Download Invisalign ClinCheck and the Aesthetic Digital Smile Design Protocol

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Invisalign ClinCheck and
the Aesthetic Digital
Smile Design Protocol
LUCA LEVRINI, MD, MSc
GIULIA TIEGHI
VALERIO BINI, MD
M
ost currently available orthodontic software
programs, including Invisalign’s ClinCheck,* allow the clinician to visualize only the
occlusal results of treatment. Today, however, new
technologies developed for prosthetic and conservative restoration make it possible to display the
expected outcome within the context of the patient’s overall facial esthetics.
Coachman’s esthetic digital smile design
(DSD) is one of the most widely used programs.1,2
Based on photographs and video clips of the patient and subsequent digital processing, DSD and
similar programs permit careful analysis of the
patient’s smile, dental esthetics, and facial proportions for precise multidisciplinary treatment planning.3-8 Depending on the esthetic parameters
taken into consideration, DSD can help clarify
treatment limits and possibilities for patients, thus
reducing the likelihood of unexpected outcomes.
McLaren and colleagues have described a
DSD protocol using Photoshop** software.9 Because DSD is not applicable in all orthodontic
cases, however, Bini developed a method called
Aesthetic Digital Smile Design (ADSD), combining a simplified esthetic analysis with new orthodontic software that projects the clinical outcome.10
The aim is to create an image of the expected
smile, taking into account the physiological limits
of the patient to ensure that the smile remains
natural. ClinCheck can be used in conjunction
with ADSD for more precise esthetic treatment
planning.
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Diagnostic Procedure
The ADSD protocol is illustrated in a 12-yearold female patient who presented with a Class I
molar relationship, agenesis of the upper lateral
incisors, a diastema between the upper central incisors, and a skeletal Class I malocclusion (Fig. 1).
The first step is to take all the photographs
needed to analyze the patient’s teeth (micro-esthetics), smile (mini-esthetics), and face (macroesthetics). In addition to the standard photographs
required for orthodontic diagnosis, ADSD uses
informal photographs showing a broad and natural
smile with the patient’s head turned at a threequarter angle to the camera, as well as a frontal
view of the upper dental arch with a piece of black
cardboard inserted to conceal the background soft
tissue. It is important to maintain the esthetic
plane, which is perpendicular to the center of the
angle between the Camper and Frankfort planes.
Another option is to make a video (starting from
a natural, relaxed position) to assess lip movement
when the patient is speaking and smiling broadly.
To process the images, we suggest using
Photoshop CC or PS1.** The first step is to import and position the photograph of the patient’s
face as if it were a map aligned to the cardinal
points. This is followed by a tracing of the bi­
pupillary line, which the software recognizes as
*Trademark of Align Technology, Inc., San Jose, CA; www.align
tech.com.
**Adobe Systems Inc., Mountain View, CA; www.adobe.com.
© 2015 JCO, Inc.
JCO/AUGUST 2015
Dr. Levrini
Ms. Tieghi
Dr. Bini
Dr. Levrini is an Associate Professor, Department of Surgical and Morphological Sciences; President, Dental Hygiene School; and Director,
Research Centre Cranio Facial Disease and Medicine, University of Insubria, Varese, Italy; and Assistant Medical Director, Dental Clinic,
Fondazione Macchi Hospital, Varese, Italy. Ms. Tieghi is a dental hygienist in Como, Italy. Dr. Bini is in the private practice of restorative dentistry
in Biella, Italy. Contact Dr. Levrini at Via Piatti 10/a, Velate, 21100 Varese, Italy; e-mail: [email protected].
the horizontal reference plane. Alternatively, a
grid allows cropping and centering of the photograph and horizontal alignment of the bipupillary
plane, verifying symmetry in the sagittal plane.
The face and smile are mapped using extraoral and intraoral morphological landmarks (Fig.
2A). For assessment of symmetry, it is crucial to
evaluate the relationship between the vermillion
borders with the lips closed and from the frontal
and profile views. It is also important to note the
size of the lips in regard to the vertical dimension
of the face, as well as any bruxism, maxillary atrophy, micro- or macrodontia, malocclusion, or
A
simple lack of lip firmness. Intraorally, the iconographic (micro-esthetic) analysis focuses on a
close-up of the mouth, the details of which are
related to the horizontal and vertical lines already
traced on the patient’s face. It is thus possible to
analyze the occlusal plane—ideally parallel to the
bipupillary line—and the main vertical lines, including the facial midline, the interincisal line, and
the subnasal areas.
The DSD process involves accurate dynamic simulation of the projected dental movements.
ClinCheck software allows the displacement of the
teeth to be calculated in three dimensions, making
B
Fig. 1 A. 12-year-old female patient with skeletal Class I malocclusion, agenesis of upper lateral incisors,
and diastema between upper central incisors before treatment. B. Pretreatment ClinCheck* with milli­
meter grid.
VOLUME XLIX NUMBER 8
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Invisalign ClinCheck and the Aesthetic Digital Smile Design Protocol
A
B
Fig. 2 A. Aesthetic digital smile design (ADSD) face mapping. B. Integration of ClinCheck frame through
superimposition of landmarks.
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Levrini, Tieghi, and Bini
it possible to predict the outcome of orthodontic
treatment. The ClinCheck grid, graduated in milli­
meters (Fig. 1B), makes it possible to check and
modify orthodontic movements on an analog scale.
It can also be used as an esthetic plane to be super­
imposed on the image of the smile.
After the ClinCheck frame is transposed
onto the image of the patient’s face (Fig. 2B), the
macro-esthetic landmarks are used to position a
close-up of the mouth. ADSD involves a precise
A
B
Fig. 3 A. ClinCheck imported onto virtual close-up of mouth (first aligner). B. ClinCheck simulation of
bridge elements.
VOLUME XLIX NUMBER 8
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Invisalign ClinCheck and the Aesthetic Digital Smile Design Protocol
conversion of the patient’s actual measurements
from analog to digital form (a process called Analogic Transfer System Communication), using
measuring tools such as Face Analogic Transfer
Support (FATS); in practical terms, this means that
a millimeter scale is applied to an image of the
face, replacing the ClinCheck grid.10 The FATS
technique is useful for working on the computer
screen, allowing millimeters to be used as the
measurement scale instead of pixels, while the
A
B
C
Fig. 4 A. Digital Dental Image Distortion of ClinCheck-processed frame (last aligner). B. ADSD image editing with orthodontic treatment simulation. C. Face markers and outlines used in esthetic virtual treatment
planning.
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Levrini, Tieghi, and Bini
Fig. 5 Comparison of ADSD virtual projection and finished clinical case.
ClinCheck still images are transferred onto the
analog landmarks (Fig. 3A). The computer screen
then displays the patient’s face, smile, and teeth in
relation to actual measurements.
Using superimposed frames of the first and
last aligner, a new virtual morphology of the missing teeth is modeled. The ClinCheck simulation
of the bridge elements (Fig. 3B) is corrected, in a
process known as Digital Dental Image Distortion
(DDID), during superimposition of the ClinCheck-processed frame (Fig. 4A). Digital Dental
Calibrated Transposition is then used to simulate
the orthodontic movements without changing the
ana­tomical dimensions of the teeth. Each element
can be virtually modeled and modified in every
direction.
Because this process accounts for the light
reflected onto the tooth surfaces, with their microand macro-textures and interproximal gaps, it is
effective in analyzing interproximal contact points,
embrasures, and interincisal angles (Fig. 4B). It
would be impossible to reproduce a “ready-made”
smile on a patient’s mouth because a smile, however perfect, has to be modeled and shaped.
DDID—the most important component of the
ADSD protocol—enables the clinician to use a
mouse rather than traditional modeling tools for
esthetic virtual treatment planning10 (Fig. 4C).
VOLUME XLIX NUMBER 8
Clinical Management
During the first visit, this patient and her
parents were informed of the diagnosis and proposed treatment plan and offered the opportunity
to view the photographs created with the ADSD
program. At the patient’s request, an esthetic
Invisalign*** treatment plan was designed. We
recommended prosthetic rehabilitation of the teeth
affected by agenesis, since the patient had not yet
reached a sufficient level of bone maturation to
allow implant-supported prosthetic rehabilitation.
The estimated treatment time was 18 months.
Impressions were taken for fabrication of the
aligners. Composite attachments were bonded to
the canines and central incisors and adjusted at
subsequent visits as necessary. When the last
aligner in the series was reached, the patient underwent final esthetic prosthetic rehabilitation,
using a zirconia ceramic Maryland bridge to close
the gaps created by the incisor agenesis. Removable Vivera*** retainers were delivered. It is interesting to compare the ADSD virtual projection
with the actual clinical outcome (Fig. 5).
***Registered trademark of Align Technology, Inc., San Jose, CA;
www.aligntech.com.
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Invisalign ClinCheck and the Aesthetic Digital Smile Design Protocol
Discussion
This ADSD protocol allows orthodontists to
preview the desired occlusal result within the context of the face as a whole. It is simple and quick
to perform during the initial examination. Moreover, by enhancing the predictability and precision
of ClinCheck technology, it enhances the relationship between orthodontist and patient. The patient’s history and the initial consultation are fundamental to this process; through effective
communication, the orthodontist learns what the
patient and parents want to change and what their
expectations are in both esthetic and financial
terms.11,12
Esthetics is a concept that embraces not only
beauty but also health, technology, and efficiency.
It no longer makes sense to propose a cosmetic
treatment simply because it will give the patient a
beautiful smile, without considering that today’s
orthodontic instruments are technologically advanced and highly efficient, promoting natural
health and prevention. From that perspective, their
use must be regarded as a part of ethical orthodontic practice.
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REFERENCES
1. Coachman, C. and Calamita, M.: Digital Smile Design: A
tool for treatment planning and communication in esthetic
dentistry, Quintess. Dent. Tech. 35:103, 2012.
2. Coachman, C.; Van Dooren, E.; Gürel, G.; Landsberg, C.J.;
Calamita, M.A.; and Bicharco, N.: Smile design: From digital
treatment planning to clinical reality, in Interdisciplinary
Treatment Planning, Volume II, ed. M. Cohen, Quintessence
Publishing Co., Chicago, 2012, pp. 119.
3. Cintra, O.; Coachman, C.; Silva, L.C.; and Santos, T.:
Standardized digital photography for virtual orthognathic
surgical planning, Select. Read. Oral Maxillofac. Surg. 20:119, 2012.
4. Llop, D.R.: Technical analysis of clinical digital photographs,
J. Calif. Dent. Assoc. 37:199-206, 2009.
5. McLaren, E.A. and Cao, P.T.: Smile analysis and esthetic design: “In the zone”, Inside Dentistry 5:45-48, 2009.
6. Rufenacht, C.R: Fundamentals of Esthetics, Quintessence
Publishing Co., Chicago, 1990.
7. Prendergast, P.M.: Facial proportions, in Advanced Surgical
Facial Rejuvenation, ed. A. Erian and M.A. Shiffman,
Springer-Verlag, Berlin, 2012.
8. Koirala, S.: Smile design wheel: A simplified protocol for
smile design, Cosmetic Dentistry, www.dental-tribune.com/
articles/specialities/cosmetic_dentistry/1157_smile_design_
wheel_a _simplified_protocol_for_smile_design.html,
December 2009.
9. McLaren, E.A.; Garber, D.A.; and Figueira, J.: The Photoshop
smile design technique (part 1): Digital dental photography,
Compend. Cont. Ed. Dent. 34:772-776, 2013.
10. Bini, V.: Aesthetic Digital Smile Design: Odontoiatria estetica software assistita (part 1), Cosmet. Dentistry 4:6-14, 2013.
11. Olitsky, J.: Principles of smile design, Inside Dentistry, www.
dentalaegis.com /id /2013/ 09/principles-of-smile-design,
September 2013.
12. Ackerman, M.B. and Ackerman, J.L.: Smile analysis and design in the digital era, J. Clin. Orthod. 36:221-236, 2002.
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