/home/opencode/cpanel/stomaeduj_hacked/uploads/2018/04/Article_5_4_3.pdf 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 Stomatology Edu Journal 229 CURRENT PERSPECTIVES ON DIGITAL SMILE DESIGN 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 DIGITAL SMILE DESIGN 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 Stomatology Edu Journal 231 CURRENT PERSPECTIVES ON 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]. 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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