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Progressive Smile Design: Changing the Shape of Cosmetic Dentistry by Tif Qureshi

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The way treatment planning is carried out for smile makeovers has fundamentally been the same for some time. Recently, digital smile design has made intelligent use of software, imaging and video to create an emotionally powerful communication tool. It can allow a patient to see a smile makeover mockup, not just on a screen as a static image, but as a video; the patient can even trial it.

Ideal smiles and fantastic results can be achieved this way, and this is appropriate for patients who want perfection … or is it?

Progressive smile design
The concept of progressive smile design (PSD) is a little different.

The idea is to allow the patient to see improvements in stages, so the patient can decide if he or she wants a perfect smile at the end of treatment. PSD and digital smile design are not mutually exclusive and, in fact, can be combined. But commonly, PSD will result in less treatment for the patient.

PSD often uses a mixture of tooth alignment, whitening, direct bonding, and contouring. Indirect treatments can certainly be considered, but only occur after the patient sees the changes that alignment, bleaching or shaping can achieve.

The logic to this approach is to see if a patient is satisfied with small, step-by-step improvements, rather than going straight to a perfect result in an irreversible way.

Patients may well end up with a perfect smile, but at least the consent process is real, since the patient is able to see the very best in his or her existing smile before moving forward to the irreversible stages.

Looking at this in a more extreme way, it might be the difference between a patient choosing 10 veneers and accepting the necessary tooth preparation, versus the alternative of absolutely no tooth removal whatsoever with less financial and biological risk.

The case below is one patient's journey and how her perception of her own smile changed with PSD.

Case presentation
A 26-year-old woman presented wanting a smile makeover. Her main complaint was her diastema, and the color and length of her teeth. She requested porcelain veneers to address this problem.

On examination, a 3.5mm diastema existed and the patient had a Class I base with a mild lower crowding, and slightly rotated upper laterals. She also had reducing canine guidance from previous evidence of para-functional wear. She had no TMJ complaints or symptoms (Figs. 1-6).



I explained to the patient that orthodontics could improve the anterior position of the teeth to make any further treatment (which might include veneers) easier at a later time.

The patient was not keen on orthodontics—particularly fixed braces—but all options were thoroughly explained, including the Inman Aligner diastema closer appliance. The patient was interested in this option because of the short treatment time and the fact that it was removable. Once she understood that the diastema could be closed in fewer than 10 weeks, she became keen on using the appliance (Figs. 7-13).



Before any treatment was decided upon, X-rays, photos and study models were taken, and a full orthodontic diagnosis and assessment was carried out.

A landmark point was also decided on with the patient. This is a critical point that is esthetically and functionally correct in a misaligned arch. An arch evaluation curve was set using Spacewize software.

The reference point sets the curve, and then the curve is used to calculate the amount of potential crowding and potential space creation that might be required.

The patient described the position of the two centrals as ideal from an anterior posterior position. She liked the angle and vertical inclination but felt they were simply too far apart. She felt both laterals were too protrusive. As a result the curve was set through the landmark points.

This Spacewize curve provides valuable information in anterior orthodontic planning, such as the following:
  • It will give the amount of space creation required or the amount of space left over after alignment.
  • It dictates the occlusal setup to the technicians who will set the case up digitally.
  • It is also important in the consenting process and evidence of planning.
The Spacewize trace revealed that the case required 0.2mm of space creation to achieve alignment. With a diastema present, this might seem a surprise, but with the laterals closing inward and being rotated, they were already accounting for much of that space.

Impressions were taken and sent to the Inman Aligner laboratory with the Spacewize trace.

Two days later a digital STL was sent of the proposed Archwize setup. This was checked and the lab was instructed to create the 3D print of the proposed setup.

The patient was keen to see this before committing so she could understand the potential outcome. The advantage of a 3D print over 3D images is that a patient can hold the models and really appreciate the potential outcome with a clearer picture of scale, position and shape. On viewing the models, the patient was highly satisfied with the proposed outcome. However, she could also see that the teeth still looked short and that further treatment would be needed to lengthen them. This was discussed and planned. The models were returned to the lab for the modified Inman Aligner to be constructed.

Treatment
One week later the appliance was fitted. Instructions were given and no space creation was needed. The patient was to wear the appliance for 18 hours to 20 hours a day. The patient turned the midline screw once every three days. After two weeks, a significant improvement was seen.

At four weeks, home bleaching was started using Daywhite 6 percent H2O2. She used super-sealed trays. These trays have had sealing grooves cut into the stone models prior to vacuum fabrication of the trays. She whitened for 35 minutes a day (with the Inman Aligner out of the mouth) for two weeks.

At a later appointment, a little flattening of the contact was carried out to reduce the risk of a black triangle. I also lengthened the connector. This was done with a Sof-Lex disc, using the digital models for guidance. Buccal anchors were also placed to help the laterals rotate in.

At six weeks the diastema was closed and the teeth were noticeably whiter (Figs. 14-20).





The moment of truth
At this review appointment the patient commented that her teeth looked far better than she ever could have imagined. She asked what could be done to the edges of her teeth to lengthen them and if there was an alternative to veneers, as the newly positioned and whitened teeth looked so good.

Flowable composite was used to mock-up an outline. This was cured and the patient was shown the new potential outline. She was immediately thrilled and happy to have a no-preparation composite bonding as the final part of the treatment, rather than veneers.

Allowing a patient to see her teeth align and whiten often helps her to comprehend the best potential in her own natural smile before taking an irreversible route.

Two weeks later, an indirect wire retainer was bonded in place after roughening the teeth. I etched and used Venus Diamond Flow (Fig. 21).

On the same day, direct composite edge bonding was carried out. Venus Diamond OL shade dentine was initially placed to block out the visual join, and shades B1 and BL were used on the facial surfaces and blended into the surface of the teeth. The patient returned for her polishing appointment and the material was fully blended into the tooth. At this point the black triangle was also closed.

Lateral and anterior guidance was rechecked and adjusted and a new impression was taken for a nighttime Essix retainer. Additional study models were also included for reference (Figs. 22-26).



This case was completed in less than 10 weeks. By allowing this patient to see small changes a little at a time, she was able to see the very best potential in her own smile and to make the decision to move to composite edges instead of jumping straight into porcelain veneers. The long-term biological cost and economic cost also meant lower risks.

Following the logic of progressive smile design, you can see that you never really know what the patient wants until she is able to see the very best in her own smile.

Add the lower long-term risks for cases like this, and that this kind of treatment is more accessible to many more patients, and you can see the potential for changing the smiles of many people around the world.



Dr. Tif Qureshi is a past president of the British Academy of Cosmetic Dentistry. He is currently the director of Intelligent Alignment Systems. Inman Aligner training runs courses and mentoring through Intelligent Alignment Systems Orthodontic Academy. Dr. Qureshi can be reached at tifqureshi@mac.com.


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