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| CASE REPORT |
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| Year : 2021 | Volume
: 11
| Issue : 1 | Page : 49-53 |
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“Microsoft PowerPoint-based digital smile designing”
Meenu Madhu Kumar1, G Praveena1, K Radhakrishnan Nair2
1 Department of Conservative Dentistry and Endodontics, Azeezia College of Dental Science and Research, Kollam, Kerala, India
2 Department of Periodontics, Azeezia College of Dental Science and Research, Kollam, Kerala, India
| Date of Submission | 27-Jun-2020 |
| Date of Acceptance | 21-Oct-2020 |
| Date of Web Publication | 22-Apr-2021 |
Correspondence Address:
Dr. Meenu Madhu Kumar
Department of Conservative Dentistry and Endodontics, Azeezia College of Dental Science and Research, Kollam, Kerala
India
 Source of Support: None, Conflict of Interest: None  | Check |
DOI: 10.4103/jid.jid_47_20
 Abstract | | |
Dental fluorosis discoloration and maxillary anterior tooth spacing are problems that require aesthetic management. Various factors will influence the selection of restorative techniques and materials used for the treatment. The digital smile designing (DSD) is a tool that helps in diagnostic vision, improve communication, and enhance predictability throughout the treatment in esthetic dentistry. In this case report, a simplified version of DSD using Microsoft PowerPoint was described. Here, we also discuss the management of dental fluorosis and a maxillary anterior tooth spacing of a young female by microabrasion, frenectomy, and direct composite restoration.
Keywords: Digital smile designing, direct composite restoration, esthetic dentistry, microabrasion
How to cite this article:
Kumar MM, Praveena G, Nair K R. “Microsoft PowerPoint-based digital smile designing”. J Interdiscip Dentistry 2021;11:49-53 |
| Clinical Relevance to Interdisciplinary Dentistry | |  |
- This case report describes the interdisciplinary management of anterior tooth spacing by both periodontal and restorative treatment procedures. Abnormal frenal attachment was corrected by surgical frenectomy
- The Microsoft PowerPoint version of digital smile designing described here in this case report can be used as a tool in enhancing patient smile in an economical way in all branches of dentistry.
| Introduction | | |
The objective of esthetic rehabilitation is to provide maximum improvement in esthetics with minimum trauma to the dentition. There are several factors that need to be considered while managing esthetic problems. Spacing of anterior teeth is one such dental problem that requires esthetic correction. Abnormal frenal attachment, tooth size discrepancy, and oral habits are some of the etiological factors for the spacing of the maxillary anterior tooth. Esthetic parameters such as face height, lip length, lip mobility, symmetry, incisal plane, and buccal corridor need to be considered while designing a smile for such cases.[1] The width to length ratio of the central incisors is an important factor that determines the treatment plan in anterior tooth spacing. The amount of proximal reduction, the number of teeth to be treated, the location of prominences and concavities to create the illusion, the decision for full-veneers or just adding to the interproximal area are decided according to the width to length ratio of central incisors.[2] These ratios can be implicated in the treatment plan with the aid of digital smile designing (DSD). The treatment options for anterior tooth spacing include direct and indirect composite restoration, ceramic veneers, crowns, and fixed partial dentures. Various factors such as time, amount of tooth structure, type of occlusion, and economical limitations determine the restorative techniques and materials used for the treatment. Direct composite veneering allows the preservation of maximum amount of sound tooth structure when compared to indirect restorations.[3] Direct composite veneering for diastema closure allows both the dentist and the patient a complete control over the treatment done.[4]
Dental fluorosis is usually associated with discoloration and enamel surface defects. The management of fluorosed teeth includes bleaching, microabrasion or macroabrasion, veneering, and crowns.[5] In this case, a simplified version of DSD using Microsoft PowerPoint was used for providing a definitive treatment. Here, the dental fluorosis and maxillary anterior tooth spacing in a young female were managed by microabrasion, surgical frenectomy, and direct composite restoration.
| Case Report | | |
A 21-year-old female reported to the department of conservative dentistry, complaining of spacing and discoloration in the upper front teeth region. On intraoral examination, spacing was seen between central incisors (11 and 21) and right central incisor (11) and lateral incisor (12) [Figure 1]. The papillary type of frenal attachment was seen between maxillary central incisors. The gingival biotype is thick. Generalized mild fluorosis was noticed (TF1-4). The whitish opacities can be seen on the labial surface of 13, 12, 11, 21, 22, 23, and brownish pitted surface seen on the cervical one-third of 12 [Figure 1]. There was no dental caries in both clinical and radiographic examination. | Figure 1: Evidence of midline diastema and maxillary anterior tooth spacing. The whitish opacities can be seen on the labial surface of 13, 12, 11, 21, 22, 23 and brownish pitted surface seen on the cervical one third of 12
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Preoperative photographs were taken. The upper and lower impression was made for the fabrication of the study model. The DSD using Microsoft PowerPoint was planned to visualize the end result. High smile photograph of the patient was taken. This smiling photograph of the patient was inserted into the Microsoft PowerPoint slide presentation. Two lines must be placed on the center of the slide, forming a cross, and the photograph is placed behind these lines. The vertical line representing the dental midline, passing through the interdental papillae. The center of the philtrum is the center of the cupids bow, and it matched with the papilla between the central incisors. The inicisal edge of maxillary central incisors was the reference line to establish a horizontal reference plane. Thus, both the horizontal and vertical reference lines forming a cross were established. Using the gridlines tool in the Microsoft PowerPoint slide, individual tooth size of central incisors (11 and 21) and lateral incisors (12 and 22) were analyzed. The measurements of each tooth were right central incisor-7.9 mm, left central incisor-8.1 mm, right lateral incisor-5.2 mm, and left lateral incisor-5.6 mm [Figure 2]a. Midline spacing between central incisors was also measured (2.9 mm). The individual tooth size of the central incisors and lateral incisors was also analyzed from the study model. The measurements of the tooth size obtained from the Microsoft PowerPoint and study model were analyzed and were almost similar. Thus the individual tooth size measurement was confirmed. Using golden proportion as a thumb rule, individual tooth size measurements was modified as right maxillary central incisors-9.4 mm, left maxillary central incisors-9.4 mm, right maxillary central incisor-5.6 mm, and left maxillary lateral incisors-5.6 mm without altering the patient's midline. Using these modified measurements, the outlines of the tooth were drawn over the photograph in the Microsoft PowerPoint. The outline drawn were manually and filled with tooth color to simulate the natural tooth [Figure 2]b. This image was shown to the patient. Then, these measurements were transferred into the study model and mock build up was done [Figure 3]a and [Figure 3]b. This mock build up model was used for putty index fabrication. | Figure 2: Digital smile designing using Microsoft PowerPoint (a) Individual tooth size was analysed and modified based on golden proportion (b) The tooth outlines was drawn with the modified measurement
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 | Figure 3: (a) Individual tooth size measured in the model using caliper (b) Mock build up
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On the first session of the treatment, the tooth shade was recorded using the VITA classical shade guide, and shade A1was considered as initial color. After isolation with rubber dam and retraction cord, the microabrasion procedure was done using opalustre microabrasion kit. A thick layer of opalustre was applied over the labial surface of 13, 12, 11, 21, 22, and 23 and microabrasion was performed using rubber cup attached to gear reduction contra-angle handpiece at slow speed for 60s/tooth. Then, the teeth were rinsed with water. Three applications of opalustre were done in one session followed by topical fluoride gel application. Following microabrasion treatment, the tooth shade was again recorded and was A1 shade [Figure 4]. | Figure 4: Post microabrasion procedure, surface irregularities got smoothen. Fading out of dark brown discoloration on the tooth can be seen
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The papillary frenal attachment was corrected surgically in the department of periodontics by frenectomy. Two weeks following surgical frenectomy, direct composite restoration was planned. During the restorative phase, shade selection was done with shade guide provided by the manufacturer (Tetric N Ceram), and shade A1 was selected. The adjascent central incisor was covered with a Teflon band while the other was restored. The Mylar strip and wooden wedges were used to achieve contact and contour. The tooth surface was etched with 37% phosphoric acid for 30 s, rinsed with water, and air dried. A single layer of bonding agent (Tetric N Bond, Ivoclar vivadent) was applied according to the manufacturer's instruction and cured for 15 s. With the help of palatal putty index, the palatal shelf was created [Figure 5]. An incremental layering technique was used to restore the tooth and each layer was photoactivated for 20 s both from facial and lingual direction. Increments of A1 shade composite (Tetric N Ceram) were used on the proximal aspect of mesial side of 12, mesial and distal side of 11, mesial side of 21, followed by finishing and polishing (Sof-lex polishing kit) [Figure 6] to simulate natural tooth color and translucency. Follow-up visit at 6 months, 1 year, and 2 years showed a good treatment outcome.
| Discussion | | |
Different esthetic treatment modalities are bleaching, microabrasion, enamel recontouring, direct, and indirect composite restoration, ceramic veneers, inlays, onlays, crowns and bridges, and orthodontic treatment. The DSD allows for careful analysis of the esthetic parameters and improves patient acceptance by helping them visualize the treatment outcome. Esthetic diagnosis, communication, feedback, patient management, and education are the advantages of DSD. It can be performed in presentation software such as Keynote (iWork, Apple, Cupertino, California, USA) or Microsoft PowerPoint (Microsoft Office, Microsoft, Redmond, Washington, USA).[6] In this case, a simplified version of DSD was performed using the Microsoft PowerPoint. This method helped to analyze the esthetic parameters and alter the width to length ratio in an economical way. It also helped to simulate the postoperative image of the patient in computer and gain patient's confidence. Replication of the tooth size measurement from the Microsoft PowerPoint onto the model cast and mock build up helped in the fabrication of putty index. The proportional ratio is important when restoring maxillary anterior teeth. One particular ratio that has been widely discussed in aesthetic dentistry is the golden proportion ratio given by Keppler. These guidelines state that if the lateral incisor has a width value of 1, then the central incisor width is 1.618, and the canine should be 0.618. In an integrated review article, it was stated as there's no relationship between golden ratio and natural teeths and this ratio is not a decisive factor to ensuring the smile attractiveness, however, if this proportion were individually applied for each patient, can become a useful guide.[7]
Treatment modalities of fluorosis were decided based on the clinical appearance. There are several different classifications for dental fluorosis. One such classification was Thylstrup and Fejerskov index. The management of fluorosis suggested by Akpata is as follows: mild fluorosis with T-F score of 1–2 should be managed by bleaching, T-F scores of 3–4 by microabrasion, T-F score 4 should be first managed by microabrasion if ineffective, the tooth should be treated by laminate veneer, in TF 5–7 by veneering and in T-F 8–9, crown is suggested.[8] In the present case, Thylstrup and Fejerskov index score was T-F 4.Based on the above treatment protocol, microabrasion using opalustre was performed. The opalustre microabrasion kit contains 6.6% HCl and SiC microparticles. Microabrasion is recommended when the enamel discoloration is not >0.2–0.3 mm deep.[9] Sundfeld et al. on a case report with long-term follow-up mentioned that correct application of microabrasion technique allowed for significant improvement in appearance and color uniformity of the teeth.[10] The effectiveness of two commercial microabrasion products, Opalustre amd Prema was compared in a study and found that Opalustre more effective than Prema although both products were effective in removing dental fluorosis stains.[11]
Direct composite restoration was planned in this case as the patient preferred a treatment with minimal cost and also to preserve the dentition through minimally invasive care. The advantages of direct composite restoration are that it preserves the maximum amount of sound tooth structure, low expense, repaired easily, can be polished and repolished to a high shine, and can be completed in single visit. Prabhu et al. done a clinical evaluation of retention rate of direct composite restoration and the results indicated 91% overall retention rate for the period of 60 months.[12] Gaur et al. done another study comparing the effect of bond strength on mild to moderately fluorosed teeth and nonfluorosed teeth using etch and rinse procedure and observed a similar bond strength.[13] Microabrasion procedure helped to smoothen the surface irregularities and fading out the dark brown discoloration on the tooth. The whitish spots remaining on the tooth after the microabrasion procedure require further treatment. As the patient was satisfied with her appearance following this treatment procedure, the whitish spots were left without further treatment.
In the 2 years follow-up visit of the present case, the maxillary anterior teeth look natural and esthetically pleasing. On clinical examination, restorations look intact without any defect or discoloration. Even though long-term follow-up is required, based on the above 2 years follow-up it can be concluded as with proper case selection, proper diagnostic tool, appropriate technique, and materials, patient esthetic can be improved with direct restoration in an economical way. Furthermore, this simplified version of DSD helped both in treatment planning and treatment procedure of smile designing.
Declaration of patient consent
The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.
Financial support and sponsorship
Nil.
Conflicts of interest
There are no conflicts of interest.
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| 13. | Gaur A, Maheshwari S, Verma SK, Tariq M. Effects of adhesion promoter on orthodontic bonding in fluorosed teeth: A scanning electron microscopy study. J Orthod Sci 2016;5:87-91. |
[Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5], [Figure 6]
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