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29 DIGITAL DENTISTRY Dental Tribune Middle East & Africa Edition | 5/2017 Digital Dentistry, From Smile Design to Occlusal Analysis A case report By Dr. Mohannad Kiswani & Dr. Iman Said Nazzal, Jordan Digital dentistry refers to the ap- plication of dental technologies or equipment to perform dental pro- cedures rather than using mechani- cal and electrical tools. The use of digital dentistry can make carrying out dental procedures more effi - cient than using mechanical tools. The digital era has brought count- less benefi ts to dentistry. An organ- ized and systematic approach is required to evaluate, diagnose and resolve aesthetic problems predict- ably¬1. It is of prime importance that the fi nal result is not depend- ent on looks alone. Our goal as clini- cians should be to achieve a pleas- ing composition in the smile by creating an arrangement of various aesthetic elements2. Digital dentistry requires that the dentist follow precise protocols in- order to obtain a standard and pre- dictable result that corresponds to an optimal clinical result3. Nowadays many digital technolo- gies have been added to dentistry, but three new innovations in Digi- tal Dentistry that have introduced major transformation in clinical practice: Digital Smile Design • Digital /Op- tical scanners • Digital Occlusion Analysis The case The patient was a 26 year-old fe- male, she came complaining off stained restorations and gaps in her upper anterior teeth. After clinical and radiographic examination; the teeth 21 and 22 had large compos- ite restorations with open margins, the teeth 21 and 11 were root canal treated and all upper anterior teeth required crowns (Fig. 1). Digital Smile Design The Digital Smile Design is a multi-use tool that can assist the restorative team throughout the treatment, improving their un- derstanding of the aesthetic issues and increasing patient acceptance of fi nal-results4. The placement of reference lines and ability to draw over extra- and intraoral digital photographs widens the dental team’s diagnostic vision and helps to evaluate the limitations, risk fac- tors, and aesthetic principles of a given case. These critical data will lead to improved results in all phas- es of treatment. The greatest challenge of smile design lies in the conversion of 2D photographs into 3D images. To- day, the use of 2-D and 3-D software for photograph editing and digital image editing allows us to process data and customize parameters for each specifi c clinical and aesthetic requirement of the smile makeo- ver3. Many digital programs and proto- cols have been introduced to the dental market in the last few years. Some of them focus on the style of imaging and producing a virtual simulation to the patient, helping Fig. 1 Fig. 2a Fig. 2b Fig. 2c Fig. 3 Fig. 4a Fig. 4b Fig. 4c Fig. 5a Fig. 5b Fig. 5c Fig. 6a Fig. 6b Fig. 7a Fig. 7b Fig. 7c Fig. 8a Fig. 8b the patient better visualise imagine what her smile will look like after the planned dental treatment. Oth- ers may have lesser virtual results but more precise measurements and tools. It depends on the practi- tioners choice of treatment and the aim of smile design to choose a suit- able software for his clinical prac- tice, some clinicians prefer to use more than one software to achieve all treatment goals. Most of compa- nies do aim to be the fi rst choice for the dental professional, but some do fail to achieve some critical char- acteristics in their product. In this case, we started with design- ing her smile digitally using "Smile Designer Pro" software. We tried to use other systems but this system showed the easiest mode of trans- fer for the fi nal- result of the design to the CAD system, using the tem- plate outline and then trace it to get a similar result. (Fig 2a, 2b, 2c Show the steps of smile design). After presenting the virtual simu- lation for the patient, she accepted the treatment and we started with replacing old composites and pro- ceeded with teeth preparation. (Fig 3) the mouth is essential in almost all clinical practises in every dental offi ce5. The fi rst dental digital scan- ner was introduced in the market in the 1980’s with limitations in- cluding low precision and high cost. New technologies were then introduced which lead to the crea- tion of enhanced in-offi ce scanners which were considered much more “user-friendly”. The new scanners have become easier to use for the clinician, give more precise digital impressions, and offer technologi- cal advances compared to early ver- sions. All systems work to capture 3D virtual images of teeth which can be used to create precise mod- els on which the restorations can be developed in a dental laboratory5. The use of these products is rapidly increasing around the world and presents a paradigm shift in the way in which dental impressions are made. Several of the leading 3D dental digital scanning systems are presented and discussed in this ar- ticle. Using the technology of optical scanners with Trios from 3Shape, we recorded the digital impression for the prepared teeth. (Fig 4a, 4b, 4c) Intraoral Digital Scanners Intra-oral mapping technology is one of the most exciting new ar- eas in dentistry as 3D scanning of The greatest challenge in this case during our digital workfl ow was to convert the 2D smile design that the patient liked and approved to Fig. 9a Fig. 9b Fig. 10a Fig. 10b a 3D workable structure. (Fig 5a, 5b, 5c). We made this by combin- ing and joining the DSD software "Smile Designer Pro” and the digital impression from Trios 3Shape and then completing the CAD design through the dental system from 3Shape. We aligned the 2D to 3D in the same way as suggested to align the patient photo with the 3D jaw. But additional steps were needed for aligning it with the template of the suggested design using the 3D connect option and trying to trace the outline of the facial appearance of the teeth design or by upload- ing the patient smile with the sug- gested design to the Dental System Software. (Fig 6a, 6b). The crowns were designed using the 3Shape Dental System Software for the CAD step. What is unique about this system is that we could upload the patients 2D facial pho- tograph and test our design on the 3D model of the patients facial smile. (Fig 7a, 7b, 7c). In this case, we tried to make it twice; fi rst with the DSD virtual template (Fig 6a), and second with her natural smile without smile simulation (Fig 5a) and then we aligned these photos with the 3D digital jaw impression. We aligned it by choosing 2 simi- lar points on each side (right and left) on the 2D photo of the patient facial smile and on the 3D digital impression, the system then aligns them together as noticed in photos attached. After this, we started to design a relatively similar design of the suggested DSD by tracing the outline of the simulation template. After making sure of the 3D design outline, labial shape of teeth, width and incisal length, and shape, it was adjusted to the marginal fi nish lines, contact with adjacent teeth was checked along with occlusion while routine lab work took place. Eventually, the fi nal-result was shown on the patient facial smile in 2D-3D mode. (Fig 7c). Further ad- justments can be easily done per the patients functional and aesthet- ic requirements. Shade measurements were con- ÿPage 30