Make Me Smile

Paul Feuerstein, DMD
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How many times have we heard the phrase “I want to improve my smile”? In many situations, the patients’ idea of what they want might be totally different from our natural response. Sometimes it’s as simple as wanting a whiter smile. The definition of “white teeth” to many patients is also far different from ours. Some of these patients are still bleaching their veneers in hopes they could be a little whiter. Other patients are concerned with “crooked teeth” that are “getting worse.” Their definition of crowding is often quite different from ours. Luckily, with the proliferation of aligner products and processes, we can often accommodate these patients with a simple, limited case. And, with a little bleaching in the final retainer, they fall in love with us.

A new idea has come from Dr. Brian Harris of Phoenix called Smile Virtual Consult (smilevirtualconsult.com). This simple system allows a patient to take a photo with his or her cell phone, answer a few questions about what he or she wants to improve, upload it, and then receive a video reply explaining aspects of possible treatment.

There are many situations that require combinations of the aforementioned processes. Before the advent of digital dentistry, we took photos, made study models, used lab wax-ups, and got a little help from Photoshop-type products, and we were able to do case presentations. Using the labs’ templates that were made over the wax-ups, we were able to deliver satisfactory end results. There were issues, though, that required time to create these projections and make modifications. If the wax-up had to be changed or the photo images were not quite what the patient had in mind, it was back to the lab and another patient visit.

Ten years ago, Kulzer launched a website, tryavenussmile.com, that allowed a patient to upload a photo and then “try in” a few smile designs. SciCan also had a great simulation program called Image FX, and several companies offered a Photoshop-type service that allowed you to send a photo and receive a digital simulation in return. These systems were very dangerous, as the simple computer manipulation often rendered results that were impossible to recreate and often led to a disappointed patient who stated that the end result “was not like the picture you showed me.” A transition came with Dr. Lawrence Brooks, a dentist in Massachusetts who created a dental lab called Smile-Vision (smilevision.com) that requires both photos and study models (or now digital scans). His lab prepares wax-ups, which are then superimposed onto the photos with a much more accurate proposition. He can also prepare clear overlays, prep guides, and temporary templates, ensuring the final result. Many other labs follow this process.

Much of the designing was (and is) based on the “golden proportion.” We looked to experts who almost seemed to be mathematicians, calculating things like “The width-to-length ratio of the centrals should be approximately 4:5,” “When viewed from the facial, the width of each anterior tooth is 60% of the width of the adjacent tooth,” “Interproximal contacts must follow ‘the 50:40:30 rule,’” and so on. The face also has to be analyzed as to its shape and relation to the teeth form (square, tapered, ovoid, etc) while using more math like “The width of the face should be the width of five eyes,” “The distance between the eyebrow and chin should be equal to the width of the face,” and so on.

We now have several computer programs that can take all this data that you or a lab can use to design a patient’s smile. The wax-ups are virtual, and now with 3-D printing, an overlay can be created quickly and inexpensively (in your office) that will sit on the patient’s teeth to see how things will look. Years ago, I would take an A1 composite and just place and shape it over the teeth to give the patient a rough idea of where we were going. This new technology is much more specific and realistic. Planmeca now has Romexis Smile Design software that can render a simulation in minutes. 3Shape Smile Design is also an option that uses an easy-to-see template and creates a new look that can then go forward into the 3Shape restorative system.

The most comprehensive system for smile design was created by Dr. Christian Coachman of Brazil and called DSD (digitalsmiledesign.com). The website has educational videos, which are among the best I have seen, and DSD offers seminars around the world that detail the journey. The math previously mentioned has been considered, but the cases start with a specific series of patient videos that allow you to see function, phonetics, facial analysis, and more. Photos are pulled from the videos to create more views to get a 3-D functional analysis. You can do your own design or have them do it for you. There are partner labs, such as The Aurum Group (aurumgroup.com), that can create prep guides, temporary templates, and more, giving the patient a totally predictable result. Even if you don’t think you need to use this service, the information on this website is eye-opening.

A totally different idea was just introduced by a company called Kapanu. Their program uses an amazing simulation they call Augmented Reality, where the patient can see transformations in real time on a computer screen or tablet. He or she can toggle the before and after images on the screen, with the arch split left and right, showing before and after views simultaneously. The website (kapanu.com) shows this dynamic process. The system was so intriguing, Ivoclar Vivadent acquired it early in its development and rebranded it as IvoSmile. According to Ivoclar Vivadent, “The main objective will be to determine how the usage of ‘Augmented Reality’ can facilitate dental diagnostics, case analysis, and treatment therapies.”

Everyone will have to find his or her comfort zone on how far to let computers run the treatments. It is surely an interesting journey we are on.

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