Face and Smile Analysis – The Power of Communication in Selecting Dental Shapes

A clinical case by our Community member Dr. Gilbert Jorquera

This article and its content are published under the Author’s responsibility as an expression of the Author’s own ideas and practice. Styleitaliano denies any responsibility about the visual and written content of this work.

During the last decades, orofacial analysis has evolved from a rigid and geometric study of facial structures with straight lines in search of mathematical symmetry and looking for standardized dental shapes, sometimes related to the sex or age of the patients. Today we know that faces are not perfectly symmetrical, and facial structures react to each other through a harmonious flow. On the other hand we know that there is no perfect dental shape for all patients, and that we have to find one that integrates into this facial flow, and not necessarily associated with the sex or age of the patient. The possibility of having included clinical photography in our profession and using digital tools, such as different softwares and applications, currently allows us to involve patients in their own treatment, especially when combined with a mock up, which is a powerful tool for communication with the patient, laboratory technicians and other specialists of the work team.
The aim of this article is to show the power of communication with the patient in choosing the most appropriate dental anatomy. Four different classical dental shapes (oval, square, rectangular and triangular) were tried in the mouth of the patient after digital smile design to see which one was the more convenient for the patient’s face with regards to smile integration.

styleitaliano style italiano smile design initial set of pictures and models

Fig.1
To carry out a correct analysis, the first thing is to have at least four basic clinical photographs of our patient (frontal smile, frontal with retractors, occlusal, and “12 o’clock” picture), in addition to an initial study model that can be a physical cast model or an STL file obtained with an intraoral scanner.

styleitaliano style italiano facial flow study

Fig.2
The first thing we have is to find the facial flow of our patient, which is where the facial structures come together in harmony, determining the green or favorable side to start designing a new smile. On the other hand, we must identify the buccal display of our patient to know what our work area will be, this is very important because it limits the work field.

styleitaliano style italiano digital smile design

Fig.3
Today, iPad or Smartphone applications can be used to design a smile easily and quickly. There’s plenty of application-guided proposals for a digital mock-up that can be shown to the patient in real time.

styleitaliano style italiano smile design for communicating with the technician

Fig.4
These applications make it also easy to create a complete report for laboratory technicians, and even upload STL files for a 3D analysis.

styleitaliano style italiano traditional and digital mock up workflow

Fig.5
We can use the type analysis that best suits our daily clinical workflow. A traditional flow with clinical photography, models and physical mock up, a simplified flow with only photographs and the use of applications to create a digital mock up or a combination of both paths, adding an intraoral scan to the simplified flow to be able to obtain a 3D model and to do a digital wax-up, print a plastic model and do a physical mock up with acrylic or bisacryl resin.

styleitaliano style italiano buccal display and retracted view

Fig.6
The first step in a keynote or power point analysis is to determine facial flow and buccal display (total area shown in smile).

styleitaliano style italiano dental smile design

Fig.7
Once the work area has been selected, shape and size proposals can be created for the teeth within the framework of the buccal display. In this case, an oval shape was proposed, with an increased length, curve of the smile and the correction of the gummy smile. The way to communicate the new measurements with the laboratory technician is to calibrate the rulers based on the real measurements of the tooth.

styleitaliano style italiano waxed up model

Fig.8
With the information sent (by Email, Dropbox, Drive, or another digital way), the laboratory technician will make a physical wax-up for the making of a silicone key and a mock up.

styleitaliano style italiano resin application for physical mock up

Fig.9
The silicone key, ideally of two consistencies, is filled with bisacryl resin and placed in the patient’s mouth.

styleitaliano style italiano removing excess material from mock up

Fig.10
For the removal of excess material, an 18-blade bur or a number 12 scalpel can be used.

styleitaliano style italiano correcting bubbles in mock-up

Fig.11
If there are any small bubbles left in the mock up, it is possible to correct them with flow resin of the same color as the bisacryl resin.

styleitaliano style italiano before and after mock up with oval tooth shape

Fig.12
Before and after the mock up with the oval teeth design. It’s possible to see the important changes in the smile and facial integration with the new dental shape.

styleitaliano style italiano square shape smile design

Fig.13
Now, we use a design with square teeth.

styleitaliano style italiano waxed up model and mock up

Fig.14
With the new information, dental technician make a square teeth wax up, changing length, curve of the smile and correcting the gummy smile.

styleitaliano style italiano before and after square teeth smile design

Fig.15
Before and after the mock up with the square teeth design.

styleitaliano style italiano rectangular shaped dental design

Fig.16
Another classical design is the rectangular teeth.

styleitaliano style italiano model wax up and mock up

Fig.17
With the information, dental technician make a rectangular teeth wax up.

styleitaliano style italiano before and after rectangular mock up

Fig.18
Before and after the mock up with the design of rectangular teeth.

styleitaliano style italiano triangular dental design

Fig.19
Finally the last classical shape is a design with triangular teeth.

styleitaliano style italiano triangular teeth waxed up on model

Fig.20
With the last design information, dental technician make a triangular teeth wax up.

styleitaliano style italiano before and after triangular shaped teeth mock up

Fig.21
Before and after the mock up with the triangular teeth design.

styleitaliano style italiano comparing different dental shapes

Fig.22
If facial flow is correctly determined in the analysis and design of tooth shapes for anterior teeth, any of the options can be harmoniously integrated with the patient’s face, so the choice is left to the patient’s preference.
This example shows the four classic forms of visagism, but it could be perfectly possible use a hybrid or custom shape for each patient. In this case, after seeing the photos, looking in the mirror and asking her family, the patient chose the triangular design, because it perfectly met her expectations of a beautiful smile.

styleitaliano style italiano before and after smile makeover

Fig.23
The digital smile design and dental mock up in any of its forms, physical or digital, is today in modern dentistry a powerful tool for communication with the patient and many times the determining factor to agree to start a treatment. The patient can see the end of the treatment before starting it and become emotionally involved in the treatment.

styleitaliano style italiano patient happy with newly shaped teeth

Fig.24
The facial and smile analysis uses the digital smile design tools based on the patient’s facial flow, and redefines the way of evaluating and designing a new smile. A new tooth shape and size doesn’t have to be associated with the patient’s age or sex, which means an infinite range of possibilities can be evaluated using softwares as common as keynote or Power Point, or specific applications for smile design available for tablets or smartphones.
The photographic evaluation of the patient can be done with a digital camera or using a smartphone with lighting systems such as Smile Lite MDP.

Conclusions

This workflow is a predictable way of planning anterior aesthetic cases and gives us the power to precisely communicating with the laboratory, and involving the patient with their own treatment. Once the dental shape that best integrates with the smile and with the patient’s face is selected, we can execute the treatment in a guided way using silicone or plastic guides for the controlled and safe preparation of the teeth based on the approved plan.

Bibliography

1. Bruno Pereira, Eduardo Mahn, Kyle Stanley and Christian Coachman. The Facial Flow Concept: an organic orofacial analysis – the vertical component. J Prosthet Dent. 2019; 121(2):189-194.
2. Christian Coachman, Marcelo Calamita. Digital Smile Design: A tool for treatment planning and communication in esthetic dentistry. Quintessence of Dental Technology. 2012.
3. Braulio Paolucci, Marcelo Calamita, Christian Coachman, Galip Gürel, Adriano Shayder, Philip Hallawell. Visagism: The Art of Dental Composition. Quintessence of Dental Technology. 2012.
4. Juan Pablo Sánchez, Eduardo Mahn, Gilbert Jorquera, Vanessa Bernasconi. Mock-Up An Old Tool Renewed. Clinical Research in Dentistry. 2018; 1 (1): 1-5.
5. Eduardo Mahn, Stephanie Walls, Gilbert Jorquera, Ana María Valdes, Alejandra Val, Camila S. Sampaio. Prevalence of tooth forms and their gender correlation. J Esthet Restor Dent. 2017;1–6.

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