Integrating electronic smile design into the analogue aesthetic workflow

Contents

Attaining a a success consequence in aesthetic dentistry is usually a ambitious problem for all dental practitioners, irrespective of their enjoy stage. The affected person describes his or her expectancies of remedy to the dentist, who then diligently works with provisional restorations to fulfill the ones aesthetic needs, best to need to depend at the dental technician (ceramist) to replicate what the dentist and affected person have labored out within the mouth. This procedure would possibly contain a number of appointments, changes and try-ins till a case can also be finalised effectively.

Virtual dentistry now gives the dentist many alternative equipment to design and keep in touch results to the affected person and laboratory that may take a lot of the guesswork out of constructing a cultured outcome that the affected person shall be proud of. For dentists who’ve been in follow for a number of years, electronic applied sciences is also tough to include into their practices on account of prices and/or struggling thru studying to make use of those with a view to undertake a distinct workflow from what they’re acquainted with. Alternatively, each dentist can input electronic dentistry even supposing taking standard impressions and interocclusal data so long as the dental technician can scan the impressions or grasp casts and convert this analogue knowledge into STL recordsdata. This text will describe a method to make use of electronic era in a singular solution to shut the loop between the affected person, dentist and technician with the objective of offering a predictable consequence that saves a lot of the trial and mistake and chair time this is in most cases related to tough aesthetic circumstances.

Fig. 1: Pre-op photograph taken with the EyeSpecial C-III (SHOFU Dental) to convey shade information to the ceramist.

Fig. 1: Pre-op {photograph} fascinated by the EyeSpecial C-III (SHOFU Dental) to put across coloration knowledge to the ceramist.

Fig. 2: Retracted view of initial provisional restorations made of Tuff-Temp Plus (Pulpdent) after removal of the existing restorations and registration of master impressions and interocclusal records.

Fig. 2: Retracted view of preliminary provisional restorations made from Tuff-Temp Plus (Pulpdent) after elimination of the present restorations and registration of grasp impressions and interocclusal data.

Virtual smile design and aesthetic communique

The weather of smile design had been taught and carried out by way of dentists for a number of years. The electronic side of smile design now permits the dentist and/or dental technician to take preoperative pictures at the side of standard impressions and interocclusal data after which to govern parameters inside device to design attainable aesthetic and useful results. Subsequent, this electronic knowledge can also be programmed right into a milling gadget to supply a three-D reproduction or prototype that may be evaluated within the affected person’s mouth. The problem with electronic smile design when used only as a device for affected person presentation is that every now and then a right kind analysis can best be made if the digitally manipulated symbol can someway be transferred to the affected person’s exact smile. Simply because one thing seems excellent on a pc display screen does no longer essentially imply that it is going to glance excellent and serve as neatly within the affected person’s oral hollow space. Handiest when the prototype is positioned within the affected person’s mouth can a practical aesthetic and useful analysis be made.1–3

Getting into electronic dentistry

Step one prior to beginning any aesthetic case is an interview with the affected person to ascertain what the affected person needs and what the affected person does no longer like about his or her smile. Virtual pictures are taken of the affected person’s complete face, complete smile, tooth in centric occlusion and lips retracted, tooth rather separated and lips retracted, mouth within the “E” place, and maxillary and mandibular tooth from the occlusal side. Those pictures will assist the affected person and dentist speak about what’s conceivable to reach and assist to set the affected person’s expectancies. Additionally, pictures with coloration tabs will help the ceramist in opting for an preliminary coloration for the restorations, in addition to in making choices on person characterisation, comparable to cervical chroma, incisal translucency and interior results. One digital camera available on the market designed particularly for dentistry, the EyeSpecial C-III (Shofu Dental), has a selected atmosphere that can isolate the coloration of the enamel and coloration tab, greying out the remainder of the intra-oral constructions (Fig. 1). With this knowledge, the ceramist can create customized coloration tabs that can be utilized to make sure the general coloration previous to fabrication of the definitive restorations. A electronic aesthetic proposal for the case is then designed in response to the diagnostic and visible knowledge equipped.

The electronic aesthetic proposal

The usage of the facility of electronic design and in-laboratory milling, it’s conceivable to create a number of variations of attainable smile designs that may be milled from PMMA and evaluated within the affected person’s mouth for cultured approval and useful design. It’s been instructed that having a decision between two or 3 choices when making emotional choices will make any person really feel extra assured that she or he is making the proper selection.4 In accordance with this premise, digitally produced PMMA prototypes can also be milled and attempted in to provide the affected person a extra lifelike selection within the emotional a part of the decision-making procedure. This procedure can save hours of chair time and hit and miss decision-making when adjusting and enhancing the provisional restorations manually.

The affected person featured within the article had selected to improve her 10-year-old porcelain veneer restorations to embellish the coloration. The ceramic subject matter used to be in moderation got rid of with rotary instrumentation and diamond burs right down to the unique arrangements. After minor changes to gingival margin placement, a grasp affect used to be taken the usage of the two-cord affect methodology. First, a #00 retraction twine is positioned on the base of the gingival sulcus of every preparation. Subsequent, a #1 twine is put on best of the #00 twine on the stage of the preparation margins. When able to continue with the affect, the number 1 twine is got rid of, leaving the #00 twine in position. Subsequent, a light-bodied affect subject matter is positioned into the gingival crevice round every preparation, and the affect tray with heavy-bodied affect subject matter is put into position over the arrangements till set. On this case, the fundamental shapes and lines of the unique restorations have been ample for the fabrication of provisional restorations, so a polyvinylsiloxane stent of the unique restorations used to be made prior to the restorations have been got rid of. After preparation, the stent used to be full of a rubberised urethane provisional subject matter (Tuff-Temp Plus, Pulpdent), contoured chairside and luted into position the usage of a flowable composite (Fig. 2).

Fig. 3: Poured master impression.

Fig. 3: Poured grasp affect.

Fig. 4: Original digital proposal for the case based on the patient’s previous restorations.

Fig. 4: Unique electronic proposal for the case in response to the affected person’s earlier restorations.

Fig. 5: Occlusal view of the digital proposal, showing the ach form and occlusal design for the case.

Fig. 5: Occlusal view of the electronic proposal, appearing the ach shape and occlusal design for the case.

The grasp affect used to be then poured by way of the ceramist and scanned to create the electronic grasp type (Fig. 3) in STL for use within the design device to increase the case proposals. From that time, the opposing type used to be additionally digitised, as used to be the chunk courting. The case used to be then fixed on a electronic articulator, and a case proposal used to be designed for the 10 zirconia veneer restorations. The technician can figure out dog disclusion and anterior steerage just about because the recovery contours are formed and changed within the device (Figs. 4 & 5). The usage of this completed proposal, PMMA restorations have been then milled for each proper and left posterior segments (first and 2nd premolars, and dog) and the 4 maxillary anterior tooth (lateral and central incisors). For the needs of offering a selection of rather changed aesthetic parameters for the affected person to judge, two different proposals have been designed by way of the ceramist for the maxillary incisors with slight diversifications to the incisal edges, embrasures and floor texture. The plan on the affected person’s try-in used to be to cement the dog–premolar segments with provisional cement. The occlusion and dog steerage constructed into those segments would no longer range within the analysis; best the 3 other incisor segments can be checked out and evaluated by way of the affected person.

Fig. 6: Situation after removal of the provisional restorations on the maxillary right side prior to placement of the PMMA prototype restorations.

Fig. 6: Scenario after elimination of the provisional restorations at the maxillary proper facet previous to placement of the PMMA prototype restorations.

Fig. 7: Situation after removal of the provisional restorations on the maxillary left side prior to placement of the PMMA prototype restorations.

Fig. 7: Scenario after elimination of the provisional restorations at the maxillary left facet previous to placement of the PMMA prototype restorations.

The affected person try-in

The chairside provisional restorations fabricated on the preparation appointment have been got rid of and the arrangements have been wiped clean with an antibacterial scrub (Consepsis, Ultradent; Figs. 6 & 7). The milled PMMA provisional segments for tooth #15–13 and tooth #23–25 (Fig. 8) have been then cemented with provisional cement, and the surplus used to be wiped clean from the recovery margins (Fig. 9). The provisional restorations on tooth #12–22 have been then got rid of, and the anterior proposed aesthetic designs have been attempted in. The primary PMMA prototype (Fig. 10) used to be in response to the affected person’s preoperative smile design (Fig. 4). As soon as this prototype used to be within the mouth, it used to be obvious that the marginal gingival tissue were moulded by way of the contours of the unique provisional restorations positioned on the time of enamel preparation such that the tissue would no longer essentially fill the contours of the milled PMMA provisional restorations at preliminary placement (Fig. 11). With a while, the gingiva would adapt to the contours of the PMMA prototype as soon as cemented into position.

Fig. 8: Occlusal view of the posterior segments (teeth #15–13 and teeth #23–25) of the original digital proposal milled in PMMA for intra-oral evaluation.

Fig. 8: Occlusal view of the posterior segments (tooth #15–13 and tooth #23–25) of the unique electronic proposal milled in PMMA for intra-oral analysis.

Fig. 9: Posterior PMMA prototypes in place with provisional cement and prepared teeth #12–22 after removal of the provisional restorations in preparation for evaluation of the anterior proposed aesthetic designs.

Fig. 9: Posterior PMMA prototypes in position with provisional cement and ready tooth #12–22 after elimination of the provisional restorations in preparation for analysis of the anterior proposed aesthetic designs.

Fig. 10: First PMMA prototype for teeth #12–22 based on the original digital proposal that was a bio-copy of the patient’s original maxillary restorations.

Fig. 10: First PMMA prototype for tooth #12–22 in response to the unique electronic proposal that used to be a bio-copy of the affected person’s authentic maxillary restorations.

Fig. 11: First PMMA prototype in place. The margin on tooth #12 of the prototype had been trimmed short of the margin in the laboratory during nishing.

Fig. 11: First PMMA prototype in position. The margin on enamel #12 of the prototype were trimmed in need of the margin within the laboratory throughout nishing.

The second one proposal (Fig. 12) used to be designed to be a little extra angular than the primary proposal. While the primary proposal had extra softened incisal angles and embrasures, just like the affected person’s authentic restorations, this 2nd PMMA proposal had incisal angles that have been extra squared and minor irregularities at the incisal edges to reach a extra herbal look. The affected person used to be no longer proud of its look (Fig. 13), so this prototype used to be no longer thought to be within the ultimate resolution. The 3rd proposal for this situation used to be a mixture of the primary and 2nd ones (Fig. 14). Whilst the incisal angles and embrasures have been softened like in first prototype, the facial surfaces have been textured, very similar to the second one prototype. The affected person selected the 3rd proposal as the only to make use of to mill her definitive restorations (Fig. 15). The prototype may be checked for dog steerage and anterior disclusion and changed, if important (Figs. 16 & 17).

Fig. 12: Second PMMA prototype for teeth #12–22. A slightly angular modication of the first prototype gave a more squared-off appearance to the incisal embrasures and angles. Minor irregularities on the incisal edges also added to a more characterised look.

Fig. 12: 2nd PMMA prototype for tooth #12–22. A rather angular modication of the primary prototype gave a extra squared-off look to the incisal embrasures and angles. Minor irregularities at the incisal edges additionally added to a extra characterized glance.

Fig. 13: Second PMMA prototype in place. Note the reflection of the facial surfaces of the second proposal compared with the first. While the first prototype was smoother in surface texture, the second proposal was more textured to accentuate the individual lobes of the facial surface.

Fig. 13: 2nd PMMA prototype in position. Observe the mirrored image of the facial surfaces of the second one proposal when compared with the primary. Whilst the primary prototype used to be smoother in floor texture, the second one proposal used to be extra textured to intensify the person lobes of the facial floor.

Fig. 14: Third PMMA prototype. A more softened look to the embrasures and incisal angles, with surface texture to delineate the individual lobes on the facial surface.

Fig. 14: 3rd PMMA prototype. A extra softened glance to the embrasures and incisal angles, with floor texture to delineate the person lobes at the facial floor.

Fig. 15: Third PMMA prototype in place.

Fig. 15: 3rd PMMA prototype in position.

Fig. 16: Anterior guidance and canine disclusion were shown in the right working movement, displaying separation of all posterior teeth.

Fig. 16: Anterior steerage and dog disclusion have been proven in the best running motion, exhibiting separation of all posterior tooth.

Fig. 17: Anterior guidance and canine disclusion were shown in the left working movement, displaying separation of all posterior teeth.

Fig. 17: Anterior steerage and dog disclusion have been proven within the left running motion, exhibiting separation of all posterior tooth.

Subsequent, the PMMA prototype used to be cemented with brief cement. At a postoperative discuss with, complete smile lateral and frontal view pictures have been taken of the cemented proposal to judge aesthetic and useful parameters when the affected person used to be no longer anesthetised previous to the fabrication of the definitive restorations (Figs. 18 & 19). The affected person used to be then in a position to take those restorations for a test-drive to make sure that she used to be utterly glad with the smile design.

Fig. 18: Right lateral view of the patient’s smile, showing the facial surface texture of the PMMA prototype and the incisal plane nicely following the contour of the lower lip. Note the beautiful aesthetic textures of these prototype restorations.

Fig. 18: Proper lateral view of the affected person’s smile, appearing the facial floor texture of the PMMA prototype and the incisal airplane well following the contour of the decrease lip. Observe the pretty aesthetic textures of those prototype restorations.

Fig. 19: Frontal view of the patient’s full smile.

Fig. 19: Frontal view of the affected person’s complete smile.

Supply of the definitive restorations

As soon as the affected person gave her approval, the ceramist used the similar STL recordsdata to mill the definitive restorations in response to the 3rd PMMA prototype (Fig. 20). As soon as the affected person used to be anesthetised, the PMMA prototype restorations have been got rid of, and the arrangements wiped clean with an antibacterial scrub. Every person recovery used to be attempted at the respective preparation and evaluated for marginal integrity. Subsequent, all ten restorations have been attempted on jointly to judge interproximal contacts and occlusion. The definitive restorations have been milled in zirconia that used to be reduce to layer on results. The restorations have been first wiped clean with a cleansing agent (ZirClean, BISCO) to take away any floor contamination from the try-in section. After rinsing and drying, the restorations have been then handled with a steel primer (Z-High Plus, BISCO) to support the bond of resin cement to zirconia. The arrangements have been etched with 38% phosphoric acid (Etch-Ceremony, Pulpdent) for 15 seconds after which rinsed with water from an air–water syringe for 15 seconds. After air-drying, the arrangements have been re-wet with a dentine desensitiser after which the surplus used to be got rid of with high-volume suction, leaving the arrangements visibly wet.

 

Fig. 20: Definitive zirconia restorations on the master model.

Fig. 20: Definitive zirconia restorations at the grasp type.

Fig. 21: One-week post-op retracted view of the definitive restorations after cementation.

Fig. 21: One-week post-op retracted view of the definitive restorations after cementation.

The restorations have been then cemented with resin cement (Include Resin Cement, Pulpdent) two at a time, beginning with the central incisors and shifting distally to the second one premolars. As every two restorations have been in short light-polymerised, the resin cement extra used to be got rid of with a sable brush after which the restorations have been light-polymerised in step with the producer’s directions. Dental floss used to be used interproximally previous to complete polymerising to make sure that the resin cement were cleared out. In accordance with the affected person’s preview of the 3 aesthetic proposals and her definitive selection of the 3rd one, the supply used to be clean, and the affected person liked the general outcome (Figs. 21–24).

Fig. 22: Post-op right lateral view of the patient’s completed smile. Comparison with Figure 18 shows how nicely the denitive restorations followed the approved PMMA restorations.

Fig. 22: Publish-op proper lateral view of the affected person’s finished smile. Comparability with Determine 18 presentations how well the denitive restorations adopted the authorized PMMA restorations.

Fig. 23: Frontal view of the patient’s full smile once the case was completed.

Fig. 23: Frontal view of the affected person’s complete smile as soon as the case used to be finished.

Fig. 24: Superior view of the smile, showing the facial surface texture of the denitive restorations and how nicely they followed the lower lip.

Fig. 24: Awesome view of the smile, appearing the facial floor texture of the denitive restorations and the way well they adopted the decrease lip.

Conclusion

The usage of electronic smile design applied sciences, the dentist can input electronic dentistry by means of chairside scanning or in the course of the electronic dental laboratory to assist design and refine the cultured parameters of a case and create PMMA prototypes which the affected person can then put on and overview to reach on the ultimate desired aesthetics previous to final touch. This step is helping be sure affected person acceptance and permits the dentist entire self assurance that the supply of the definitive restorations shall be a convincing luck.

Acknowledgement

The writer wish to recognize the experience of grasp ceramist and electronic smile design specialist Vincent Devaud of West Hollywood in California for his superbly inventive paintings in this case.

Aesthetic dentistry
Virtual dentistry
Virtual smile design
PMMA
Restorative dentistry

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