Please activate JavaScript!
Please install Adobe Flash Player, click here for download
ePaper created 2018-04-06, 15:48:03 | version 1.38.0
22 GENERAL DENTISTRY Dental Tribune Middle East & Africa Edition | 3/2017 The Concept of Progressive Smile Design Dr. Tif Qureshi, Past President of the BACD and Director of IAS Academy, shows how a step-by-step approach to smile design can make things simpler and safer and is something many dentists can do By Dr. Tif Qureshi, UK While I have been publishing articles on Progressive Smile Design for the past six years (1,2), this is a concept I actually discovered in 2006. How- ever, while attending many confer- ences and witnessing fierce debates on Facebook, it has become clear to me that its potential significance has not quite yet sunk in amongst many practitioners of aesthetic and cos- metic dentistry. It is also true that the subject of smile design commonly polarises readers. Some will think they know it all al- ready, while others will think it is not relevant to their practice. I’m hoping to prove both groups wrong by provoking some debate, focusing on three suggestions that I truly believe. 1. Every single dentist could carry out simple forms of aesthetic dentistry that can have dramatic effects with minimal risk. 2. Smile Design planning, as it has been known, is taught is back to front (I’ll explain this later) and only serves a niche market, which is disconnect- ed from most dentists. 3. The tools are now available for any dentist to create beautiful smiles without picking up a drill. I would argue that cosmetic dentist- ry has traditionally focused on large, high-end cases and that this has ac- tually been a very shortsighted ap- proach. It effectively became a very well-publicised niche market that very few patients could afford. This also means that very few dentists have the option to offer this treat- ment, since many patients simply do not have the budget or, indeed, do not want to take the risk. With Progressive Smile Design, a much wider range of patients can potentially be treated by a much larger number of dentists at much lower risk. Traditional smile design focuses on an endpoint - now processed in a digital manner via computer soft- ware. This is translated to a wax-up and the patient is shown what could be achieved. This can even be tried in the mouth with a stent made from the wax-up. Often, ideal smile design parameters are built into this set-up so a patient will commonly be shown their ap- pearance with 8-10 different units in their mouth via simulation or a trial smile. These parameters will include golden proportion, connec- tor harmony, wider buccal corridors, perfect incisal outlines and correct gingival zeniths. But, if a patient is shown this at the start point, they will naturally as- sume that this is what they want. Irreversible treatment is then com- monly carried out to achieve this, using porcelain, composite veneers or even no-prep veneers. Currently, many patients are having the concept of no-prep, minimal- prep or composite veneers promot- ed to them as the way to achieve a perfect smile. The big question is: Do these people really need these techniques at all? huge number of cases I have been involved in, patients who initially thought they wanted ideal smile de- sign changed their minds after see- ing their teeth aligned/whitened and after receiving edge additions. The cynical will commonly say, “Im- proving smiles in any way at all is completely unnecessary,” but that not only shows ignorance of the wishes of many patients, but also of the fact that restoring a smile can often have significant functional benefits. In practical terms, we, as dentists, also commonly ignore factors be- yond the purely clinical. Dentists are trained to make clinical judgments. Psychological and long-term judg- ments are not always discussed and/ or have not, historically, been well- researched in dentistry. Long-term case follow-ups with good photography are, sadly, extremely rare. Yes, consent is commonly - and rightly - talked about, but it only seems to go as far as a legal consent form and some note taking. What the case outlined below will show is how a patient achieved a dramatic improvement in her smile aesthetics and function, with hardly any tooth removal at all. Most im- portantly, the patient’s overall per- ception changed, once these small changes began. Significantly, this kind of dentistry is achievable by any dentist and not just by high-end cos- metic gurus. Digital smile design, as clever as it is, does not allow patients to see small, in situ changes and, more often than not, means a patient will opt for a far more dramatic treatment plan than may actually be required to make them happy. Based on the Equally, and just as importantly, many patients - like this one - might not want - or perhaps cannot afford - complex treatments and so are sim- ply left with no real solution. In my experience, many patients who think they want ideal smile Diagnosticphotoguide.001 SpacewizeTM design change their minds almost without fail, once they start to align/ bleach and bond their teeth. They are commonly happy to accept compromises which they would not have appreciated if they had gone straight ahead to a final 8-10 unit re- sult. Given the short amount of time required for Anterior Ortho cases, it is essential that patients fully under- stand these options, in order to make an informed choice. The argument of, “Patient did not want ortho,” sim- ply does not wash, if it is later discov- ered that the only option they were given was a comprehensive one that might take a year or more. Case At one point, this patient had consid- ered ceramic veneers to improve her smile, but was concerned about the amount of preparation needed. As a result, she was happy to try aligning and whitening her teeth beforehand. Assessment - Pt 25 - Skeletal 2 - Decreased FPMA - Canine Class - RHS 1/2 cl2 LHS 1/2 cl2 - Molar class 3/4 unit class 2 RHS mo- lar class 3/4 unit class2 LHS - Incisor class 2 div 2 75% OB and 4mm OJ - Upper laterals crowded centre lines in coincident - Soft tissues NAD, symmetrical, lips competent High lip line - Lower face height slightly reduced - No TMJD - Canine guidance positive - No Posterior interference on the an- terior slide On examination, her upper teeth were slightly retroclined and the edges were chipped. Slightly worn, irregular lower edges on the lower teeth were causing chipping on the upper teeth because of some para-function. All possible options were discussed with the patient, including a ceramic solution or orthodontics. All avail- ÿPage 24 Pic 1. Before side retracted view Pic 2. Right side retracted view after alignment and whitening (10 weeks) Pic 3. Before upper model Pic 4. After 3D Print Pic 5. Before Upper Occlusal View Pic 6. After upper Occlusal View and Bleaching (10 weeks) Pic 7. After wire retainer Pic 8. Right side view before Pic 9. Wearing IA Superslim Pic 10. Right side retracted view after alignment and whitening (10 weeks) Pic 11. Right Side after edge bonding Pic 12. Front view