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Once activated, zoom in (Fig. 16) and trace the teeth with the lasso tool. •To create a pencil outline of the tooth, with the transparent layer active,clickontheeditmenuinthe menu bar; in the edit drop-down menu, select“stroke”; choose black for colour, and select a two-pixel strokepencilline(Fig.17),whichwill create a perfect tracing of your selection. Click “OK” to stroke the selection.Select(tracewiththelasso selection tool) one tooth at a time andthenstrokeit(Fig.18).Selectand stroke (trace) the teeth up to the second premolar (the first molar is acceptable;(Fig.19). •The image should be sized now foreasyfutureuseinasmiledesign. Intheauthors’experience,itisbest to adjust the size of the image to a height of 720 pixels (Fig. 20) by opening up the image size menu and selecting 720 pixels for the height. The width will adjust pro- portionately. •At this time, the tooth grid tracing can be saved, without the image of the teeth, by double-clicking on the layer of the tooth image. Adialogboxreading“newlayer”will appear; click “OK”. This process unlocks the layer of the teeth so it can be removed. Drag the layer of the teeth to the trash, leaving only the layer with the tracing of the teeth(Fig.21).Inthefilemenu,click “save as”and choose“.png”or“.psd” (Photoshop) as the file type. This willpreservethetransparency.You do not want to save it as a JPEG, sincethiswouldcreateawhiteback- ground around the tracing. Name thefileappropriately(e.g.,75%W/L central). •By tracing several patients’ teeth thathavetoothsizeandproportion in the aesthetic zone and saving them, you can create a library of tooth grids to custom design new teethforyourpatientswhorequire smiledesigns. ThePhotoshopsmile designtechnique The Photoshop Smile Design (PSD) technique can be done on any image,andimagescanbecombined toshowthefullfaceorthelowerthird with lips on or lips off. This article demonstrates how to perform the technique on the cheek-retracted view. ThefirststepinthePSDtechnique is to create a digital conversion of the actual tooth length and width, and then digitally determine the proposed new length and propor- tionoftheteeth. Determiningdigitaltoothsize To determine digital tooth size, followthesesteps: •Createaconversionfactorbydivid- ingtheproposedlength(developed from the smile analysis) by the existinglengthofthetooth. •The patient’s tooth can be meas- ured in the mouth or on the cast (Fig. 22). If the length measures 8.5mm but needs to be at 11 mm for an aesthetic smile, divide 11 by8.5.Theconversionfactorequals 1.29, a 29% digital increase length- wise. •Open the full-arch cheek-retracted view in Photoshop, and zoom in onthecentralincisor. •Select the eyedropper palette. A new menu will appear. Select the rulertool(Fig.23). •Click and drag the ruler tool from the top to the bottom of the tooth to generate a vertical number, in this case 170 pixels (Fig. 24). Multi- ply the number of pixels by the conversion factor. In this case, 170x1.29=219 pixels; 219 pixels is digitally equivalent to 11mm (Fig.25).Determinethedigitaltooth widthusingthesameformula. •Createanewlayer,leaveittranspar- ent, and mark the measurement withthepenciltool(Fig.26). Applyinganewproposedtoothform Next,followthesesteps: •Afterperformingthesmileanalysis and digital measurements, choose a custom tooth grid appropriate for the patient. Select a tooth grid based on the width-to-length ratio oftheplannedteeth(e.g.,80/70/90 or 80/65/80). Open the image of thechosentoothgridinPhotoshop anddragthegridontotheimageof teethtobesmiledesigned(Fig.27). •If the shape or length is deemed inappropriate,pressthecommand button(controlbuttonforPCs)and “z” to delete and select a suitable choice. •Depending on the original image size, the tooth grid may be pro- portionally too big or too small. To enlarge or shrink the tooth grid created (with the layer activated), presscommand(orcontrol)and“t” tobringupthefreetransformfunc- tion. While holding the shift key (holdingtheshiftkeyallowsyouto transform the object proportion- ally), click and drag a corner left or right to expand or contract the customtoothgrid. •Adjustthesizeofthegridsothatthe outlinesofthecentralincisorshave thenewproposedlength.Movethe grid as necessary using the move tool so that the incisal edge of the tooth grid lines up with the new proposedlength(Fig.28). •Areas of the grid can be individ- ually altered using the liquify tool (Fig.29). Digitallycreatingnewaestheticteeth Next, follow these suggested steps: •With the new tooth grid layer and themagicwandtoolbothactivated, click on each tooth to select all of theteethinthegrid(Fig.30). •Expand the selection by two pixels in the expand menu; click“select > modify>expand”(Fig.31).Notethat the selection better approximates the grid. You can expand the selec- tion or contract as necessary using thesamemenu. •Activate the layer of the teeth (cheek-retracted view) by click- ingonit(Fig.32). •Next, activate the liquify filter (you will see a red mask around the shapes of the proposed teeth). The mask creates a digital limit that the teeth cannot be altered beyond. This is similar to creating a mask with tape for painting a shape(Fig.33). •Use the forward warp tool by click- ingonanareaoftheexistingtooth and dragging to mold/shape the tooth into the shape of the new proposedoutlineform(Fig.34). Repeat this for each tooth. If you make a mistake or do not like some- thing, click command (or control) and“z”togobacktothepreviousedit (Fig.35). Adjustingtoothbrightness The following steps are recom- mendednext: •Select the whitening tool (dodge tool) to brighten the teeth. In the dodge tool palate, click on “mid- tones” and set the exposure to ap- proximately20%.Clickontheareas of the tooth you want brightened (Figs.36&37). •Alternatively, with the teeth selected,youcanusethebrightness adjustment in the brightness/con- trast menu; click “image > adjust- ments>brightness/contrast”. Performing the changes on only onesideofthemouthallowsthepa- tient to compare the new smile de- sign to his/her original teeth before agreeingtotreatment. Createacopy To save the information you have created for presentation to the pa- tient,followthesetips: •Goto“file”andselect“saveas”. •When the menu appears, click on the“copy”box. •Namethefileatthatstep. •SaveitasaJPEGfiletype. •Designatewhereyouwantitsaved. •Click“save”. Afileofthecurrentstateoftheim- age will be created in the designated area. You can now continue working on the image and save again at any pointyouwant. Conclusion Knowledge of smile design, cou- pled with new and innovative den- tal technologies, allows dentists to diagnose, plan, create, and deliver aesthetically pleasing new smiles. Simultaneously, digital dentistry is enabling dentists to provide what patients demand: quick, comfort- able,andpredictabledentalrestora- tions that satisfy their aesthetic needs. Editorialnote:Acompletelistofrefer- encesisavailablefromthepublisher. This article was originally published in the Journal of Cosmetic Dentistry, spring issue, No 1/2013, Vol. 29, and the Clinical Masters Magazine No1/2015. 23Cosmetic Tribune United Kingdom Edition | 4/2015 TRENDS&APPLICATIONS Prof. Edward A. McLaren is the direc- tor of the University of California, Los Angeles Center for Esthetic Dentistry. He can be contact- ed at emclaren@ dentistry.ucla.edu. Lee Culp, CDT, is an adjunct facultymem- ber at the Univer- sity of North Car- olina at Chapel Hill School of Dentistry. 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