The impact of dental midline angulation towards the facial flow curve on the esthetics of an asymmetric face: Perspective of laypeople and orthodontists.

PURPOSE: The objective of the present article was to evaluate the impact of dental midline angulation in asymmetrical faces. MATERIALS AND METHODS: A full-portrait image was used to create a set of digitally modified images with a different degree of facial asymmetry, towards the right and the left side of the face respectively. Half of the images were designed with an equivalent angulation of the dental midline in respect to the curve of the lower third of the face and half of them without. Through a web survey, 250 laypeople and 250 orthodontists were asked to assess the attractiveness of each image separately. RESULTS: As the asymmetry of the face was increased, facial attractiveness was further decreased both for laypersons and orthodontists. For each one of the modified images, when the dental midline was following the curve that was formed from the inclination of the simulated asymmetry of the face, the smile attractiveness scores were significantly higher compared to a straight dental midline. CONCLUSION: Facial asymmetries derived from the inclination of the nose, the chin and the commissural line of the lips can significantly affect the smile attractiveness. An orientation of the dental midline towards the facial asymmetry in order to follow the facial curve, can be beneficial for the smile attractiveness compared to a perpendicular to the face dental midline. During the design of a smile, clinicians have to take into consideration deviations in facial midline, in order their restorations to be in harmony with the rest of the face. CLINICAL SIGNIFICANCE: During the design of a smile, clinicians have to take into consideration deviations in the facial midline, in order their restorations to be in harmony with the rest of the face.

Perception of smile attractiveness among laypeople and orthodontists regarding the buccal corridor space, as it is defined by the eyes. An innovated technique.

OBJECTIVE: To investigate whether there is a relationship between the distance between the iris and pupil with the ideal size of buccal corridors. MATERIALS AND METHODS: A full-portrait image of a male Caucasian was used to create a set of 11 digitally modified images with different buccal corridor space. A web-based cross-sectional study was designed and distributed via an online survey to 200 laypeople and 200 orthodontists to assess image attractiveness, using a Visual analogue scale. For the statistical analysis, Wilcoxon signed-rank and Mann-Whitney U tests were used. The significance level was set at p < 0.05. RESULTS: The response rate for laypeople was 70% (n = 139), while the rate for orthodontists was 73% (n = 146). For the layperson group, the maximum smile attractiveness score was 10% of buccal width reduction, compared to the iris-pupillary distance, while for the orthodontists, it was 20%. The attractiveness of the smile was significantly reduced in both groups when the buccal corridor width was increased in comparison to the iris-pupillary distance. CONCLUSION: The length between the mesial part of the iris and the distal of the pupil, may constitutes a landmark for the estimation of the desired width of the buccal corridor. CLINICAL RELEVANCE: Inter iris-pupillary distance can be the starting point in the smile designing process, in order to perform a facial driven selection of buccal corridor size.

The crown lengthening double guide and the digital Perio analysis.

OBJECTIVE: This article describes a surgical crown lengthening double guide, which was digitally obtained to improve diagnosis, treatment outcome, and follow-up. CLINICAL CONSIDERATIONS: The rehabilitation of anterior dental esthetics should involve interdisciplinary and facially driven planning for achieving pleasant long-term outcomes. Surgical crown lengthening is one of the most common periodontal surgery, which can be assisted by digital tools to improve surgical planning and follow-up. CONCLUSION: The double guide for surgical crown lengthening allows the proper management of hard and soft tissues for achieving a predefined goal based on biological requirements and facially driven planning. In addition, the digital quality control allows the follow-up compared with the pre-operative condition and planned treatment plan. CLINICAL SIGNIFICANCE: The use of digital tools allow the clinician to develop a facially driven planning with proper communication with the team and patient, leading to a shorter, more predictable, and less invasive surgical technique, reducing postoperative inflammation and increasing patient comfort.

CAD-CAM natural restorations-Reproducing nature using a digital workflow.

OBJECTIVES: Natural restorations combine digital workflow and shell technique to create CAD/CAM restorations with the form and texture of natural teeth. This case report describes an interdisciplinary digital workflow combined with CAD/CAM natural restorations to achieve the naturalness of an anterior rehabilitation. CLINICAL CONSIDERATIONS: A 38-year-old patient attended to the office with esthetic issues. An interdisciplinary treatment plan was conducted, which included periodontal surgery to recreate the gingival contour, associated with bleaching and manufacturing CAD/CAM ceramic veneers to return an optimal teeth surface texture and shape. CONCLUSIONS: The design and manufacturing of CAD/CAM natural restorations using a digital workflow allowed a predictable result and overcame the limitations of conventional shell technique. CLINICAL SIGNIFICANCE: Conventional shell technique is used to create restorations with the form and texture of natural teeth. This article presents a combination of the conventional shell technique with a digital workflow, facilitating the design and manufacturing of CAD/CAM natural restorations.

Digital approaches to facially guided orthodontic and periodontal rehabilitation in the anterior esthetic zone: A case report.

OBJECTIVE: The present case report describes digital approaches to plan an orthodontic and periodontal rehabilitation at the anterior esthetic zone. CLINICAL CONSIDERATIONS: A young patient attended to the dental practice with esthetic concerns. The facially driven digital planning showed the need of an interdisciplinary treatment to improve smile harmony. Orthodontic treatment was conducted with aligners, followed by periodontal and restorative approaches. Tooth alignment was performed with 31 aligners, whereas eight aligners were used for refinement. Harmony between pink and white esthetics was improved with crown lengthening, followed by bleaching. CONCLUSION: By using a conservative approach, a successful esthetic result was achieved respecting functional and biological principles. CLINICAL SIGNIFICANCE: Digital resources can be used to the interdisciplinary esthetic planning taking into consideration the harmony between smile and face. This approach allows a predictable outcome of the treatment.

Esthetic treatment planning with digital animation of the smile dynamics: A technique to create a 4-dimensional virtual patient.

A method is presented for obtaining a virtual 4-dimensional patient that replicates the intended esthetic treatment. The process involves facial and intraoral scanning to acquire records and software manipulation to enable a virtual waxing of the smile. Once the digital design is complete, patient information can be merged to generate an animated video of the projected rehabilitation, displaying movement and smile dynamics. This strategy provides a noninvasive and reliable diagnostic tool for predicting clinical outcomes.

Three-Dimensional (3D) Facially Driven Workflow for Anterior Ridge Defect Evaluation: A Treatment Concept.

The esthetic rehabilitation of anterior ridge defects and achieving patient satisfaction have become major clinical challenges for dentists and technicians. Poor diagnosis and treatment planning are frequently associated with multiple surgical procedures that fail to meet patient expectations. The loss of hard and soft tissues in anterior ridges results in an esthetically compromised zone that affects the rehabilitation prognosis. The presence of interdental papilla and papillary configuration play a decisive role in patient satisfaction. A treatment plan considering esthetic parameters, prosthetic needs, and morphological defects must be used to improve treatment outcomes. Therefore, this study aims to propose a treatment concept for anterior ridge defects that focuses on digital evaluation systems and is guided by an ideal facially driven smile design project. In addition, the relevance of the papilla for esthetic outcomes and treatment alternatives for anterior ridge defects are also addressed.

Interdisciplinary guided dentistry, digital quality control, and the "copy-paste" concepts.

OBJECTIVE: The aim of this report is to present an interdisciplinary approach with novel concepts to virtually plan and achieve esthetics and function. CLINICAL CONSIDERATIONS: Despite the advancements in the digital workflow applied to restorative dentistry, the final outcomes are commonly not similar to initial planning. To overcome this major limitation, three concepts are proposed: guided dentistry, digital quality control and "copy-paste" dentistry. Guided dentistry consists of simulations in 3D software and also includes the manufacture of guides/appliances to assist dentists in all clinical steps. Digital quality control involves the use of intraoral scanners and 3D software to compare the real outcomes with the pre-operative simulations after every procedure. "Copy-paste" dentistry is a consequence of the previous two concepts. Using the capacity of the software to overlap files, the original project can be maintained and adapted to achieve results more comparable with the initial design. The proposed method associates facially driven treatment planning and periodontal and restorative procedures to perform the patient's dental rehabilitation. CONCLUSION: Through a guided workflow and digital control of clinical steps, the final outcomes obtained were equivalent and closer to the initial design. CLINICAL SIGNIFICANCE: In interdisciplinary cases, the treatment plan needs to address individual requirements and to coordinate sequential clinical stages. It is challenging to meet these demands in a conventional process. The proposed concepts engage technological resources to orientate the procedures and to provide assessment in each step. This approach enables the development of a complete and accurate functional-esthetic rehabilitation. Ultimately, the technique presented is reproducible and the results reflect the established plan.

Dental software classification and dento-facial interdisciplinary planning platform.

OBJECTIVE: Despite all advantages provided by the digital workflow, its application in clinical practice is still more focused on device manufacturing and clinical execution than on treatment planning and communication. The most challenging phases of treatment, comprehensive planning, diagnosis, risk assessment, and decision-making, are still performed without significant assistance from digital technologies. This article proposes a new dental software classification based on the digital workflow timeline, considering the moment of patient's case acceptance as key in this classification, and presents the ideal software tools for each phase. CLINICAL CONSIDERATIONS: The proposed classification will help clinicians and dental laboratories to choose the most appropriate software during the treatment planning phase and integrate virtual plans with other software platforms for digitally guided execution. A dento-facial interdisciplinary planning platform virtually simulates interdisciplinary clinical procedures and assists in the decision-making process. CONCLUSIONS: The suggested classification assists professionals in different phases of the digital workflow and provides guidelines for improvement and development of digital technologies before treatment plan acceptance by the patient. CLINICAL SIGNIFICANCE: Three-dimensional interdisciplinary simulations allow clinicians to visualize how each dental procedure influences further treatments. With this treatment planning approach, predictability of different procedures in restorative dentistry, orthodontics, implant dentistry, periodontal, and oral maxillofacial surgery is improved.

Chairside 3D digital design and trial restoration workflow.

Different digital tools have been used in clinical practice to assist in the planning and rehabilitation of patients. Some applications (apps) and software programs used in esthetic planning allow simulation of the smile design, improving communication between patients and professionals. Nonetheless, they are usually difficult to use, time-consuming, unattractive to present to the patient, and complicated to link with the 3D workflow. This article presents a new 3D digital smile design app for esthetic planning, smile simulation, chairside 3D virtual wax pattern, and trial restoration performed with portable devices. In this technique description, a facial frontal photograph, a facial scan standard tessellation language (STL) file, and a maxillary intraoral scan STL file were uploaded to the app. The files were calibrated to each other to allow a 3D facially driven smile design project. The definitive maxillary 3D digital waxing of facial templates was exported to a 3D printer as an STL file. The printed resin templates were directly placed in the mouth with flowable composite resin for an immediate trial restoration without the need for casts, silicone guides, or autopolymerizing resin. The workflow presented in this article linked the 3Dapp project to a printer and allowed straightforward chairside trial restorations.

Comparing the use of static versus dynamic images to evaluate a smile.

STATEMENT OF PROBLEM: Smile analysis, as part of the overall facial analysis, is an important component of diagnosis and treatment planning in the esthetic rehabilitation of a patient. Most studies that refer to smile analysis are based on static images. A more comprehensive evaluation can be made with dynamic video images that can be stopped at the most appropriate frame to ensure the best static images for analysis. PURPOSE: The purpose of this clinical study was to evaluate the posed and dynamic smiles of both sexes, considering the type of smile, prevalence of gingival display, dental display at rest, dentogingival display at posed and spontaneous smile, and lip mobility, through digital image acquisition (photographs and video clips) manipulated by using a software program. MATERIAL AND METHODS: Three photographs and 1 video clip were made for each of the 380 voluntary participants aged between 18 and 32 years by using an iPhone 6 iSight 8 MP camera, Moment lens, and artificial 5500 Kelvin light (IceLight). Digital files were evaluated by using a software program (Keynote), determining each point to be evaluated with posed and spontaneous smiles. RESULTS: With static images, 90% of women and 74% of men had gingival display, with only 35% of women and 21% of men having continuous gingival display. With dynamic analysis, these values increased to 100% of women and 95% of men having gingival display and 62% of men and 81% of women having a continuous gingival display (P<.05). The difference between dentogingival display during posed and spontaneous smiles was clear, with 68% of the participants having 2.25 mm more gingival display. Women tend to show slightly more dental display at rest, posed and spontaneous dentogingival display, as well as lip mobility, than men. CONCLUSIONS: The type of smile changes significantly when posed and spontaneous smiles are compared. Women generally show more gingiva and teeth in all the parameters evaluated than men. Dental treatments should be individually planned according to each patient's smile characteristics.

Development of a surgical guide for minimally invasive corticotomies with a complete digital intraoral and laboratory workflow.

AIM: Surgically facilitated orthodontic treatment is increasingly being used, especially for adults, to facilitate tooth movements and reduce the duration of orthodontic treatment. The present article reports on an innovative, safe, and minimally invasive technique to perform flapless corticotomies using a dedicated surgical guide produced with a complete digital intraoral and laboratory workflow. MATERIALS AND METHODS: A 51-year-old man presented with maxillary and mandibular anterior crowding. He required rapid treatment with limited use of braces. Corticotomies were planned for both arches before the use of orthodontic appliances. The matching of the stereolithographic files obtained from the digital prints of the full arches and the cone beam computed tomography images allowed for the positioning of the cutting planes for corticisions. The guide was printed with a transparent, biocompatible, and photopolymerizable resin, and cold sterilized. Minimally invasive corticotomies were performed using a piezoelectric instrument. The orthodontic treatment started immediately after surgery. RESULTS: No adverse events were recorded during surgery. The piezoelectric instrument was guided accurately, and precise application of the corticisions prevented all the anatomical elements from being injured. The healing was uneventful and the patient experienced no pain. CONCLUSION: The present report shows that a surgical guide specifically and digitally produced for corticotomies allowed for the performance of a minimally invasive flapless technique and accurate piezosurgery. The use of such a guide was easy to implement, made the procedure safer, and reduced postoperative pain.

Integrating a Facially Driven Treatment Planning to the Digital Workflow for Rehabilitation of Edentulous Arches: A Case Report.

AIM AND OBJECTIVE: This case report presents the integration of a digital facially driven prosthetic plan to the computer-assisted implant planning for rehabilitation of edentulous arches. BACKGROUND: Diagnosis of edentulous arches is hampered by the lack of intraoral references. However, a digital facial profile analysis facilitates the treatment plan, taking into consideration the harmony among teeth, lips, and face to restore a pleasant smile. CASE DESCRIPTION: The first appointment consisted of digital documentation including intraoral scans, facial scans, and photographs. Based on these data, a smile frame was created to guide the digital wax-up. Cone-beam computed tomography (CBCT) scans were merged to facial and intraoral scans to perform the virtual surgical planning. Integration between facial, intraoral, and bone tissues were used as a reference to define implant position and prosthetic planning. The digital planning was integrated into the surgical procedure using stackable templates, and an immediate loading was performed. The interim prosthesis was manufactured based on the digital wax-up. With digital data, quality control could be performed to evaluate the esthetic outcome of the treatment. CONCLUSION: An esthetic and functional rehabilitation was possible using the respective digital workflow to define harmony between a smile and facial tissues. CLINICAL SIGNIFICANCE: A digital treatment implant planning can be conducted considering patient's individual needs to improve the esthetic outcome.

Layperson's preference of the transverse occlusal plane in asymmetric facial model.

OBJECTIVE: Facial asymmetries are common, especially deviated nose and chin. The clinician must consider these variables when establishing the smile, placement and angulation of the occlusal plane. The purpose of this article is to determine if nose and chin deviations affect the perception of laypeople towards different angulations of the occlusal plane cant. MATERIALS AND METHOD: An asymmetric facial model was created from a symmetric facial model used in a previous study. Nose and chin were deviated 3 mm to the left and eight different pictures were created, each with different degrees of occlusal plane cant in both direction. Using a visual Likert scale delivered via Websurvey within the private practice setting, 120 randomly selected laypersons evaluated each image according to their own beauty preferences. RESULTS: In an asymmetric face, nose and chin deviated 3 mm to the left, a minor occlusal plane angulation of 2° can be perceptible regardless of the direction of the cant. CONCLUSIONS: The occlusal plane should be as parallel to the interpupillary line as possible. If occlusal cant is present, less than 2° of angulation it is preferable, regardless of the direction of the nose and chin. CLINICAL SIGNIFICANCE: In the presence of an asymmetric face, the occlusal plane should be as parallel as possible to the interpupillary line. The direction of the deviation of the nose and the chin are irrelevant factors to determine the occlusal plane. An inclination of the occlusal plane can cause vertical discrepancy, which could subsequently create malocclusion. A complete dentofacial analysis can aim at assessing the angulation of the occlusal plane not only for esthetic outcomes, but for also allowing correct occlusal function.

The facial flow concept: An organic orofacial analysis-the vertical component.

Orofacial analysis has been used by dentists for many years. The process involves applying mathematical rules, geometric principles, and straight lines to create either parallel or perpendicular references based on the true horizon and/or natural head position. These reference lines guide treatment planning and smile design for restorative treatments to achieve harmony between the new smile and the face. The goal is to obtain harmony and not symmetry. Faces are asymmetrical entities and because of that cannot be analyzed using purely straight lines. In this article, a more natural, organic, and dynamic process of evaluation is presented to minimize errors and generate harmoniously balanced smiles instead of perfect, mathematical smiles.

Layperson's perception of axial midline angulation in asymmetric faces.

OBJECTIVE: Asymmetric facial features such as a deviated nose and chin are common and known to affect smile esthetics. When presented with these asymmetries, the clinician must consider the impact they will have on the smile design parameters-especially the placement and angulation of the dental midline, which is a common starting point for a case involving smile design. The purpose of this article is to determine if the nose and chin deviations affect the perception of dental midline angulation. MATERIALS AND METHODS: An asymmetric facial model (AFM) was created from a digital symmetric facial model, used in a previous study by digitally deviating the nose and chin to the same side. Eight different pictures of this AFM were created, each with different degrees of maxillary midline angulation (both in and against the direction of the deviated nose and chin). Using a visual Likert scaled delivered via Websurvey in the private practice setting, one hundred and ninety-six randomly selected laypersons were asked to evaluate each image according to their own notions of beauty. RESULTS: A minor axial dental midline angulation of 3.5° can be perceived independently of the direction of the cant. All pictures where the midline was canted pointing in the opposite direction of nose and chin deviations presented lower rating mean values. CONCLUSIONS: Off-center noses and chins can influence the perceived attractiveness of a smile with a canted dental midline. The degree and direction of a canted midline can influence the harmony between the smile and overall face, with canting in the same direction of the asymmetric features being rated as more attractive. CLINICAL SIGNIFICANCE: The dental midline should be as vertically straight as possible. If a midline cant is present, however, it is more favorable to have a dental midline angulation which points in the same direction as nose and chin deviations, rather than in the opposite direction.

Fully digital workflow, integrating dental scan, smile design and CAD-CAM: case report.

BACKGROUND: This report is a presentation of a clinical case that follows a full digital workflow. CASE PRESENTATION: A 47-year old man presented with pain in the TMJ (temporomandibular joint) and whose aesthetic concern was having a chipped maxillary central incisor veneer. The concern was solved following a fully digital workflow: it was applied the digital smile design protocol, as well as CAD-CAM monolithic lithium disilicate ceramic veneers and crowns (following a minimal invasive preparation approach). The aim of this rehabilitation was to solve a loss of vertical dimension, subsequent aesthetics and temporomandibular joint disorders. CONCLUSION: Thanks to the evolution of technology in dentistry, it is possible to do a full digital case and solve problems such as loss of vertical dimension successfully. Nevertheless, more clinical studies are needed to obtain consistent results about the digital work flow compared to the conventional technique in loss of vertical dimension cases.

Facially generated and cephalometric guided 3D digital design for complete mouth implant rehabilitation: A clinical report.

Harmony among the teeth, lips, and facial components is the goal of prosthodontic treatment, whether performed by conventional or digital workflow methods. This clinical report describes a facial approach to planning computer-guided surgery and immediate computer-aided designed and computer-aided manufactured (CAD-CAM) interim complete-arch fixed dental prostheses on immediately placed dental implants with a digital workflow. A single clinical appointment for data collection included dentofacial documentation with photographs and videos. On these photographs, facial reference lines were drawn to create a smile frame. This digital smile design and sagittal cephalometric analysis were merged with 3-dimensional scanned casts and a cone beam computed tomographic file in virtual planning software, thus guiding virtual waxing and implant positioning. Computer-guided implant surgery and CAD-CAM interim dental prostheses allowed esthetic and functional rehabilitation in a predictable manner and integrated with the patient's face.

The Complete Digital Workflow in Implant Dentistry.

Current diagnostic and treatment planning tools support a complete digital workflow that takes the guesswork out of implant dentistry and facilitates asynchronous collaboration between all involved specialties, from the restorative dentist to the surgeon to the dental laboratory. Long gone are the days of freehanded implant placement as guided as well as navigated surgery and now even robots provide unprecedented precision and predictability in implant placement based on the individual medical, morphologic, and anatomic situation of each patient.