MSc Aesthetic Dentistry Module 2 Unit 2 Part 2. This edition 2010.

MSc Aesthetic Dentistry

Module 2 Pre-treatment Considerations for Aesthetic Dentistry

Unit 2 Photography & smile

imaging software. Part 2 –
Aesthetic Diagnosis, Computer
Imaging and Treatment Planning.
Jonathan B. Levine

© King’s College London, 2009.

All rights reserved. No part of this work may be reproduced in any form, or by any means, without
permission in writing from the publisher. This material is not licensed for resale.

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The content in this Unit is provided for teaching and instructional purposes only in connection with the
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While it is accurate to the best of our knowledge, King's College London and the authors disclaim any
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Consent by patients has been granted to the author solely for the use of images by the author as part of a
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Please note: This PDF may be out-of-date so should be used as a back-up only to the final version of the
unit on the VLE. It must NOT be used for assignment information.

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MSc Aesthetic Dentistry Module 2 Unit 2 Part 2. This edition 2010.

Contents:
Introduction ...................................................................................................................................... 3
Welcome ...................................................................................................................................... 3
Aim ............................................................................................................................................... 3
Objectives .................................................................................................................................... 3
Key points summary .................................................................................................................... 4
Reading lists .................................................................................................................................... 4
Essential reading list .................................................................................................................... 4
Recommended reading list .......................................................................................................... 5
Further reading list ....................................................................................................................... 6
1.1 Introduction ................................................................................................................................ 6
How do we avoid this? ............................................................................................................. 7
What is our objective with computer imaging?......................................................................... 7
1.1.2 The reasons for the approach............................................................................................ 7
1.2 The methodical approach .......................................................................................................... 8
1.3 The three step analysis ............................................................................................................. 8
1.3.1 Aesthetic evaluation form.................................................................................................... 8
Facial photos ............................................................................................................................ 8
Lateral facial photos ................................................................................................................. 9
Examples of photographs......................................................................................................... 9
1.3.2 Diagnostic wax up............................................................................................................. 11
1.3.3 Computer imaging............................................................................................................. 12
1.3.4 Programs of Use ............................................................................................................... 15
1.3.5 Direct mock-up.................................................................................................................. 16
2 Case study.................................................................................................................................. 16
2.1 Diagnostic wax-ups.............................................................................................................. 19
Summary ....................................................................................................................................... 21
References .................................................................................................................................... 22
Unit Assignment............................................................................................................................. 21
Self-Assessment Questions .......................................................................................................... 21

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MSc Aesthetic Dentistry Module 2 Unit 2 Part 2. This edition 2010.

Introduction
Welcome

Jonathan B. Levine DMD, PC.

Hello. My name is Jonathan B. Levine and I have written this section on Aesthetic Diagnosis,
Computer Imaging and Treatment Planning. I am a prosthodontist and clinical director at NYU
Continuing Education Program in Advanced Aesthetics and Associate Professor at New York
University College of Dentistry.

This part of the unit provides information regarding how computer imaging software has
influenced and advanced our profession’s formidable task of diagnosing and treating patients
whose desire is to improve their smile and function. It is not by any means a simple task, but we
hope that the information provided will enable you to embrace and successfully execute a
systematic approach and plan that will facilitate this process.

Aim
To provide you with a three step process that can be applied to any patient seeking treatment. By
following these guidelines, and armed with the necessary techniques to communicate effectively
with both patient and technician, you can deliver predictable aesthetic dentistry. By the end of this
section the reader will be able to integrate the three-step analysis into their clinical practice.

Objectives
On completion of this section you should expect to:
 Be able to utilize a methodical approach to analyze and understand aesthetic problems.
 Be able to explain when diagnosing patients the importance of a three step analysis
method and how to incorporate it.
 Be familiar with how to use an Aesthetic Evaluation Analysis worksheet.
 Be able to incorporate the use of Digital Photography in your work, to help record and
diagnose patient information.
 Be familiar with various Computer imaging programs and their benefits.
 Be able to explain the use of diagnostic waxups and their clinical significance.
 Be able to show a clinical case to illustrate your objectives.

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Key points summary

 A methodical approach should be taken to aesthetic diagnosis by identifying the problem
and then visualizing the solution, using a three step analysis.
 The three-step analysis consists of the aesthetic evaluation form, diagnostic wax-up and
computer imaging or a mock-up in the mouth.
 The aesthetic evaluation form is a checklist approach to gathering information
systematically. Open-ended questions should be used with patients to elicit information
and establish trust.
 Digital photographs are mandatory to evaluate the patient's smile.
 Information gathered from the aesthetic evaluation form and digital photographs are then
integrated into the diagnostic wax up and computer imaging.
 Computer imaging involves both digital photography and digital manipulation of the
images to simulate possible treatment outcome(s).
 Proper use of the diagnostic wax-up phase and key rules is essential.
 The wax try-in/mock up is an important phase in which the patient can actually visualize
what the possibilities of treatment are, and can be used as a validation of the information
previously gathered.
 Established communication with the technician, patient and practitioner is a must for
success.

Reading lists
Essential reading list

Arnett, GW, DDS, Bergman RT. Facial keys to orthodontic diagnosis and treatment planning. Am
J Orthod Dentofacial Orthop. 1993;103(4):299-411.

Brigante RF. Patient assisted aesthetics. J Prosthet Dent. 1981;46(1):14-20.

Gane D, Levine JB. Imaging the esthetic case. Esthetic Dentistry Update. 1995;6(4):85-90.

Levin E. Dental esthetics and the golden proportion. J Prosthet Dent. 1978;40(3):244-251.

Levine, JB. Esthetic diagnosis. In Golub-Evan J (ed). Current opinion in cosmetic dentistry.
Philadelphia: Current Science, 1995, pp 9-17.

Lombardi, Richard. A method for the classification of errors in dental esthetics. J Prosthet Dent.
1974:32:501-513.

Matthews TG. The anatomy of a smile. J Prosthet Dent.1978;39(2):128-134.

Mavroskoufis F, Ritchie GM. Variation in size and form between left and right maxillary. J
Prosthet Dent. 1980;43(3):254-257.

Miller EL, Bodden WR, Jamison HC. A study of the relationship of the dental midline to the facial
median line. J Prosthet Dent. 1979;41(6):657-660.

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Miller L. Organizing color in dentistry. J Am Dent Assoc. 1987;special issue:26E-40E.

Preston JD. The golden proportion revisited. J Esthet Dent. 1993;3(6):247-251.

Rosentiel SF, Ward DH, Rashid RG. Dentists’ preferences of anterior tooth proportion - A web-
based study. J Prosthet Dent. 2000;9(3):123-136.

Shavell HM. The aesthetic of occlusion forms, function, finesse. Pract Periodontics Aesthet Dent.
1993;5(3):47-55.

Spear FM, Kokich VG, Mathews DP. Interdisciplinary management of anterior dental esthetics. J
Am Dent Assoc. 2006;137(2):160-169.

Tjan AHL, Miller GD, Josephine GP. Some aesthetic factors in a smile. J Prosthet Dent.
1984:51(1):24-28.

Vig RG, Brundo GC. The kinetics of anterior tooth display. J Prosthet Dent. 1978;39(5):502-504.

Winter R. Visualizing the natural dentition. J Esthet Dent. 1993;5(3):101-116.

Recommended reading list

Andres LF. The six keys to normal occlusion. Am J Orthod. 1972;62(3):296-309.

Chu S, Devigus A, Mieleszko AJ. Fundamentals of color: shade matching and communication in
esthetic dentistry. Quintessence Publication Co., 2004.

Goldstein C, Garber David, Goldstein R. Imaging in esthetic dentistry. Quintessence Publication,

1998.

Gurel G. The science of art of porcelain laminate veneers. Quintessence Publications, 2003.

Heymann H. The artistry of conservative esthetic dentistry. J Am Dent As. 1987;special

edition:14-E-23-E.

LaVacca MI, Tarnow DP, Cisneros GJ. Interdental papilla length and the perception of
aesthetics. Pract Proced Aesthet Dent. 2005;17(6);405-414.

Lee EA. Aesthetic crown lengthening classification, biologic rationale and treatment planning
considerations. Pract Proced Aesthet Dent. 2004;16(10):769-778.

Lee RL. Anterior guidance. In: Lundeen HC, Gibbs CH (eds). Advances in occlusion. Boston:
John Wright-PSG, 1982, pp 51–80.

Magne P, Gallucci GO, Belser UC. Anatomic crown width length ratios of unworn and worn
maxillary teeth in white subjects. J Prosthet Dent. 2003;89(5):453-461.

Rufenacht C. Fundamentals of aesthetics. UK: Quintessence Publications, 1990.

Salama M, Sarne O. Esthetic considerations in adult orthodontic treatment. Esthetic

considerations in adult orthodontic treatment. 1993;67-74.

Singer BA. Principles of esthetics. Curr Opin Cosmet Dent. 1994;39:6-12.

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Snow SR. Esthetic smile analysis of maxillary anterior tooth width. J Esthet Dent. 1999;11(4):177-
184.

Stade EH, Hanson JG, Baker C. Esthetic considerations in the use of face-Bows. J Prosthet
Dent. 1982;48(3):253-255.

Further reading list

Albino T, Conny, DJ. Patient perceptions of dental-facial esthetics: Shared concerns in

orthodontics and prosthodontics. J Prosthet Dent. 1984;52(1):9-13.

Chu SJ, Karabin S, Mistry S. Short tooth syndrome: diagnosis, etiology, and treatment
management. Calif. Dent. Assoc. Jour. 2004;32(2):143-152.

Dietschi D. Free-hand composite resin restorations: a key to anterior aesthetics. Pract.

Periodontal & Aesthetic Dent. 1995;7:15-25.

Hunt, K: Bioesthetics: The impact of bioesthetics on the face, smile and teeth. Dent Econ. 1995
Mar;85(3):81-2.

Kim J, Chu S, Gurel G, Cisneros G. Restorative space management: treatment planning and
clinical considerations for insufficient space. Pract Proced Aesthet Dent. 2005 Jan-Feb;17(1): A-
H.

Rosentiel SF, Rashid RG. Public preferences for anterior tooth variations: a web-based study. J
Esthet Restor Dent. 2002;14:97–106.

Stapper CFJ, Stathopoulou N, Gerds T, Strub JR. Survivial rate and fracture strength of maxillary
incisors, restored with difference kinds of full veneers. J Oral Rehabil. 2005;32(4):266-72.

1.1 Introduction
Computer imaging in aesthetic dental practice is a powerful visualization technique of the
aesthetic process. This technique has been utilized in dentistry for the last 15 years and has
never achieved mass appeal by the aesthetic dental community. Often it may be too cumbersome
for a practitioner to utilize effectively the latest technology at hand. He/she may prefer instead the
tried and true techniques, an approach that has been successful in the past. But what enables us
as practitioners and educators is our search for better answers and better methodologies to
continue our craft. It is no surprise that the first individual who took a ‘before’ and ‘after’ photo
realized the massive significance it brought when the patient saw what was previously there, and
what now existed as a result of the practitioner’s skills. We can take this information for granted
since it is now considered routine. Think of the power this has had over how we practice today.
Many programs are now available to show the potential ‘afters’ before a clinician even picks up
the handpiece.

The greatest concern for us as clinicians is that the computer imaging will offer a visualized
solution that is not easily achievable, or may even be impossible to achieve. Such imaging
systems have been made easier to use and can be integrated with many office computer

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database systems. However, the same issues from 15 years ago still exist today, thus fuelling the
unrealistic expectations of patients with an unachievable computer image.

How do we avoid this?

If we build a system in the aesthetic process that ensures the picture we show to the patient is a
realistic outcome, we will avoid building unrealistic expectations. In fact, as in all service
business, we need to make sure we underpromise and overdeliver - and not the other way
around.

What is our objective with computer imaging?

Computer imaging is a tool that we can use to have an “opportunity for conversation” with the
patient before any treatment starts. This conversation is a visual one and has to be part of a
systematic approach to aesthetic diagnosis. Using a 3-Step Analysis to identify the problem and
then visualize the solution, computer imaging illustrates the product of your well thought-out
diagnosis and communication with both patient and technician.

In this section, we will review the 3 Step Analysis for aesthetic diagnosis and how computer
imaging needs to be part of a systematic approach that integrates into clinical practice to be
viable. We will then review the latest computer imaging software programs currently available.

1.1.2 The reasons for the approach

A patient’s desire for improved aesthetics and smile has motivated many to seek treatment, with
varying results for both patient and the practitioner involved. Considering that many dentists and
specialists are available, patients often become confused as to who can deliver the most
competent care. Our responsibility, therefore, is to become fully competent in diagnosing these
cases prior to rendering treatment to maximize patient (and practitioner!) satisfaction.

All dentists rely upon visual aids and information gathering to assist in diagnosis and treatment
planning and newer advances in technology have further strengthened this concept. This
information not only helps the dentist, but the patient and the technician’s understanding of
treatment parameters as communication is maximized. However, such technology is helpful to a
point, but without a methodical approach to diagnosis and clear communication between the
doctor, patient, and technician, all gathered information would be of little use without systems and
flow.

I have found that a Three-Step approach to aesthetic diagnosis, as follows, is fundamental to

achieve predictable results. You should:

 Use an aesthetic evaluation form.

 Use mounted diagnostic casts and wax-ups.
 Include computer imaging as part of the process. With computer imaging, the patient
concerns are presented and potential solutions are digitally simulated onto the patient
image.

Combining all these factors will ensure the analytical process is successful and execution of the
proposed treatment is predictable.

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1.2 The methodical approach

All practitioners must develop a methodology of how to think and approach any aesthetic case.
Such thought processes need to be systematic and structured so that all points to be considered
are covered and explored fully and the information can be shared between patient, technician and
practitioner. Peter Dawson is often quoted, "If you know where you are and you know where you
want to go, getting there is easy"1. Or, as Steven Covey likes to say, you should keep "The End in
Mind"2. These statements are the keys to tackling any case.

You can proceed to utilize a methodical approach to visualize a solution so that the patient can
see what the practitioner and technician are thinking and communication is maximized.

The first step is to identify the problem. Problem(s) concerning the patient can be identified using
the three step process. This involves using an Aesthetic Evaluation Form to gather basic
anatomical data from a Three View approach. As a camera zooms in, the facial, dentofacial and
dental perspectives are analyzed closely with the fundamentals of aesthetics as guidelines.
Open-ended questions are asked to let the patient define what they want, enabling maximum
communication between the dentist and the patient. Mounted study casts are also taken.

You can visualize a solution to the aesthetic problems by waxing up ideal shapes and positions
of teeth on the study casts derived from the aesthetic evaluation form, resulting in a well thought
out diagnostic wax-up. This is done prior to the computer imaging and is now part of the
integrated system. This process can help avoid the pitfalls of the past by just relying on computer
imaging alone.

Finally, you can choose the appropriate technique by working backwards from the visualized
solution and choose the most conservative technique to get you there. This entire process is
enabled by a three step analysis that is incorporated in the diagnostic process. Many failures are
often attributable to breakdown of communication between patient, doctor and technician, rather
than technical nature involving the restorations themselves.

1.3 The three step analysis

1.3.1 Aesthetic evaluation form

Obtaining radiographs, diagnostic casts and photographs of the patient are the first steps in
acquiring the information we need to assist proper diagnosis; it outlines what we need to identify
the problem. The digital photographs are used solely in a medico-legal sense, and are therefore
used in the evaluation of the patient. A standard series of images should be acquired via digital
camera and should compose of the following photo shots broken down into three basic
categories: facial, dentofacial and dental views.

Facial photos
Full headshots to show the following:
 Full Smile.
 Normal Smile.
 Repose.

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Lateral facial photos

Dentofacial shots
Frontal, oblique and lateral

Dental shots
Retracted photos, frontal, oblique and lateral.
Occlusal Maxillary/Mandibular shots.

Examples of photographs

Facial views

(lips at rest) (full smile) (half smile)

Figure 1. Full facial photographs.

Lateral views

Figure 2. Lateral views.

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Dentofacial views

Figure 3a. Dentofacial views, frontal.

Figure 3b. Dentofacial views, lateral.

Dental views

Figure 4a. Dental views, facial.

Figure 4b. Dental views, lateral.

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Figure 4c. Dental views, close up.

Occlusal views

Figure 5. Occlusal views, Maxillary and Mandibular arches.

Using the aesthetic evaluation form (see figures 6a and 6b), organize key elements from the 3
views: facial, dentofacial and dental. When meeting with a patient, start a discussion with
effective open ended questions. These are proposed to the patient with the goal of eliciting
information.

Questions you might ask are:

 Is the patient happy or unhappy about their smile?

 How do they feel about their appearance?
 If there was one thing above all else that you could change about your smile, what would
it be?

These are just a few examples of how to draw a patient into a conversation about their smile. This
important step allows a patient to fully express their desires and goals with respect to actual
treatment. The aesthetic evaluation form is used to review elements of the face, smile, teeth, and
gingiva in a methodical fashion and is used in conjunction with the patient discussion. The
information can be considered a technical blueprint for the ensuing aesthetic imaging phase. All
information gathered will assist in defining the incisal edge position of the central incisor and the
gingival margin position so that the technician knows precisely how to do the next step - the
diagnostic wax-up.

1.3.2 Diagnostic wax up

Once study models have been taken and mounted properly on an semi-adjustable articulator,
(CR bite record and facebow), the technician can fabricate a diagnostic wax up. This needs to be

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done prior to any computer imaging. Bear in mind that several factors should be considered when
evaluating the wax up with your technician, all of which should follow the basic fundamentals of
aesthetic restorations:

1. Decide upon central incisor dominance, wherein the central incisors are at least 1.5x the
size of the lateral incisors and/ or balance with Divine Proportion of the maxillary anterior
dentition (1.6: 1) (i.e. incisal edge position and gingival margin).
2. Define symmetry at the midline.
3. Evaluate Golden Proportion of the maxillary anterior dentition (central:lateral:canine,
appropriate to apparent in the wax up).
4. Keep axial inclination distal with existing dentition.
5. Incisal embrasures should steadily increase in size from anterior to posterior.
6. Evaluate the inner line angles appropriately.
7. Keep in mind texture, incisal contour, and a generalized natural appearance. Most wax-
ups can be very age specific unless there are particular requests and goals in mind.
8. The gingival zeniths of all dentition should be at the appropriate height and placed
relative to each tooth.
9. Occlusal function should be in existence to create anterior guidance, and a mutually
protected occlusion.

1.3.3 Computer imaging

All information gathered in the previous step allows a clear and mutual understanding of all
problems and issues of concern to the patient. Digital images are then uploaded onto the patient
file and placed in a diagnostic section to allow for visual analysis. At this point, the dentist and
patient can enter into an open dialogue with these visual aids to display the issues at hand.
Questions that stimulate the patient to speak openly and plainly about their teeth and smile, i.e.,
likes, dislikes, what they desire, should be posed at this point. The key is to listen and respond
only where appropriate. The patient can help “lead” the dentist to a path that he/she desires. The
viewing of these photos represents a powerful tool in the diagnostic process. A patient can view
their photographs in the pre-operative phase and identify their concerns and issues while also
helping in the diagnostic process by actively participating in careful analysis alongside the dentist.
Anything the dentist sees, the patient can actively see and analyze, and vice-versa.

The next step in the process would be to digitally alter the images in accordance with the patient’s
preferred treatment options and the diagnostic wax-up. This validates any computer imaging
changes, since the dentist knows what is possible in 3-dimensions. The program allows for
multiple changes, involving color, size, shape, texture, of each individual tooth as well as position
and gingival contour. The dentist is free to choose from a set library of sample smiles that are
pasted into the existing photograph or is able to directly alter each tooth in the patient photo.
Remember that this process can present dangers, since we need to make sure all
computer imaging changes are realistic. All this can be done with the patient viewing the
changes and, again, participating in the process. Further changes can be made and done if the
results are not in accordance with the requested changes.

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Figure 6a. Aesthetic evaluation form.

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Figure 6b. Aesthetic Evaluation form, page 2.

A careful side-by-side analysis of the images can then be posted on the monitor. Further
discussion can take place to direct the patient into evaluation of the proposed treatment. Such
actions will further develop the communication process between dentist and patient, and also
allows for development of trust between the two. A final image can be then printed out for both

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patient and doctor. All elements of the “final” suggested treatment can therefore be relayed to the
technician for the ensuing step.

1.3.4 Programs of Use

A prominent software application is available from Digident.com (http://digident.com/home.htm). It
uses a 3-step system to aid dentists in designing a smile that would benefit the patient best. A
Smile Style Guide booklet is included that patients can browse. It depicts smile types based upon
cuspid shape, incisor shape, and length of incisors in relationship to cuspid length. The program's
main feature is the iSSG/Interactive Smile Style Guide. This aids both dentist and patient to select
the shape, size and color of the restorations proposed. Four variable lengths seem to be the norm
for this program. The program also utilizes the Smile CD, a disc that contains approximately 18
smile designs with four different versions based upon the previously mentioned variables totalling
72 designs.

The program is designed to work with any computer software system as an adjunctive program.
Therefore, if the office is using, say, Dentrix, then the Digident software can be opened up to add
to the designs and then to the patient file. Of note is the usage of the Lorin Library, which is the
basis of their smile design database. This library is available on a separate disc and can be used
with other imaging software systems. The program works with a basic click, drag and scale
action. The smile area of the digital photo of the patient is outlined and removed with the mouse.
The selected smile is then dragged onto the area and then scaled accordingly to fit the patient
photo. Also, the individual teeth may be shaped and altered as desired.

Cieos (cieos.com) has a proprietary software system for use called Visora. The program is
intended for use with any office software suite and it integrates digital photography, cosmetic
imaging, intraoral photo capture, digital x-ray capture, and document management. The interface
is clean and attractive to look at for both patient and dentist. The system is virtually the same as
Digident's software except for the ability to anchor and resize each individual tooth to adjust them
to the patient image after the smile design has been selected. Again, the program is intended for
use with Cieos' software suite, but can be incorporated into any other system you choose.
Apteryx imaging (apteryx.com) also has its own proprietary program for use with its office
software suite, called the cosmetic imaging module. It is similar in most ways to the previous
software, and also makes use of the Lorin Library (which it sells online), but it is sold as a bundle
with their office programs (which include charting, digital x-ray imaging and intraoral cam
imaging).

Dentrix G4 (http://www.dentrix.com) is the newest iteration of the Dentrix office program, and
there is an add-on feature that involves Dentrix image 4.0 and incorporates its own smile library.
The program seems similar in most aspects to the Digident system.

There are other services available online, such as Smile Pix.com, Smile Art
Communications.com, and VirtualSmiles.com, which do all the work for you. The doctor provides
the photos and the service creates versions of smiles for you depending upon the request
parameters you provide. Lester A. Dine (Dinecorp.com) is a photography sales center that
specializes in cameras, etc and has their own imaging software suite (Pixelease) that can be
incorporated into an office's system, but offers little in terms of changing/planning cases like the
Digident software. Obviously there is a delay in the time it takes between sending images and
receiving the altered ones. Moreover, the dentist and patient are not present when any changes
are made. You are only able to suggest changes that the imaging technician will make to the
existing photos.

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1.3.5 Direct mock-up

The true test of any wax–up is to actually place the wax–up in a patient without preparing any
tooth surface. A simple silicone impression can be made of the wax-up at hand and any
temporary acrylic material (Integrity [by DentsplyCaulk], Luxatemp [by DMG], etc) can be injected
directly into the matrix and placed directly into the patient’s mouth. It is left to cure and the matrix
is then removed. A mock- up of the wax up is then delivered directly to the patient’s oral cavity
where he/she can view the results. Photographs and an explanation of concepts are good, but
when the patient can see and feel the proposed treatment, it becomes a powerful tool! Such a
mock- up is vital to any case. It is important to note that this phase can be considered analogous
to the computer imaging step. However, each phase has distinct advantages. The computer
imaging step has the ease of use to downsize any restoration the dentist is proposing, whereas
the mockup can enlarge the relative size of the restorations and arch form. Both steps are helpful
to demonstrate the visual proposal to the patient and technician.

2 Case study
A 41 year old female patient presented with the desire to "improve her smile" as she was
becoming self-conscious about smiling. We started with the three step analysis and the aesthetic
evaluation form. We asked first about her smile and what bothered her. Based on her answers we
found that the overall color, shape and position of the anterior teeth needed to change. Basic
information was taken as per the Aesthetic Evaluation Form: digital photographs were taken
(facial, dentofacial and dental views), mounted study models via alginate impression and
facebow. The form indicated the number of teeth that the patient shows in a natural smile,
horizontal and vertical components of the smile, midline position, buccal corridors, lip line, and
occlusal pattern, among others. A discussion followed as to how the desired changes could be
effected in treatment of the anterior teeth.

From the pre-operative photographs taken (full smile, head shot), we used the Cieos Visora
software to simulate new restorations on her anterior teeth. This illustrated what changes could
occur via stock ideal dentition dragged into place. The photos were posted side by side for a
comparative analysis discussion by patient and dentist.

Figure 7. Cieos Software with stock smile software, pre-op photo.

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Figure 8. Cut out of patient’s current dentition.

Figure 9. Click and drag of stock smile onto patient photograph.

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Figure 10. Drag and sizing of stock smile.

Figure 11. Side by side photo comparison.

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Note the size, shape, color, and position of the teeth, the position of the midline, and gingival
zeniths in the altered photograph. What is different about the two photographs? From the
anatomical perspective, the computer image is not viable without radical changes to the existing
dentition and surrounding alveolar environment, changes that may not be actually possible. The
computer imaging picture was done without the diagnostic wax-up first and illustrates the
potential drawbacks of computer imaging alone without a three-dimensional wax-up for validation.

With the patient's approval, the photographs and aesthetic evaluation form were discussed with
the dental technician. The diagnostic wax-ups are now generated and the information can be
loaded into the computer imaging proposal.

2.1 Diagnostic wax-ups

Figure 12. Diagnostic wax ups.

Further discussion with the technician indicated that the suggested size and shape of the teeth
could be displayed in a more idealized fashion but not to the extent that the original computer
image indicated. Another computer image was created using the same software, this time with
direct regard to the positions of each individual tooth and also with the information culled from the
aesthetic evaluation form. The program was able to assist in selecting each individual tooth and
creating an aesthetic result. The process is more time-consuming, but the net result is directly
related to patient's existing anatomy and the proposed changes from the diagnostic wax-up.

Figure 13. Digital imaging subsequent to wax ups.

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Note the changes in size, shape and color of the individual dentition for the maxillary teeth as well
as the buccal corridor with the suggested restorations. Gray margins were eliminated, and
lengthening of all teeth is also displayed. The patient made suggestions for the individual teeth
and all changes were made while the patient watched.

A PVS (polyvinylsiloxane) matrix was then crafted from the wax-ups and a mock try in of the
proposed changes was inserted into the patient's mouth using temporary acrylic resin Integrity
shade A1 Vita injected into the matrix. The material was allowed to set for 2 minutes and the
matrix was then removed. Excess material was removed carefully with a blunt plastic instrument.
Additional contouring and shaping was performed directly with a handpiece intraorally.

Figure 14. Direct mock up.

Note again, the size, shape, color, and position of each "restoration". Again, with the patient's
emphatic approval, treatment was subsequently initiated for the maxillary and mandibular
dentition. Treatment was approached sequentially and in direct consultation with the technician.
The final results were exceptional - even to the patient's own initial expectations.

Figure 15. Final restorations.

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MSc Aesthetic Dentistry Module 2 Unit 2 Part 2. This edition 2010.

Summary
Solving aesthetic problems for patients needs to be predictable and, therefore, the main reason
for aesthetic failures is the lack of communication between dentist, patient and technician. Using
a methodical approach to identify the problem, visualize the solution, and choosing the
appropriate technique creates the system necessary for predictability. The three step analysis of
aesthetic evaluation form, diagnostic wax-up and computer imaging/direct mock-ups to assist in
identifying the problem and visualizing the solution offers a defined methodology to solve
aesthetic problems in clinical practice.

Self-Assessment Questions
1. When interviewing a patient for the first time, is it important to ask direct questions? Should
these questions be open-ended to elicit discussion?

2. What purpose(s) do the digital photographs serve? What kinds of photographs should be taken
of the patient?

3. In selecting a digital imaging software program, what should the practitioner be aware of?
What features should a software suite have? What does a practitioner need to be wary of when
utilizing any type of digital imaging software?

4. During the diagnostic phase, what purpose(s) does a wax-up of the patient’s dentition serve?
In what way(s) does the patient benefit from the wax-up?

5. What is the standard sequence of events in the Three-Step Analysis? How does this process
benefit practitioners?

6. What is the main purpose behind the Aesthetic Evaluation Form? Why is this essential in
diagnosing and treating patients’ aesthetic needs?

Unit Assignment
Select a patient from your practice and produce a comprehensive set of pre-operative records to
simulate an aesthetic assessment prior to possible smile design. Include:

 A smile analysis and design (you can use the New York assessment package from Dr
Levine's section).

 Relevant charts, diagrams and radiography.

 A full set of high quality photographs.

You will be assessed on the quality of the images and records you submit. Please note you do
not need to use an actual case that you are planning to treat in your practice. This assignment is
about recording and presenting records, not treatment.

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References
1. Dawson, Peter. Functional occlusion: From TMJ to smile design, Mosby, 2006.

2. Covey Steven. The Seven Habits of Highly Effective People. Simon & Schuster, 1998.

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