The Interntionl Journl of Periodontics & Restortive Dentistry
183 Dynmic Documenttion of the Smile nd the 2D/3D Digitl Smile Design Process 1 Privte Prctice, São Pulo, Brzil. 2 Assistnt Professor, Deprtment of Prosthodontics, School of Dentistry, University of São Pulo, São Pulo, Brzil. Christin Cochmn, DDS, CDT 1 Mrcelo Alexndre Clmit, DDS, MSD, PhD 1 Newton Sesm, DDS, MSD, PhD 2 Medicl nd dentl histories, clinicl exmintion, study models, nd photogrphs provide the dt for proper dignosis nd the tretment pln for esthetic dentistry. However, they do not offer ll the informtion necessry to nlyze the smile nd crete hrmony with the lips nd fce without excessive introrl djustments. Dentolil prmeters vry ccording to lip dynmics nd re influenced y oth sttic posed smile nd smile in motion s cptured in video. This rticle descries documenttion protocol using smrtphone videos to improve the nlysis, smile design decisions, nd elortion of 2D smile frme tht will guide the 3D digitl smile design project. The use of dynmic documenttion of the smile (DDS) llows esthetic rehilittive plnning from fcil perspective, improvement of communiction with the ptient, integrtion etween the specilists, nd the predictle qulity of the tretments. Int J Periodontics Restortive Dent 2017;37:183 193. doi: 10.11607/prd.2911 Correspondence to: Dr Newton Sesm, 2227 Professor Lineu Prestes Avenue, São Pulo, Brzil 05508-000. Fx: +55 11 30917888. Emil: sesm@usp.r 2017 y Quintessence Pulishing Co Inc. Esthetic dentl rehilittion hs een fced with three gret chllenges: (1) relte the working models to the fce, (2) interdisciplinry communiction nd plnning, nd (3) interction with the ptient. Drwing reference lines nd forms on extr- nd introrl photogrphs hs een used to roden the dignostic view nd help the restortive tem evlute esthetics nd function nd mke dequte clinicl decisions. 1 3 Digitl Smile Design (DSD) is conceptul tool tht llows esthetic rehilittive plnning from fcil perspective, improving communiction etween specilists nd incresing the predictility of the tretments. 1 There re prmeters tht guide smile evlution nd design, such s the midline, height, nd curve of the smile nd intr- nd interdentl proportion. 4 8 Although mny studies hve mesured the sttic smile, 9 13 it is lwys difficult to cpture the idel frme in photogrph. 14 The euty of smile emntes from its motion nd the dynmic integrtion of teeth, gingiv, lips, nd fce, so sttic photos re n indequte sis for smile design. The perception of esthetics in motion is different thn the sttic view. Ech second of video footge covers pproximtely 29 frmes, incresing the chnce of finding the correct spontneous moments for the smile design. Volume 37, Numer 2, 2017
184 2 m d 0.5 m e 1 m 1 m 1 m f c 2 m g Fig 1 Suggested studio for smrtphone videos. () Two LED pnels in front of the ptient will generte the idel light to crete videos with sufficient qulity. () An extr LED pnel cn e plced ehind the ptient when using white ckground to remove the shdows. (c, d) A room with lck nd white wll used for ckgrounds. (e) Ptient pproximtely hlf meter wy from the wll. (f) An extr LED light ttched to the phone to reduce introrl shdows in the close-up imges. (g, h) A smrtphone or tlet used to film the ptient. The device should not e too close to the ptient to void lrge distortions. Dynmic video evlutions hve een used in orthodontics for some yers. 14 20 However, few studies of the smile in motion hve een conducted in esthetic dentistry. The im of this study ws to descrie the smrtphone video protocol for mking the photo documenttion with snpshots of the video, nd to show the dvntges of using video documenttion to fcilitte nd simplify the documenttion process, improving fcil nlysis, smile design, tem communiction, tretment plnning, nd ptient eduction. Smrtphone Video Protocol for DSD Photogrphs tken with digitl single lens reflex (DSLR) cmers re still the gold stndrd to fricte eutiful documenttion for lectures nd pulictions. When it comes to imge qulity, smrtphone cmers re not s good s DSLR cmers. However, they re dequte for smile design, tretment plnning, ptient eduction, nd the digitl workflow, llowing the tem to deliver optiml routine dentistry on dily sis. The key to recording videos of cceptle qulity with smrtphone is to hve intense light coming from LED pnels (Fig 1). When filming with the smrtphone, the opertor hs to mke sure idel frming nd zoom re djusted to the fce with idel exposure nd focus djusted to the mouth (Fig 2). A monopod nd smrtphone holder re used to stilize the phone, nd glove ox should e plced ehind the ptient to void hed movement (Fig 3). The Interntionl Journl of Periodontics & Restortive Dentistry
185. When clicking over the mouth for 2 seconds this icon will show AE/AF LOCK informing tht exposure nd focus re locked.. Click over the mouth to djust idel exposure nd focus on this re. c. Move the sun icon up nd down to fine tune exposure. d. One-qurter of digitl zoom to frme the fce without hving to get too close to the ptient, reducing the distortion. e. Plce it on video mode. Fig 2 Adjusting the smrtphone. Fig 3 Stiliztion of the smrtphone nd the ptient s hed. Technicl Videos Four videos should e tken from specific ngles for idel development of the fcilly guided smile frme. A fcil frontl video should e recorded, including with nd without retrctor smiling (Fig 4). The key is to keep the cmer nd the ptient s hed still to crete photos with nd without retrction from similr distnces, ngles, nd distortions. Both imges then cn e overlpped on the DSD process, linking the fcil nlysis to the introrl nlysis. The Fig 4 Fcil frontl video. () Retrcted. () Smiling. Volume 37, Numer 2, 2017
186 c Fig 5 Fcil profile video. () Ptient positioning. () At rest. (c) Smiling. cmer should e level with the eyes slightly ove the mouth, creting nturl smile curve. The closer the cmer gets to the ptient, the igger the distortion of the imge. To minimize this distortion, keeping 1-meter distnce nd slightly zooming in digitlly re recommended. In oth frontl videos, the mouth should e open with the teeth prt for etter visuliztion of the esthetic issues, the mndiulr teeth, nd drwings nd simultion. The ptient should ite on jig on the molr re to keep the teeth t similr distnce in oth photos. A fcil profile video (Fig 5) should e tken with the lips t rest nd in wide E smile. The key is to provide totl profile view. The reference should e the upper lip. A 12 o clock video (Fig 6) should lso e tken from ove the hed t the most coronl ngle tht still llows visuliztion of the incisl edge of the six nterior mxillry teeth with the ptient retrcting the upper lip with oth thums. This imge should show the reltionship etween the fcil midline, interpupillry line, intercommissurl line, ngles of the mndile, menton, rch form, nd vermilion of the lower lip. Finlly, n nterior occlusl video (Fig 7) should e mde without mirror nd perpendiculr to the occlusl pln. The gol is to cpture the mxillry teeth from second premolr to second premolr with the pltine rphe s stright line. Complementry Videos Four complementry videos should lso e tken for fcil, phonetic, functionl, nd structurl nlysis (Fig 8). A fcil interview (Fig 8), short interview of the ptient with sic questions, cn give importnt informtion out the ptient s desires nd chief complint. This informtion is vitl for the dentl tem to develop strtegy of communiction to the ptient nd increse the ptient s confidence. The following four sic questions should e sked: (1) Why re you seeking dentl tretment? (2) Wht do you like nd wht do you dislike out your smile? (3) Wht re your expecttions? (4) Wht do you consider s n idel smile? In close-up 180-degree phonetics video (Fig 8), the ptient will count from zero to ten, pronouncing the importnt phonetic sounds (F, V, S), nd give regulr smile nd The Interntionl Journl of Periodontics & Restortive Dentistry
187 Fig 6 12 o clock video. () Ptient positioning. () Close-up view. Fig 7 Anterior occlusl video. () Ptient positioning. () Close-up view. stretched E smile. As the smile design process is relted to the speech process, dentists should include the phonetic nlysis when designing new smiles. If etter speech findings re needed, the video cn e esily sent to speech therpist for further nlysis. In n introrl functionl video (Fig 8c), tken with retrctor, the ptient is sked to perform the functionl excursive movements (protrusion nd lterl movements). Both sides, working nd nonworking, re filmed. Asking the ptient to chew nd do the functionl Volume 37, Numer 2, 2017
188 Specific moments of fcil expression must e nlyzed to understnd the dentofcil dishrmonies nd mke clinicl decisions. For exmple, the lip rest position, the height of the smile line, the shpes of the lips, the integrtion of fcil nd dentl midline, lip support, soft tissue disply, uccl corridor, nd fcil profile cn ll pper distorted when only photos re considered. Wht my look good or d in sttic photo my seem the opposite when these elements re in motion. A common prolem with the digitl smile design is tht the photos my e tken t the wrong ngle. Video cn cpture specific view with slightly different ngles nd cn e trnsformed into photos y pusing the video nd mking screen shot of the desired ngle. This simplifies the documenttion process nd sves time. It lso removes the responsiility of the photogrpher to snp the photo t the perfect moment, llowing choice of the est recorded moment. The fcil nlysis through video should guide the smile design process tht will e done over sttic imges in two (2D) nd three dimensions (3D). DSD Technique c Fig 8 Complementry videos. () Fcil interview. () Close-up 180-degree phonetics. (c) Introrl functionl. (d) Introrl structurl. excursive movements provides insight into their envelope of function, clrifying some interferences tht re difficult to cpture in still photos. d An introrl structurl video (Fig 8d) is lso tken with retrctor to visulize the occlusl surfces of the mxillry nd mndiulr rches. The min gol of the DSD technique on the computer is to djust the photos from the three min views of DSD (12 o clock, frontl, nd occlusl) with one nother using the digitl ruler, nd to dd the lines nd drwings tht will crete the smile frme sed on the video nlysis. This frme, together with The Interntionl Journl of Periodontics & Restortive Dentistry
189 the conventionl ptient documenttion (eg, medicl history, dentl history, clinicl exm, perio chrt, rdiogrphs, models), completes the informtion needed to improve the decision-mking process, interdisciplinry interction, nd tretment plnning. The frme is not definitive rule tht needs to e mtched t ny cost, ecuse euty does not men perfect symmetry. The ide is to develop tretment pln tht gets s close s possile to the frme creting the simplest, most strightforwrd, most conservtive tretment possile. Anlyzing the video should guide plcement of the lines over the photos. Creting the Fcilly Guided Smile Frme in Eight Steps Step 1: The Digitl Fceow The fcil midline my not mtch the dentl midline. The ide is to discover if dentl midline shift nd/or cnt is present nd select position to strt smile decision. Discrepncies etween dentl nd fcil midline up to 2 or 3 mm were generlly not noticed in study tht oserved imges limited to the perspective of the smile. 21 However when full-fcil imges were nlyzed, minor dentl midline shift such s 1 mm could e seen in symmetric fces depending on the direction of the shift. It could e concluded tht extrorl fcil structures such s the nose nd chin cn ffect the perception of dentl midline shift. 22 Step 2: Smile Curve The smile curve position nd shpe will depend on the fcil nd lips dynmic nlysis through the video. The video is pused when necessry, nd three photos re cptured: rel rest position, nturl smile, nd ngled smile. In the first photo, the reltionship etween the upper lip nd the incisl nterior mxillry edge is nlyzed. The second one llows nlysis of the reltionship of the uccl corridors with the cheeks, which cn e used to determine whether they should e chnged y widening or nrrowing the rch. In the ngled smile photo, the length of the posterior teeth is nlyzed in reltion to the lower lip to determine the pproprite length nd smile curve. Step 3: Interdentl Width Proportion The uthors recommend using the recurring esthetic dentl (RED) proportion, 10 insted of the golden proportion, to determine the idel width from the frontl perspective of the centrl nd lterl incisors nd cnines to crete nturl nd plesnt smiles. These proportions, from frontl view, dictte tht if the centrl incisors re x, the lterl incisors should e 0.7x nd the cnines 0.5x. Fcil references, such s the inner prt of the eyes nd the interlr nd intercommissurl lines t rest, cn e used to determine the outer edge of this ruler tht refers to the distl of the cnines. This ruler cn e dpted to ny tooth tht seems to e in hrmonious position with the fce, with the other lines suggesting the width of the remining nterior teeth. Step 4: Centrl Incisor Width/ Length Proportion The idel centrl incisor proportion should e round 80%. 23 The present uthors usully work within the rnge of 70% to 90%. Since the incisl edge position nd the width hve lredy een determined, working with the centrl templte will llow nlysis of the reltionship of the gingivl mrgin to the other prmeters. Step 5: Gingivl Curve The gingivl curve must e determined with the help of the video nlysis. The gingivl curve should e plced over the cervicl spect of the proposed new centrl incisor, nd the posterior inclintion of the curve will e determined to crete relistic reltionship etween the curve nd the upper lip ccording to the posterior gingivl disply. Step 6: Ppille Curve The ppille curve should e slightly closer to the gingivl curve, ecuse the height of the ppille is usully 40% of the height of the crown. 24 Step 7: Vermilion Curve After the imge is djusted to the guidelines, the clinicin cn zoom in nd nlyze the reltionship etween the teeth, the rch curve, nd the vermilion curve in the 12 o clock view tht will help determine the idel uccl-pltl position of ech mxillry nterior tooth (Fig 9). Step 8: Arch Curve Integrting the nlysis of the occlusl photo with the fcil frontl video helps determine if the rch is Volume 37, Numer 2, 2017
190 Fig 9 Finished 2D digitl smile design. () 12 o clock view (top), frontl view (middle), occlusl view (ottom). () Fcilly guided smile frme. c Fig 10 Three views of DSD (12 o clock, frontl, nd occlusl). () 2D digitl design. () Superimposition of digitl design nd model scns. (c) 3D dignostic virtul wxing. too nrrow or too wide in reltion to the fce. This view is lso key to nlyzing spce distriution, plnning cses with crowding or distemt, nd checking spcing for implnts. The curve cn then e plced over the occlusl view to trnslte this oservtion nd nlyze the symmetry of the rch. Also from the occlusl view, the interdentl proportion guide is overlid to evlute the spce distriution. The 2D smile frme cn e trnslted into 3D project, either through nlog (conventionl wxup) or digitl (3D digitl wx-up on CAD softwre) mens (Fig 10). Regrdless of the 2D nd 3D softwre used, the finl 3D file (in STL formt) will e exported to printer to generte the physicl model of the new design. This model cn e used to fricte mtrix for mock-up nd provisionl nd lso guides for tooth preprtion, crown lengthening, nd implnt plcement (Fig 11). The presenttion to the ptient strts with the plcement of the motivtionl mock-up followed y the photo/video session (Figs 12 nd The Interntionl Journl of Periodontics & Restortive Dentistry
191 Fig 11 3D-printed model nd vcuum try. Fig 12 The vcuum try is trimmed following the gingivl line to llow for n immedite esthetic mock-up. Fig 13 Screenshots of smrtphone videos: imges of the ptient without () nd with () the mock-up for the motivtionl presenttion. 13). Next, the tretment pln is presented. If the ptient pproves the pln, the rehilittive procedures my e performed in completely digitl flow, integrting the initil smile design project into orthodontic, periodontl, orthognthic surgery, guided implnt surgery, nd/ or restortive procedures. Discussion Estlishment of n esthetic rehilittive tretment pln requires correct dignosis tht identifies Volume 37, Numer 2, 2017
192 nd quntifies which elements of the smile need to e corrected or improved, nd which must e mintined. Medicl nd dentl history, clinicl exmintions, dt from imges, study models, nd photogrphs hve een used for this purpose. Although these sources of guidnce provide relevnt dt for dignosis, they do not offer ll the informtion necessry for nlyzing the smile. Dynmic records of the smile on video re fst nd esy nd llow n effective nlysis of esthetics, phonetics, nd function. It is difficult to cpture photo t the idel moment for smile nlysis. Usully when the dentist sks the ptient to give full smile, the ptient shows less thn the rel mximum height of the smile. The sme cn occur on the rest position nlysis. A photo cnnot gurntee tht the moment cptured is the relistic rest position. Fcil nlysis sed only on photogrph my provide incomplete nd/or incorrect informtion. Tjn nd Miller 9 evluted sttic photogrphs of posed smile nd reported tht 11% of the ptients presented high smile, s opposed to 21% of ptients with n nterior high smile in study with video recording. 18 Trntili et l 17 lso evluted the smile on video nd oserved tht the verge durtion of spontneous smile ws 500 ms, which reinforces the difficulty of recording this moment in photogrphs. These dt hve contriuted to n understnding of the findings of Mulik nd Nnd, 18 who reported greter exposure of the posterior teeth nd gingivl strip chrcterizing high posterior smile in 42% of the ptients evluted on video. This high exposure of teeth nd numer of teeth visile in the smile tend to diminish with ge, fct confirmed in oth photogrphic 12 nd dynmic 20 evlutions. However, mny other esthetic prmeters tht hve een estlished in photogrphs hve not yet een defined in videos. Creting photo protocol from videos cn sve significnt time for the photogrpher (dentist/stff) nd for the ptient. An efficient nd fst initil photo session will generte positive feeling for the ptient. It is much simpler to trin the stff to tke photos with smrtphones thn to trin them to use sophisticted DSLR cmers nd studios. With proper illumintion, good smrtphone cmer cn e useful tool tht cn generte enough qulity imges for the smile design nd tretment plnning process nd for ptient communiction. All the photogrphic fcil documenttion tken from videos llows the cretion of 2D smile frme completely integrted into the fce. Photogrphs, videos, nd drwings of the DSD protocol shred in the cloud hve llowed memers of the interdisciplinry tem to ccess this informtion t ny time. All the discussions, solutions, nd decisions cn e performed online, even in n synchronous wy, dding pieces of informtion or comments t ny time, nywhere. In ddition, technicins cn evlute their work y reviewing the videos of try-ins nd finished cses to improve the results for ptients. Conclusions The use of dynmic smile documenttion ssocited with the DSD protocol will mke dignosis more efficient nd tretment plns more consistent. It will lso provide more logicl nd strightforwrd tretment sequences, reducing the risks nd improving the finl results. Acknowledgments The uthors reported no conflicts of interest nd no finncil support for this study. References 1. Cochmn C, Clmit MA. Digitl smile design: A tool for tretment plnning nd communiction in esthetic dentistry. Quintessence Dent Technol 2012; 35:103 111. 2. McLren EA, Grer DA, Figueir J. The Photoshop Smile Design Technique (prt 1): Digitl dentl photogrphy. Compend Contin Educ Dent 2013; 34:772 774. 3. Imurgi M. Ptient nd tem communiction in the ipd er A prcticl pprisl. Int J Esthet Dent 2014;9:26 39. 4. Rufencht CR. Principles of Esthetic Integrtion. Chicgo: Quintessence, 2000. 5. Frdeni M. Esthetic Rehilittion in Fixed Prosthodontics, Volume 1: Esthetic Anlysis: A Systemtic Approch to Prosthetic Tretment. Chicgo: Quintessence, 2004. 6. Dvis NC. Smile design. Dent Clin North Am 2007;51:299 318. 7. Sous Dis N, Tsingene F. SAEF Smile s Aesthetic Evlution form: A useful tool to improve communictions etween clinicins nd ptients during multidisciplinry tretment. Eur J Esthet Dent 2011;6:160 176. 8. Clmi JR, Levine JB, Lipp M, Cisneros G, Wolff MS. Smile design nd tretment plnning with the help of comprehensive esthetic evlution form. Dent Clin North Am 2011;55:187 209. The Interntionl Journl of Periodontics & Restortive Dentistry
193 9. Tjn AH, Miller GD. The JGP. Some esthetic fctors in smile. J Prosthet Dent 1984;51:24 28. 10. Wrd DH. A study of dentists preferred mxillry nterior tooth width proportions: Compring the recurring esthetic dentl proportion to other mthemticl nd nturlly occurring proportions. J Esthet Restor Dent 2007;19:324 337. 11. Bidr AS, Urie F, Tylor TD, Agr JR, Rungrungnunt P, Nece WP. The reltionship of fcil ntomic lndmrks with midlines of the fce nd mouth. J Prosthet Dent 2009;102:94 103. 12. Hochmn MN, Chu SJ, Trnow DP. Mxillry nterior ppill disply during smiling: clinicl study of the interdentl smile line. Int J Periodontics Restortive Dent 2012;32:375 383. 13. Nold SL, Horvth SD, Stmpf S, Bltz MB. Anlysis of select fcil nd dentl esthetic prmeters. Int J Periodontics Restortive Dent 2014;34:623 629. 14. Desi S, Updhyy M, Nnd R. Dynmic smile nlysis: Chnges with ge. Am J Orthod Dentofcil Orthop 2009; 136:310.e1 e10. 15. Srver DM, Ackermn MB. Dynmic smile visuliztion nd quntifiction: Prt 1. Evolution of the concept nd dynmic records for smile cpture. Am J Orthod Dentofcil Orthop 2003;124: 4 12. 16. Srver DM, Ackermn MB. Dynmic smile visuliztion nd quntifiction: Prt 2. Smile nlysis nd tretment strtegies. Am J Orthod Dentofcil Orthop 2003;124:116 127. 17. Trntili VV, Hlzonetis DJ, Spyropoulos MN. The spontneous smile in dynmic motion. Am J Orthod Dentofcil Orthop 2005;128:8 15. 18. Mulik C, Nnd R. Dynmic smile nlysis in young dults. Am J Orthod Dentofcil Orthop 2007;132:307 315. 19. Rshed R, Hervi F. Lip-tooth reltionships during smiling nd speech: An evlution of different mlocclusion types. Aust Orthod J 2010;26:153 159. 20. Chetn P, Tndon P, Singh GK, Ngr A, Prsd V, Chugh VK. Dynmics of smile in different ge groups. Angle Orthod 2013;83:90 96. 21. Kokich VO Jr, Kiyk HA, Shpiro PA. Compring the perception of dentists nd ly people to ltered dentl esthetics. J Esthet Dent 1999;11:311 324. 22. Silv BP, Jiménez-Cstellnos E, Mrtinez-de-Fuentes R, Fernndez AAV, Chu S. Perception of mxillry dentl midline shift in symmetric fces. Int J Esthet Dent 2015;10:588 596. 23. Rosenstiel SF, Wrd DH, Rshid RG. Dentists preferences of nterior tooth proportion- we-sed study. J Prosthodont 2000;9:123 136. 24. Chu SJ, Trnow DP, Tn JH, Stppert CF. Ppill proportions in the mxillry nterior dentition. Int J Periodontics Restortive Dent 2009;29:385 393. Volume 37, Numer 2, 2017