As a clinician who has been practicing dentistry for over 30 years (wow, that is sounding pretty old to me), I believe that there are certain processes that have not changed all that much. For instance, we still numb our patients using fairly similar protocols. We still, for the most part, prepare teeth using a handpiece. And even though many of us have moved from air-driven handpieces to electric handpieces, these are still fairly similar "equipment" in the eyes of our patients. As a matter of fact, these are two areas that normally elicit some level of pushback from patients; they hate needles, and they hate the noise of our handpieces.

Truth be told, our profession has advanced substantially and continues to do so. Our knowledge in the areas of adhesive dentistry, osseointegration, and airway certainly will not cease to evolve.

Furthermore, dentistry today lives in the intersectionality between healthcare, lifestyle, and technology, and as such, we need to ride the innovation wave. Hence, if we consider yet another one of our patients' "classic" things to complain about, it is the "gooey stuff" that we use to make their impressions. We certainly have evolved here!

This virtual essay demonstrates our present digital workflows, aiming to enhance communication between patients and our clinical and technical teams. It focuses on the use of intraoral scanners, design software, and 3D printing in smile design and acquisition processes. Additionally, it highlights the importance of printed models for efficient communication with patients seeking smile upgrades.

A Patient's Journey Using Digital Workflows

In this example, the patient's chief complaint had to do with the fact that he did not like his smile as he felt that his teeth were rather short. In fact, in repose, he hardly displayed any tooth structure at all (which, as we know, is normally commensurate with an individual considerably older than our patient). He also mentioned that he disliked the slight diastema that was present between his central incisors.

Extraoral images showing various perspectives of the patient's facial features and occlusal assessment
Figure 1A: Extraoral picture in repose, demonstrating the absence of incisal display. 1B: Extraoral picture during a smile. 1C: Cheek retractors placed to evaluate the orientation of the occlusal plane.
Intraoral views capturing occlusal details and range of motion
Figure 2A: Intraoral view in maximum intercuspation. 2B: Intraoral view during mouth opening to assess the occlusal plane's orientation.

Upon clinical examination, there is evidence of incisal wear at the incisal edges of the central incisors, which also reveals some compensatory eruption, as their gingival levels were positioned coronal to the levels of the laterals and canines.

Close-up views of the maxillary anterior teeth and occlusal wear
Figure 3A: Close-up of the maxillary anterior teeth. 3B: Occlusal view depicting slight wear of the incisal edges of the central incisors.

This was something the patient was not aware of, nor did he find it critical at all since his lip mobility did not reveal such gingival discrepancy.

This enforces the importance of going through a lip mobility assessment as it could certainly shift the conversation and the treatment plan. In other words, if the patient's lip mobility would reveal such gingival discrepancy, our treating team would have likely suggested altering the gingival levels either by recommending orthodontic intrusion or clinical crown lengthening.

Intraoral images acquired from the IOS
Figure 4: Intraoral images captured digitally using intraoral scanning technology.

At any rate, clinical pictures, radiographs, and an IOS (intraoral scan) were obtained as part of the initial appointment. Then, the STLs were imported to design software.

Digital design process and enhancements for dental restoration
Figure 5: View of the imported scan into the design software and digital enhancements made, such as closing the diastema, enhancing facial contours, and lengthening the incisal edge.
Evaluation of virtual dental design in facial aesthetics
Figure 6A: Assessing the virtual design's impact on facial aesthetics by overlaying it onto preoperative scans.6B: Comparison of the virtual design with preoperative images.
Fabrication process for mockup restoration
Figure 7A: 3D printed models of the virtual restorative design. 7B: Putty matrix created from the printed model for mockup fabrication.

Following our recommendations and the patient's desires regarding smile design enhancement, our technician went ahead and proceeded to close the slight midline diastema, as well as adding contour to the facial aspect of the maxillary teeth to provide a more pleasing arrangement, with more defined line angles and interincisal embrasures, as well as slightly lengthening the incisal edges of the anterior teeth.

Comparison of preoperative and mockup images
Figure 8A: Retracted view showing preoperative and mockup images. 8B: Close-up views comparing preoperative and mockup images.
Comparison of preoperative and mockup esthetic outcomes
Figure 9A: Close-up of preoperative condition. 9B: Enhanced esthetics achieved with the mockup.
Extraoral views highlighting the improved dentofacial esthetics with the mockup
Figure 10: Extraoral images demonstrating the enhanced dentofacial aesthetics achieved with the mockup restoration.

Once the design was verified and accepted by us, we proceeded to obtain a 3D printed model from which we can make a conventional putty matrix.

Extraoral comparison between preliminary condition and mockup restoration
Figure 11A: Extraoral view of the preliminary condition. 11B: Extraoral view highlighting the improvement with the mockup restoration.
Gingival retraction on minimally invasive preparations
Figure 12A: Gingival retraction on minimally invasive preparations. 12B: Ceramic veneers ready for bonding

Then, the patient came back for a mockup try-in to validate that he accepts the suggested design.

So, once the team and the patient reviewed and validated the esthetic and functional aspects of the mockup, we proceeded to prepare the teeth for ceramic veneers. The laboratory fabricated ten feldspathic ceramic veneers.

Postoperative pictures of the bonded ceramic veneers
Figure 13: Postoperative images showing the results of the bonded ceramic veneers.
Sequence of preoperative, mockup, and bonded ceramic restorations
Figure 14A: Preoperative condition. 14B: Mockup restoration. 14C: Bonded ceramic restorations.

Improving Patient Experiences with Innovative Dental Tools

In the above case, the digital workflow brought the patient on board with a treatment plan by allowing them to take part in their care every stage of the journey. By opening communication lines, practices can improve case acceptance and outcomes.

This virtual essay describes the relative simplicity of incorporating a digital workflow in the treatment of esthetic ceramic veneers, facilitating patient and laboratory communication. While these workflows continue to evolve, incorporating these protocols in contemporary dental practices results in great benefits for all parts involved.

Ricardo Mitrani, D.D.S., M.S.D., is a Spear Resident Faculty member.

Figure legends

Fig 1. 1A Extraoral picture in repose, depicting lack of incisal display., 1B Extraoral picture in smile.

1C: Cheek retractors in place to assess the orientation of the occlusal plane.

Fig 2. 2A Intraoral view in maximum intercuspation. 2B Intraoral view opening to assess the orientation of the plane of occlusion.

Fig 3. 3A Close up view of maxillary anterior teeth. 3B Occlusal view depicting slight wear of the incisal edges of the central incisors.

Fig 4. Intraoral images acquired from the IOS.

Fig 5. View of the imported scan to the design software and the digital design, enhancing the contours: closing the diastema, increasing the facial contour, and lengthening of the incisal edge.

Fig 6. 6A Evaluating the virtual design in the facial esthetics by over imposing the preliminary scan 6B and the design in the preoperative pictures.

Fig 7. 7A The 3D printed models of the virtual restorative design, and 7B putty matrix made in the printed model to fabricate the mockup.

Fig 8. 8A Retracted view of preop and mockup pictures 8B: Close up views of preop and mockup pictures.

Fig 9. Comparison of Preoperative close up and 9B enhanced esthetics with mockup 

Fig 10. Extraoral views of mockup, depicting the improved dentofacial esthetic outcome.

Fig 11. Extraoral comparison of 11A: Preliminary condition and 11B: mockup try in.

Fig 12. 12A: Gingival retraction on minimally invasive preparations, and 12 B: ceramic veneers ready to bond.

Fig 13. Postoperative pictures of the bonded ceramic veneers.

Fig 14. Sequence of 14 A preoperative, 14B: mockup and 14 C: bonded ceramic restorations.