Clin DSD

Digital Smile Design
clinical | EXCELLENCE Instructor Course

29-31 July 2016
Dental Education Centre
SYDNEY, AUSTRALIA
www.dfyeducation.com.au
Figure 1. Facial image comparing patient before and after treatment.
Case report: Full mouth maxillary

and mandibular implant rehabilitation
utilising Digital Smile Design (DSD)
By Fadi Yassmin, BDS (Syd), MSc Ae Dent (Kings College London) MFGDP (UK) and
Dr Komal Jaswal, BSc (Hons), BDent (Hons)
W
ith the recent surge of This case demonstrates the effectiveness of DSD
digital treatment plan- and how it can be implemented throughout an
ning being incorporated immediately loaded implant case for an aestheti-
into a dentist’s arma- cally pleasing and functional result.
mentarium, the advent The patient initially presented to us with a heavily
of Digital Smile Design decayed dentition, missing teeth and consequent loss
(DSD) ushers in a more streamlined workflow. of function and aesthetics. The underlying cause
Traditionally, there have been outdated methods was a chronic soft drink addiction amongst a his-
to incorporate a simulation of what a patient can tory of social issues including a poor diet and four
expect treatment to involve, whilst communicating consecutive pregnancies by the age of 20 in a low
the exact variables effectively with the patient and socioeconomic climate. Sadly, the patient had no
the dental team. access to ancillary dental care within the last 15 years.
146 Australasian Dental Practice May/June 2016

clinical | EXCELLENCE
Figure 2. Retracted views of patient’s dentition and smile.
Figure 3. Intraoral photographs showing highly carious dentition with missing teeth and loss of OVD.
DSD is a concept pioneered by Dr

Christian Coachman. It is a methodology
that encompasses the whole dental team
to enable not only the best quality care for
the patient, but also to develop the best
result throughout the patient’s journey
through effective communication and
reproducibility.
As Dr Coachman states, DSD initially
consists of a series of high-resolution pho-
tographs and videos that enable integration
of the patient’s needs, desires, functional,
structural and biological issues into the
aesthetic treatment. This is tabulated as a
Figure 4. Pre-operative OPG demonstrating gross caries, failing dentition and frame of reference for the treatment that
impacted wisdom teeth. will be performed (Coachman et al, 2012).
May/June 2016 Australasian Dental Practice 147

Figure 6. DSD smile curve overlay showing ideal

teeth positioning and proportions with considera-
tions to patients age gender and current dentition.
Figure 5. Initial DSD facial landmark alignment used to Figure 7. Use of the virtual ruler to assess alveolectomy level
create ideal smile curve. based on ideal tooth position.
Figure 8. DSD Smile Frame and video assessment.
A DSD workflow was established for this case, which started each patient’s dental characteristics based on their facial type,
with ideal dento-facial aesthetics and tooth positions being gender and age. This was pertinent in this case as there was
imprinted onto specific photographs to enable formation of a smile not only a loss of OVD but posterior over-eruption and lack of
curve (Figures 1-8). Video assessment, phonetics and images any functional occlusion.
of what little remained of the intact dentition were also used in The ideal teeth position and smile curve for the final
the formulation. prosthetic are marked using a virtual ruler to mark alveolectomy
It is important to note that the workflow enables not only position and provide this information both to the surgeon and to
effective communication to the patient but is individualised to the laboratory (Figure 8).

Figure 9. DSD Simulation.
Figure 10. Pre-treatment DSD virtual lab showing combination of patient’s CBCT
overlayed with ideal implant placements and teeth positions (from the 2D design).
The Digital Smile Design Virtual lab Treatment was performed under general
was used to create surgical stents and bone anesthetic. All maxillary and mandibular
reduction guides that were ideally fabri- teeth were extracted. Tooth 48 was encased
cated and positioned based on the initial in bone and had a close association with
2D smile design. the right inferior dental nerve and was not
These modified images can then be extracted due to the low chances of clin-
transferred onto the STL files of the study ical sequalae. Surgical guides (Figure 11)
models, the Cone Beam CT scan and com- were used to assist in achieving a precise
bined with the Digital Smile Design. This alveolectomy with adequate restorative
creates the ideal overlay where implant space and implant positioning guides were
planning and subsequent guide production also used for ideal placement within the Figure 11. Surgical guides and
can occur (Figures 9-10). planned prosthesis. alveolectomy guides.
May/June 2016 Australasian Dental Practice 149

Figure 12. Primary try-in with acrylic prosthesis immediately Figure 13. CBCT of final prosthesis.
after surgery.
Figure 14. Post-operative OPG showing implant placements. Figure 15. Upper and lower acrylic prosthesis patient
Note 48 was kept due to low chance of complications by leaving can interchange between monolithic zirconia based on
the tooth encased in bone and proximity to nerve. aesthetics and function.
Figures 16-17. Post-operative extraoral photographs.
The original plan was for an All-on-4™ during the impression. The prosthesis in We all want ideal treatment for our
on upper and lower arches. Due to the this case was base acrylic dentition with patients. DSD ushers in a new more
poor quality of the bone and concern CoCr floating bar with titanium cylinders streamlined workflow that is used for
about whether adequate torque was able to (Figures 12-17). effective communication with both the
be achieved, an extra implant was placed Due to the complex rehabilitation in patient and your laboratory. As a result,
in both arches (Figure 13). such a short timeframe, an upper full arch there is high case acceptance due to the
At the time of surgery completion, splint was prescribed for nighttime wear. consistent functional and aesthetic out-
analogue impressions were taken of both The patient has been given a strict oral comes. The DSD protocol can be used for
arches along with indexing of upper and hygiene regimen and appropriate appoint- complex cases as well as simple anterior
lower mandibles utilising the printed ments for review. To complete ideal facial restorative cases.
guide from the virtual DSD lab. aesthetics and facilitate neuromuscular
The impression was taken with impres- change, Botox was placed in the masseter References
sion copings and a light activated resin and dermal fillers were used to correct the Coachman, C, and Calamita, M.A. Digital Smile
was used to ensure implant stability defect in the upper lip. Design. (2012).

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Digital Smile Design

clinical | EXCELLENCE Instructor Course

Figure 1. Facial image comparing patient before and after treatment.

Case report: Full mouth maxillary

146 Australasian Dental Practice May/June 2016

Figure 2. Retracted views of patient’s dentition and smile.

DSD is a concept pioneered by Dr

May/June 2016 Australasian Dental Practice 147

Figure 6. DSD smile curve overlay showing ideal

Figure 8. DSD Smile Frame and video assessment.

148 Australasian Dental Practice May/June 2016

Figure 9. DSD Simulation.

May/June 2016 Australasian Dental Practice 149

Figures 16-17. Post-operative extraoral photographs.

150 Australasian Dental Practice May/June 2016

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