Utilizing of Photoshop® Smile Design to achieve predictable outcomes for minimally invasive porcelain laminate veneer
Alisa Tapananon DDS MSC, Edward A McLaren DDS, MDC, Agata Stankiewicz MDC Center for Esthetic Dentistry, University of California, Los Angeles School of Dentistry
Computer design software is a powerful tool for showing patients the possibilities for enhancing their smiles. Moreover, it is an extremely useful communication technology between dentists and ceramists to facilitate treatment planning and restorative design. This clinical report demonstrates how to utilize Photoshop® during the smile design process to achieve predictable outcomes for anterior teeth esthetic restorations with porcelain laminate veneer.
A 30-year-old female patient presented to UCLA, Center for Esthetic Dentistry clinic. She was dissatisfied with the esthetic appearance of her four anterior teeth. Her chipped teeth (#8,9) were caused by using the inhaled drug for many years. After thorough diagnosis and analysis, the treatment plan was presented to the patient with the following stage 1) documentation and Photoshop® Smile Design; 2) wax-up and mock-up; 3) teeth whitening; 4) minimal invasive preparation and adhesion of laminate veneer; 5) night guard delivery and follow-up.
Photoshop® Smile Design
1. After the smile analysis was performed, a custom tooth grid was chosen appropriate for the patient. The image of the chosen tooth grid was opened in Photoshop® and the grid was dragged onto the image of teeth to be smile-designed. (Fig 1).
2. The tooth grid was enlarged or shrunk by pressing command “t” to bring up the “free transform” function. The size of the grid was adjusted so that the outlines of the centrals have the new proposed length.
3. The tooth grid layer and magic wand tool were activated, followed by activate the layer of the teeth. (Fig 2)
4. The liquefy filter was activated, the red mask created a digital limit that the teeth cannot be altered beyond. (Fig 3)
5. The “forward warp” tool was used by clicking and dragging on an area of the existing tooth to shape the tooth into the shape of new proposed outline form. (Fig 4-5)
A design (diagnostic) wax-up cast is fabricated according to data obtain from the Photoshop® Smile Design prior to treatment and transferred into the patient’s mouth using silicone index. Photoshop® Smile Design was used in the formation of the treatment plan and patient communication. A Putty impression of a design wax-up was taken. Auto-polymerizing resin (A1 Integrity, Dentsply) was used as a bonded functional esthetic prototype (mock-up) to obtain the patient approval.
The putty impression from the design wax-up was also used as a guide depth for minimally invasive tooth preparation. Consequently, the preparation for laminate veneers remained within enamel, to ensure the bond strength and minimize the occurrence of postoperative sensitivity.
Feldspathic veneer was fabricated with skeleton builtup technique. This technique performed the exact placement of the internal dentin layers (skeleton) to support the surface enamel layer (skin). Soft tissue and acrylic dies were made in order to ensure the emergence profile and the final color of veneer before try-in.
The provisional veneer was removed without the soft tissue trauma. Before the teeth dehydration, the veneer was checked for color, fit and contact point. For try-in and color check, a try-in paste (translucent Choice 2, Bisco) was taken. At the cementation, the veneer was etched with 9% hydrofluoric acid for 60 seconds followed by silanization (Bis-SilaneTM, Bisco). The tooth was sandblasted, etched with 35% phosphoric acid followed by 2% Chlorhexidine Digluconate (Cavity CleanserTM, Bisco) and Gluma®. The bonding agent (All-Bond 3, Bisco) was applied onto the tooth without polymerization. The veneer was lined with Choice 2 Veneer Cement (Bisco), gently seated and light cured. The excess cement was removed, the occlusion was checked. One week after cementation, the patient was seen for night guard delivery and follow-up.
The utilizing of Photoshop® as an aid for smile design is a predictably and minimally invasive technique, allows the easy pre-visualization of esthetic treatment possibilities that would facilitate treatment waxing and final restorative design. Also the Photoshop® Smile Design can be quickly changed as per patient desires that were very time-consuming prior to digital smile design techniques.