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25 Dental Tribune Middle East & Africa Edition | July- August 2014cad/cam | digital tribune > Page 26 Simple, planned aesthetic orthodontics for the General Practitioner Figure 1 Figure 4 Figure 5 Figure 3 Figure 2 ByDr.TifQureshi Dr. Tif Qureshi shows how digital technology has moved progressive smile design on and the enormous benefits this will have on planning and consent. Digital Smile Design is mak- ing a come back in a very smart and intelligent form through the use of live video, cameras, and keynote presentations. I commend the users of this technique as it is clearly a far better form of smile design plan- ning than just using plain static before and after pictures with someone else’s smile stitched into place. However in cases where there are alignment issues, I would still argue that any pa- tient who does not at least go down the pathway of alignment and bleaching, cannot really see their teeth change in a dynamic way. I have found that patient’s feelings about their smiles change, you may think they want one thing but after they see their smile change a little they start to appreciate it in a differ- ent way. How can someone real- ly be consented unless they are given the opportunity to bleach their teeth, perhaps with slight alignment and bonding. This case is the perfect ex- ample and will show how pro- gressive smile design also using digital technology can produce beautiful predictable results that often require far less invasive treatment. We use digital technology in a different way of course and this is all to do with planning and consent. Previously with Inman Aligners, we had to use Kesling models. These are effectively fairly crude stone models which take a cut and once repositioned in wax the aligner is then built on that model. As soon as the aligner is fitted into an uncor- rected mouth the forces are there to push the teeth to the final position. The real down- side of it at the wax creates quite large inaccuracies. Also it is very difficult to see how much adjust- ments have been made to the teeth to get them to fit within the curve. This is even more so of a problem for flared teeth which have been out of the arch for many more years. These teeth tend to be highly triangular and often need more targeted adjust- ment to get them to fit within the arch form. You can visualize the wits of these teeth, it is almost impossible to accurately know how much production is re- quired to each. Of course with digital 3-D printing this has all changed. The difference if you like is night and day. We can also use print- ed models to show the patients the proposed outcome. This is excellent for the consenting process. Untreated patients will now see any compromises areas and the final outcome. If they are not happy they could reject the treatment before it starts. A case A 22 year old gentleman did not like the appearance of his teeth especially because the two cen- trals was so prominent. He had considered having porcelain ve- neers done just to improve his smile in one treatment. He did not like the appearance of his enamel and also the discrepancy intheshapeofhisfrontteeth.We showed him the occlusal view of his teeth and he could see that the upper anterior is one mildly misaligned. Indirect veneers would have been fairly aggres- sive towards the preparation of the upper central incisors. By showing examples of other cas- es where simple alignment had dramatically improved the aes- thetic value the patient agreed to try to align his teeth first before having veneers done. Consent part one A full orthodontic examination was carried out. All orthodontic options were discussed and the patient understood the benefits of fully comprehensive ortho- dontics, and was also given a range of short-term techniques that he could have chosen. He declined comprehensive ortho- dontics on the basis that he only wanted to deal with his anterior teeth. He chose to have an Inman Aligner because of the shorter wear time and the minimal cost impact on his overall treat- ment desires. Our first goal was to evaluate the aesthetics and function to decide on landmark or reference teeth. As part of the digital planning process- these teeth are not moved and ensure the setup accommodates these teeth to ensure the proposed curve is not flared out or over constricted. In this case the patient also had a retained upper left de- ciduous tooth (no canine had developed). Fortunately this tooth was in the right position so it became the reference tooth and hence no orthodontic force would need to be applied to it. Both upper centrals needed to be retracted and both laterals slightly advanced. It was impor- tant to visualize a chin up view to ensure this is viable for the patient from an occlusal and guidance point of view. All the movements were possible. (Figure 1) Occlusal showing landmark and desired move- ments. (Figure 2) Showing Spacewize trace In the chair the occlusal photo is taken and uploaded into the spacewize digital calculator. The curve is set according to the landmark teeth and required movements. This showed a crowding result of 3mm which was within the easy limits for In- man treatment. Impressions were taken and were sent to the lab with the spacewize trace Setup Using a calibrated Ortho ana- lyzer software, the teeth are then moved according to the space- wize trace- meaning the decidu- ous tooth and other canine were not moved at all. Centrals were retracted by about 3mm and the laterals advanced by about 1.75mm exactly. These setups can be viewed as digital files in 3D if needed be- forehand by the dentist and ad- justments can be made if need- ed. Once we are happy, the 3D model was printed. Consent part two The 3D model was returned and we could view the proposed set- up made according to the space- wize instructions Figure 3: Overjet before Figure 4: Overjet reduced and proposed on 3D print Figure 5: 3D Print Occlusal An appointment was made with the patient to sit down and examine the models. At this point the patient clearly sees any compromises in the poste- rior region of his mouth. These were again highlighted but the patient insisted he did not want these treated. The over jet was also discussed with the patient he could see a reduction but not complete closure, he was happy with this. You can see the width differ- ences in the anterior teeth that would require adjustment and