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Dental Tribune Middle East & Africa Edition | 6/2016 14 general dentistry TheConceptofProgressiveSmileDesign anditspotentialimpactonCosmeticDentistry ByDr.TifQureshi,UK Cosmetic dentistry is commonly at the forefront of everything interest- ingandexcitingindentistry.Rightly, all dentistry can and should be car- ried out in an aesthetic way, and as a result the term “cosmetic “could ap- ply to nearly any type of treatment, even an extraction if executed with aestheticsinmind. The way treatment planning is car- ried out for smile makeovers has fundamentally been the same for some time. Recently Digital Smile Design has taken another step and has made the very best and most intelligent use of software, imaging and video to creating a very power- ful and emotional communication tool. This can allow a patient to see a smile makeover mockup not just on a screen as a static image, but watch- ingthemselvesonvideoandactually to trial it within their mouths also and deliver an emotional response tothatpreview. Ideal smiles and fantastic results can be achieved this way and this is ap- propriate for patients who want per- fection…orisit? The concept of progressive smile de- signisalittledifferent. The idea of PSD to allow the patient to see improvements in staged ap- proachestoreallydecideiftheywant a perfect smile at the end of treat- ment. Now of course Progressive smiledesignandDigitalsmiledesign are not mutually exclusive, they can be combined but commonly PSD will result in less treatment for the patient. The Concept of Progressive Smile Design often a uses mixture of tooth alignment, whitening, direct bond- ing and contouring. Indirect treat- ments can certainly be considered but are only ever after the patient is able to see changes alignment, bleachingorshapingcanachieve. The logic to this approach is that we are trying to see if a patient is satisfied with small staged improve- mentsratherthangoingstraighttoa perfectresultinanirreversibleway. It may well be that they do end up with a perfect smile but at least the consenting process is real, because thepatientisabletoseetheverybest in their own smile before moving forwardtotheirreversiblestages. Looking at this in a more extreme way, it might be the difference be- tween a patient choosing 8-10 ve- neers accepting some tooth prepa- ration to do so, and alternatively absolutelynotoothremovalwhatso- everwithlessfinancialandbiological risk. The case described shows a patient’s journey and how her perception of herownsmilechangedwithprogres- sivesmiledesign. TheCase This young 26 year-old lady present- ed wanting a smile makeover. Her main complaint was her diastema, thecolorandlengthofherteeth.She requested porcelain veneers to ad- dressthisproblem. On examination, a 3.5 mm diastema existed and the patient had a class 1 base with a mild lower crowding and slightly rotated upper laterals. She also had reducing canine guid- ance from previous evidence of pa- ra-functional wear. She had no TMJ complaintsorsymptoms. It was explained to the patient that orthodontics could improve the an- terior position of the teeth to make any further treatment, which might includeveneers,easieratalatertime. The patient was not keen on ortho- dontics particularly fixed braces, but all options were thoroughly ex- plained,includingtheInmanAligner diastema closer appliance. The pa- tient was interested in this option because of the short treatment time and the fact that it was removable. Once she understood that the dias- tema could be closed in less than 10 weeks she suddenly became keen on usingtheappliance. Before any treatment was decided upon,x-rays,photosandstudymod- els were taken and a full orthodontic diagnosis and assessment was car- riedout. A landmark/ reference point was also decided on with the patient. Thisisacriticalpointthatisaestheti- cally and functionally correct in a misaligned arch. An arch evaluation curveisthensetusingSpacewizeTM software. The reference point sets the curve and the curve then is used to calculate the amount of potential crowding and potential space crea- tionthatmightberequired. (1). The patient described the posi- tion of the two centrals as ideal from an anterior posterior position. She liked the angle and vertical inclina- tion. But she felt they were simply toofarapart. She felt both laterals were too pro- trusive. As a result the curve was set throughthelandmarkpoints. This Spacewize curve provides valu- able information in anterior ortho- donticplanning. 1) It will give the amount of space creation required or the amount of spaceleftoverafteralignment 2) It dictates the occlusal setup to the technicians who will set the case up digitally. 3) It is also important in the consent- ingprocessandevidenceofplanning The Spacewize trace revealed that the case would required 0.2mm of space creation to achieve alignment. With a diastema present, this might seem a surprise but the laterals clos- ing inwards and being rotated were already accounting for much of that space. Impressions were taken and sent to the Inman Aligner laboratory with thespacewizetrace. Two days later a digital STL was sent oftheproposedArchwizesetup. This was checked and the lab was in- structed to create the 3d print of the proposedsetup. The patient was keen to see this be- fore committing to understand the real potential outcome. The advan- tage of a 3d print over 3d images is that a patient can hold the models and really appreciate the potential outcome with a clearer picture of scale,positionandshape.Onviewing the models the patient was highly satisfiedwiththeproposedoutcome and could also see that the teeth still looked short and further treatment would be needed to lengthen them. This was discussed and planned. The models were returned to the lab for the modified Inman Aligner to be constructed. One week later it was fitted- Instruc- tions were given and no space crea- tion needed. The patient was to wear the appliance for 18-20 hours a day. Thepatientturnedthemidlinescrew onceevery3days.After2weeksasig- nificantimprovewasseen. At 4 weeks home bleaching was started using Daywhite 6% H2O2, (Philips) using super-sealed trays. (trays with sealing grooves cut into the stone models before sucking down). She whitened for 35 minutes a day while the Inman Aligner was outofthemouthfor2weeks. At this appointment a little flatten- ing of the contact was carried out to reduce the risk of a black triangle andlengthentheconnector-thiswas done using a soflex disc using the digital models for guidance. Buccal anchors were also placed to help the lateralsrotatein. At 6 weeks the diastema was closed andtheteethwerenoticeablywhiter. Themoment oftruth- At this review appointment the pa- tientthencommentedthatherteeth lookedfarbetterthanshe everimag- ined. She asked what could be done to the edges of her teeth to lengthen them and if there was an alternative to veneers as the newly positioned andwhitenedteethlookedsogood. Flowable composite was used to mockup an outline. This was cured Fig.1. Fig.7. Fig.11. Fig.8. Fig.12. Fig.9. Fig.13. Fig.10. Fig.14. Fig.4. Fig.2. Fig.3. Fig.5. Fig.6. ÿPage 15