
Data extraction: The analysis included 13 articles regarding prosthetic rehabilitations, PhD, President, Dental Hygiene School,
7 articles about surgery (periodontal or rehabilitation), 11 articles describing DSD and Director, Research Centre Cranio Facial
Disease and Medicine, University of
2 articles about orthodontics. The research included articles in English from 2000 to Insubria
2018. Via Giuseppe Piatti, 10, I-21100 Varese
VA, Italy, Tel/Fax: 0332.825.663,
Data synthesis: DSD is an excellent way to design dental treatments thanks to its e-mail: luca.levrini@uninsubria.it
versatility in managing the treatment plan; however further improvements are required Copyright: © 2018 the Editorial
to refine the software and permit an appropriate clinical application. Council for the Stomatology Edu
Journal.
Keywords: digital smile design, diagnosis, communication.
1. Introduction workflow”. Actually, for this reason the term digital
In the digital era new technologies are revolutionizing smile design is considered as the main method to
the world of dentistry in order to facilitate and describe all the digital clinical works that simulate a
expedite normal procedures. Clinicians are seeking dental treatment. The purpose of DSD is to simplify
for new ways to implement more comfortable a complex task and to make sure that the patient
and rapid treatments yet keep high quality results. can have a better impression of what the treatment
Due to the high aesthetic demand from patients, is going to be. The virtual 2D smile design could
displaying a preview of the outcome is the new make a diagnostic wax to facilitate clinical steps,
trend. As Coachman said, for every work of art such as a computer-aided design and computer-aided
as painting, sculpture or dentistry, it is necessary to manufacturing programs (CAD-CAM). Unfortunately,
make a plan or a prototype [1]. Currently, there are 3D virtual patient including intraoral soft tissue,
some programs available like smile designer pro, craniofacial hard tissue and extra-oral soft tissue has
digital smile design, aesthetic check, digital smile some limitation, it is still complex to recreate as real
system to serve this purpose [2]. Digital Smile Design [3]. Digital Smile Design (DSD) is based on the use of
is among the most used, it is a software designed to static and dynamic digital images, transferred to the
make diagnostics and simulate the outcome of the digital software which uses different tools to “draw
future treatment: it can be seen as “outcome based the smile”. 2D smile design is gaining popularity as
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an important tool for the communication between was created for each of them with the most important
Review Article clinicians, between clinician and patient and information about the topic and what marks it.
also between clinician and laboratory [4]. Before
DSD, dental technicians used to make restoration
treatments either through standard rents, photos 3. Results
or instructions provided by the clinician. A lot of At the end of the research 33 relevant articles were
information was missing in regards to the context found: 22 articles from Pubmed and 11 from Google
in which the restoration was done, including lip Scholar. We can divide the articles selected in four
position, middle facial line, incisal plane, and some groups, each one belonging to a different argument:
characterizations of the nearby teeth, such as colour, 1. Prosthetic rehabilitations: 13 articles were about
shape, spots or cracks. DSD can help the dental the use of digital smile design as a means to plan
technician to make higher quality restorations and a prosthetic rehabilitation, like aesthetic veneers,
more exactly, avoid extra phases that delay the singular crown, metal-ceramic bridges or porcelain.
treatment. Furthermore, it is possible to re-evaluate 2. Digital Smile Design (DSD): 11 articles were about
every step of the rehabilitation, comparing it with the main theme, described the method to acquire
the diagnostic plan. The use of DSD can help plan the digital information and to develop it
simple and complex cases with more control by the 3. Surgery: 7 articles were about surgery, periodontal
laboratory and the clinician[1]. First, digital intraoral plastic surgery, bone sculpturing, gummy smile, or
photos against black backgrounds are needed: implant rehabilitation
full smile from the front, left and right side, upper 4. Orthodontics: 2 articles were found about the use
and lower occlusal view (The American Academy of digital smile design associated to the Clin Check
of Cosmetic Dentistry Photographic Accreditation software of Invisalign aligners.
Review in 1995)[5]. Second, the extra-oral photos: full There are several application fields; traditionally
smile, mid facial right and left; the patient’s 3D facial the digital design was associated to conservative
soft tissues are captured with a 3D scanner (Sense, dentistry; although its use will be improved
3D system Inc). Files are then transferred as a JPEG in prosthodontic, surgery and in particular in
format to the software. A diagnostic impression orthodontic in the future.
with an intraoral scanner in a stereolithography file
format (STL) is also transferred into the software.
Intraoral photos and the 2D virtual smile design are 4. Discussion
superimposed to create a virtual patient with facial 4.1. Digital Smile Design (DSD)
tissue and a full smile. Digital Smile Design (DSD) can be performed with Key
The above mentioned are used to show the final result. Note (for Macintosh) and Power Point (for windows).
The JPEG photos and STL files are then forwarded Through DSD, pre-existing dental anomalies such
to the laboratory and subsequently imported to as shape, size, position, color or texture can be
the CAD-CAM software to make a mock-up and a identified and modified with the ultimate goal of
provisional restoration, even if the conversion from designing the optimal smile [6]. It starts with data
the 2D design to the 3D waxing could still cause gathering and digital planning. On the full face extra-
distortions of the images. The definitive restoration oral photo horizontal and sagittal plane are tracked
will be created based on the test with provisional in accordance with anatomical references: inter-
restoration and in accordance with the diagnostic pupillary line and middle facial line (glabella-nose-
plan [3]. chin).
In view of the advantages that this system has, a These lines are transferred to the full smile intraoral
learning curve is required to use it to its full potential. photo for a comparison with the occlusal plane and
Starting from these considerations, we decided to the dental midline.
develop this review to analyze the most relevant The second step is the dental analysis (horizontal
literature about on the theme. lines): the outline of each tooth is drawn and enclosed
in a rectangular, combined with the future treatment,
the tip of each canine, the incisal edge of both central
2. Methodology incisor and dental midline. The ideal proportions of
A computerized database search was performed to length and width are placed to be compared with the
identify relevant articles. The purpose of this work was project, including measurements in millimeters to
not to aim at being a systematic review of literature, calibrate the size of each element. Finally, the smile
but to state the topic from the point of view of the design is superimposed on the initial situation to
literature analysis. The keywords introduced for the show the relation with the gingival contour, and then
research were: Digital Smile Design, DSD, digital the virtual waxing is performed [7,17]. A digital ruler
work flow, Digital Smile Design and Orthodontics. is used to show the measurement of the teeth.
The databases used are PubMed and Google Scholar After having investigated the patient’s expectations,
and the research includes works in English from 2000 the treatment proposals are exposed; the patient
to 2018. The articles were analyzed and a unique file approves the design and chooses which treatment
230 Stoma Edu J. 2018;5(4): 229-235 http://www.stomaeduj.com
CURRENT PERSPECTIVES ON
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plan to proceed with and subsequently the clinicians to the anatomical features, the lip dynamics, the
Review Article
decide the operative time table. In the traditional incisal edge position and midlines [18]. With the DSD
DSD protocol the digital wax-up is transferred to the software it is possible to design different types of
master cast, maintaining the tooth’s design, and it is prosthetic rehabilitation such as porcelain laminates
used to fabricate the silicone guide for the provisional veneers, ceramic crown or bridges [19]. The most
denture[8]. It is important to have a check list to common are aesthetic veneers, both of feldspathic
follow in each step; there is a constant double-check ceramic, lithium disilicate and zirconium. In order
between the DSD and every phase of the treatment to perform an aesthetic rehabilitation with veneers/
to identify and correct any errors and give a higher dental crown a silicone index is obtained from
quality to the treatment [9]. the dental cast to evaluate the need for reduction
If patients are not satisfied with the result of an and another silicone guide is for the provisional
aesthetic rehabilitation the clinician can change restorations [20]. The creation of an interim
something about the design and can adapt the prosthesis allows us to visualize possible errors in the
functionality. Thanks to the DSD clinicians can reach design and thus be able to make changes to the final
the patient’s compliance and patients have no prostheses; additionally, it is also serves as a further
surprise at the end of the treatment thanks to the pre-visualization of the patient, even though he can
pre-visualization of the outcome [10]. already see the result thanks to the DSD software [21].
Often the aesthetics of the smile can be improved
4.2. DSD in Prosthodontics without resorting to a prosthetic treatment but
In recent years the expectations of dental patients preferring a more conservative treatment such as
have greatly increased regarding their aesthetic dental bleaching or the application of infiltrative
appearance, which has already reached the same resins or aesthetic reconstructions in composite
importance as the function [11,12]. To pursue the [22]. In cases of morphology changes (microdontics,
least invasiveness is a priority in every prosthetic conical teeth) or colour (dyschromia, tinctures, dark
restoration which aims to improve the smile non-vital teeth) and structure (enamel deficiency as
aesthetics, preserving as much dental tissue as hypoplasia, white spot) this is not possible and the
possible and respecting the surrounding soft prosthetic option remains the best choice [17,23].
tissue [13]. As demonstrated by Magne et al, a While in the traditional DSD protocol the digital wax-
veneer preparation approach driven by the final up is transferred to the master cast, maintaining the
volume of the restoration (the mock-up) allows for tooth design, and it is used to fabricate the silicone
more enamel preservation, avoiding unnecessary guide for provisional denture [8], in recent months
overpreparations by removing just the dental tissue an evolution of smile design protocols has been
needed to create proper prosthetic thicknesses, and achieved and a project using only digital methods
more predictable bonding, biomechanics and final has been executed called Digital Smile Planning [24].
aesthetics [14]. According to Coachman’s protocol, In this case the design of the patient’s restoration was
the realization of the diagnostic wax-up is anticipated then performed using the DSS-2D software (3D Lynx,
and, above all, guided by the Digital Smile Design, 3D Lynx srl, Italy).
which has proved to be a fundamental and useful The software allows designing digital aesthetic and
tool for improving communication and the patient’s functional smile rehabilitation through a guided
acceptance, but all the remaining steps are the path, and which, thanks to the automatic calibration
same as the traditional ones [15]. The DSD used for tools, can perform mathematically controlled
planning a prosthetic rehabilitation is probably the measurements. This program allows the patient to
most common application of the software, as it preview the prosthetic result directly on a photograph
also emerged from our literature review. It allows to of himself and provide the dental technician with
design treatments without needing the patient to sit all the information needed to perform the work
on a chair and analyze the treatment plan in this way, through a detailed report [24]. The digital restoration
by considering all the aesthetic parameters [16]. project was realized using the patient’s photos, and
The key to the success of the treatment is the harmony choosing dental shapes from the software libraries.
between the various components of the smile’s The use of a specific landmark while taking the
aesthetics, such as colour, shape, volume, texture, patient's photographs, with reference points, allows
dental alignment, gingival contour, the relationship the software to calibrate the system on the picture so
between the teeth of the upper arch and those of the that it can give precise measurements in millimeters,
lower arch as well as the contextualization in the face useful to guide the work of the clinician and, above
[17]. all, the technician. It is also necessary to take an intra
The starting point is always drawing the references oral optical impression to feed the original shape of
lines extra and intraorally: the reference planes are the natural elements into the CAD software. The STL
drawn (bipupillary line, middle facial line, Frankfurt files of the patient’s arches have been uploaded to
plane), dental middle line, occlusal plane, tooth the software for the realization of the digital wax-ups
contour. When parameters are provided we proceed by the DSS-3D system (CAD Lynx-, 3D Lynx srl, Italy),
with designing the diagnostic wax-up, referring direct implementation of the DSS-2D system, and a
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DIGITAL SMILE DESIGN
milled mock up has been produced and tested in the more invasive treatment [29].
Review Article mouth of the patient, to guide the tooth preparation
and, if necessary, also the surgical evaluation of the 4.4. DSD in Orthodontics
soft tissue design. Nowadays, modern orthodontic techniques (clear
Nowadays it is also possible to apply the digital aligner) allow early visualizations of the orthodontic
planning protocol not only on natural teeth, in simple treatment that is necessary to proceed further with
or complex cases, but also in the initial phase of the the production of aligners. In the perspective of
full-arch implant supported rehabilitation protocol considering DSD as a digital visualization of the
[25]. The Virtual Implant-Prosthetic Procedure: result that could be obtained, this early visualization
VIPP Technique [25], can be used to integrate the already guarantees an excellent projection of the
prosthetic and the implant project helps the correct result.
guided implant positioning [26], optimized either However, these simulations do not permit to predict
for bone volumes available and to absorb the how the results of an orthodontic treatment can be
masticatory loads and the fabrication of an adequate compared to the patient's mini-aesthetics (smile with
prosthesis, in compliance with the intermaxillary the lips) and macro-aesthetic (face): the available
relationship, the function and the occlusal balance, digital models of orthodontic treatment, in fact, are
the soft tissue support [27]. substantially 3D-image digital devices that simulate
only the patient's dentition.
4.3. DSD in Surgery For this reason, digital methods have been developed
Digital smile design has also found its usefulness in in a way which permitted to combine the views of
the surgical field. The digital workflow in the surgical orthodontic treatment with images of the patient's
area begins with the collection of radiographic data face: the result was an image that represented the
and then the photos. It is possible to superimpose patient's smiling face with the simulation of the
on the CBCT the DICOMs files (Digital Imaging and teeth as it would appear after the changes at the
Communications in Medicine) for planning the micro- and macro-aesthetic level obtained thanks
surgery. Unfortunately, the combination of several to the orthodontic treatment. These digital methods
files can create image distortion and diagnostic are generally performed with professional photo
dental models are needed to overcome this problem processing software (photo editing), such as Adobe
[2]. An analysis of the distance between the margin Photoshop®.
of the future prosthetic rehabilitation and the For this aim it may be sufficient: -to make a digital
existing bone is necessary to determine if a grafting transparent model that simulates the result of
procedure will be required, if implants can be orthodontic treatment of the patient's dentition; - to
placed at the level of the bone, or if bone reduction position, overlap and manually align the transparent
is needed and if the future restoration needs to digital model onto an image of the smile or face of
incorporate a pink prosthetic area. Some guidelines the patient with his original teeth and gingiva. This
using the margin of the planned crown as a reference photo must be taken with the patient's occlusal
can be applied. Implants must be placed 3 mm plane in a perpendicular position to the lens, with
apically from the margin of the planned crowns to the teeth in front view compared to the camera; -
create space for average biological width thickness erase the original teeth and gingiva from the image
[28]. Regarding the orthognathic surgery, a sagittal of the smile or face, in order to obtain an image of
analysis with cephalometric guide is essential to the face without teeth but with a residual of the
place the maxillary central incisor in the best position original gum on the transparent digital model; -
and in harmony with the lips and face [28]. bring the transparent digital model below the smile
A combination between periodontal surgery and image or face without teeth and with a residual
prosthetic rehabilitation is possible to carry out gum; - eliminate the transparency from the digital
in case of a gummy smile. A preliminary study is model, obtaining an image of the smile or face,
essential to make the diagnosis: once the treatment which integrates the orthodontic simulation of the
has been established, if a bone or gingival reduction digital outcome; - change the color of the gums and
is necessary, digital planning of the mock up and the teeth to simulate a natural effect of the patient's
the surgery is performed. The surgery is guided gums and teeth.
by a splint made according to the digital design so Actually, this method can be called "orthodontic
that the gum is in the correct position for the future digital face design"; practically, an image of the
prosthesis. The provisional made on the basis of the patient's face or smile is produced and is integrated
planning is used as a surgical stent [23,27]. In many with the occlusal result of the orthodontic treatment.
cases it is not possible to correct a gummy smile only In this way, the patient is able to appreciate the
with a gingival reduction; often an orthognathic simulation of the orthodontic outcome which he
surgery or orthodontic treatment is required. Thanks is undergoing or must undergo before starting
to the digital smile design the patient can see the and appreciate the aesthetic of his smile or face. It
outcome and decide whether to accept the aesthetic is possible to add restorative rehabilitation, either
compromise in case he does not want to undertake a prosthetic or conservative. The method could also
232 Stoma Edu J. 2018;5(4): 229-235 http://www.stomaeduj.com
CURRENT PERSPECTIVES ON
DIGITAL SMILE DESIGN
include a patient's three-dimensional (3D) image of in the anterior sector [36]. However, there are still
Review Article
the smile or the face [22]. uncertainties regarding the occlusion adjustment:
Schabel et al. published a study that compares the in fact, errors can be found during the transfer of
accuracy between photographs and video clips data from the scan to the realization of the study
regarding the possible distortion of the image in a models. This could be the biggest disadvantage
sample of patients treated orthodontically. The results of the program. The chances of not reaching a
showed that there was no significant difference correct occlusion emphasize the importance of
between obtaining images using traditional the temporary restoration to recheck and correct
photographic method or extrapolating them from any errors. For this reason, the technique requires a
video. Yet, a slight difference of 1mm was seen when learning time to be able to take full advantage of its
analyzing the upper incisor in relation to the lower usefulness.
lip. Therefore, photography is still considered the The topic is mainly addressed for the clinical
best tool and the most immediate tool [5]. application, for this reason there is not significant
literature evidence; the idea could be to create a
panel of experts in the fields to edit the clinical
5. Conclusion guidelines on the DSD.
The appearance of a beautiful smile is impregnable,
because the mouth is the most important
manifestation of a human being. The DSD protocol, Author contributions
consisting in drawing reference lines on extra and LL: Idea, study concept and preparation of manuscript.
intra-oral photos and superimposing the dental SC: literature search and analysis orthodontic topic.
design, is an excellent tool for a diagnostic vision and SMP: Contributed to re-writing manuscript. MVC:
help the team members to predict and facilitate the Revision of manuscript and literature search. RB:
treatment [31]. It reduces the risk of asymmetries, literature search and analysis surgery topic.
disharmonies, guided by the diagnostic wax based FC: literature search and analysis prosthodontics
on aesthetic principles. It works both with macro topic
aesthetic (face and neck), mini aesthetic (the smile
and the lips) and micro aesthetic (details about
the shape, the color and defects of the teeth). Acknowledgments
The purpose of DSD is to guide every step of the The authors have no conflicts of interest. This research
treatment by focusing on anatomical features, did not receive any specific grant from funding
parameters provided, and planes of references, agencies in the public, commercial, or not-for-profit
each of them conducted by the wax-up design sectors. The authors declare that the research was
[33]. Among the advantages of this software one conducted in the absence of any commercial or
can list: reduction in the number of appointments, financial relationship that could be construed as a
low clinical costs and a global access to the service potential conflict of interest.
as it allows the clinical staff to visualize the relevant
data and transfer other information via Internet. Lot
of diagnostic data are stored in a single software References
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Luca LEVRINI
DDS, PhD, Associate Professor
Deputy President, Dental Hygiene School
University of Insubria, Varese, Italy
Assistant Medical Director
Dental Clinic Fondazione Macchi Hospital, Varese, Italy
President Fondazione Alessandro Volta, Como, Italy
CV
Professor Luca Levrini, born in 1967. Associate Professor in Clinical Somatology and deputy president Dental Hygiene School,
University of Insubria, Italy. Assistant Medical Director, Dental Department, Fondazione Macchi Hospital, Varese. Member of the
Medical Council, Como, Italy. Medical Journalist. President Fondazione Alessandro Volta, Como, Italy. Author of more than 200
scientific papers dealing with oral prevention and orthodontics. He is an active member of Società Italiana di Ortodonzia and
a Certificate speaker for Align Technology.
234 Stoma Edu J. 2018;5(4): 229-235 http://www.stomaeduj.com
CURRENT PERSPECTIVES ON
DIGITAL SMILE DESIGN
Questions
Review Article
1. Which information is transmitted to lab through classical recordings?
qa. Lip position;
qb. Middle facial line;
qc. Incisal plane;
qd. Tooth position.
2. Which is the limitation of DSD?
qa. Simplifying a complex task and making sure that the patient can have a better impression of what is going to be the
treatment;
qb. Making a diagnostic wax;
qc. Facilitating clinical steps, as a computer-aided design and computer-aided manufacturing programs (CAD-CAM);
qd. Too complex to recreate as real.
3. Digital Smile Design (DSD) can be performed with computer programs like:
qa. Key Note (for Macintosh);
qb. Excel (for windows);
qc. Word (for windows);
qd. Paint (for windows).
4. With the DSD software it is possible to design different types of prosthetic
rehabilitation. Which are the most common?
qa. Aesthetic veneers;
qb. Crown;
qc. Bridge;
qd. Denture.
www.ciosp.com.br
Stomatology Edu Journal 235