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Alternative Treatment To Orthognatic Surgery by The Application of Digital Smile Planning
Alternative Treatment To Orthognatic Surgery by The Application of Digital Smile Planning
296 | The International Journal of Esthetic Dentistry | Volume 17 | Number 3 | Autumn 2022
Henriques et al
The International Journal of Esthetic Dentistry | Volume 17 | Number 3 | Autumn 2022 | 297
Clinical Research
298 | The International Journal of Esthetic Dentistry | Volume 17 | Number 3 | Autumn 2022
Henriques et al
a b c
Fig 1 Frontal facial photograph Fig 2 (a) Lateral cephalometric radiograph. (b and c) Profile photographs.
showing excessive gingival
display during spontaneous
smiling.
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Clinical Research
Fig 3 Initial photograph of the pretreatment condition. Fig 4 Anterior occlusal guidance.
Fig 5 Left lateral occlusal guidance. Fig 6 Right lateral occlusal guidance.
300 | The International Journal of Esthetic Dentistry | Volume 17 | Number 3 | Autumn 2022
Henriques et al
1.4
3.5
3.0 mm 2.7 3.0 3.0 2.9
3.5
4.5 1.5
2.0 1.2
1.4
Fig 8 Determination of the central incisor proportion, Fig 9 Selection of tooth format, with tooth shape
measurement of 5 mm of gingival exposure, and plan selection based on face shape and final crown size
to increase the dental crown by 3 mm. planning.
1.618 0.618
Fig 10 Digital Smile Planning measures transferred to Fig 11 Conventional wax-up according to the initial
the plaster cast before diagnostic waxing. digital planning.
treatment, with less removal of the alveolar which was approved by the patient, consist-
bone crest required to increase the crown ed of orthodontic therapy, crown length-
length during periodontal surgery. Further- ening surgery, BTX type A injections to
more, the digital design was shown to the reduce the extent of the gingival display,
patient, who also preferred the 85% propor- and 10 maxillary ceramic restorations to
tion. Thus, DSP was completed according establish a new dental anatomy.
to established proportions obtained through Orthodontic treatment was the first
mesial, distal, and cervicoincisal measure- treatment step and was performed to align
ments (Fig 9). the midline between the maxillary and man-
Based on 2D digital planning measures, dibular arches. After 8 months, the align-
a conventional diagnostic wax-up from the ment was completed, and an orthodontic
second right premolar to the second left pre- contention was made.
molar was created (Figs 10 and 11). A mock- The treatment of the excessive gingival
up with bis-acryl resin (Systemp C&B II; display was carried out with crown length-
Ivoclar Vivadent) was fabricated that res ening surgery with osteotomy, and a papil-
pected the occlusal guidance and allowed la preservation technique was performed
the patient to visualize and understand the (Fig 13–14). A surgical template was digi-
treatment (Fig 12). The proposed treatment, tally defined during the DSP, based on the
The International Journal of Esthetic Dentistry | Volume 17 | Number 3 | Autumn 2022 | 301
Clinical Research
Fig 12 (a to c)
Mock-up of the final
rehabilitation format.
a c
a b c
chosen tooth measurements and verified The next clinical procedure for the man-
with the mock-up. Approximately 1.6 mm agement of the EGD was the application of
of gingival tissue was removed, and a new BTX type A (Dysport; Ipsen).14,21,22 Diluted ac-
distance from the gingival margin to the al- cording to the manufacturer’s recommen-
veolar bone crest of approximately 2.74 mm dations and under sterile conditions, 6 IU
was established with osteotomy. There was of BTX type A was injected once per side
a 6-month waiting period for periodon- to target the levator labii superioris alaeque
tal tissue healing before dental preparation nasi, zygomaticus minor, and levator labii
procedures were initiated (Fig 15).20 superioris muscles (Fig 16).
302 | The International Journal of Esthetic Dentistry | Volume 17 | Number 3 | Autumn 2022
Henriques et al
Fig 14 Immediate postoperative photograph after Fig 15 Postoperative photograph after periodontal
periodontal surgery based on final dental crown size surgery showing the increased clinical crown before
planning. the application of botulinum toxin (BTX) type A.
Prosthetic treatment
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Clinical Research
Discussion
b
EGD is a nonpathologic condition in which
there is an overexposure of the maxillary
gingiva during smiling.12 The potential caus-
es of EGD are short lip length, hypermobile/
hyperactive lip activity, short clinical crown,
dentoalveolar extrusion, APE, VME, and gin-
Fig 18 (a to c)
Images of scanned
gival hyperplasia.11 Proper diagnosis of the
preparation and etiologic factors determines the most ap-
wax-up in Ceramill propriate treatment technique, taking into
c
Map 200+ software. consideration patient preferences.12,22,23 In
the present case, the patient was diagnosed
with APE, VME, and a hyperactive upper lip.
The indicated treatment for VME is ortho
gnathic surgery.16 However, as this proced-
silicone index. The impression was sent to ure requires hospitalization, some patients
the dental laboratory technician and the cast are unwilling to undergo these more inva-
was scanned. The wax-up was also scanned sive surgeries18 and, consequently, w elcome
and the images were overlaid (Ceramill Map alternative treatments.
200+; Amann Girrbach) (Fig 18). The data The success of any dental treatment is
were then sent to a milling machine that based on correct diagnosis, planning, exe-
performed stratification of the e.max CAD cution, and monitoring. Thus, tools that
304 | The International Journal of Esthetic Dentistry | Volume 17 | Number 3 | Autumn 2022
Henriques et al
a b
Fig 19 Testing right (a) and left (b) lateral occlusal guidance.
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Clinical Research
Regarding the prosthetic treatment made with excess that is later removed in
phase, it is important to note that alter- the finishing/polishing process. Unfortu-
natives, including direct restorations with nately, this process can cause invasion of
composite resins and ceramic laminates, the periodontal space when performed
were presented with the pros and cons of close to this region and can thus result in
each, and the treatment option using ce- severe injuries.28
ramic veneers was chosen. Thus, the selec-
tion of the restorative material considered Conclusion
the preference of the patient and her family,
the experience of the dentist and the den- The present clinical report described how
tal laboratory technician, and the scientific the DSP technique, through precise photo
evidence, ie, the fundamental tripod of evi- graphs and based on the golden ratio
dence-based dentistry was respected.26 applied to vertical face proportions, can
The term ‘veneer’ refers to the prosthetic assist the dentist in planning a conservative
itself, which can be made: a) without the treatment.
need for dental preparation (also known The case involved the oral rehabilitation
as ‘prepless’ and limited to very specific of a patient with EGD using alternative treat-
cases); b) with uniform tooth preparation
ments to orthognathic surgery, including
guided by the shape of the diamond burs crown lengthening surgery, ceramic veneers
(the traditional tooth preparation, which is on 10 maxillary teeth, and the application of
very aggressive); or c) with selective tooth BTX type A to reduce lip hyperactivity.
preparation (guided by previous planning
and silicone-based guides).27 The last op- Acknowledgments
tion was selected in this case. In addition
to the advantage of the preparation being The authors thank Renato Valle de O liveira,
very subtle, this approach allows for a more DDS, for the application of BTX type A;
uniform prosthetic piece, which is desirable Monica Samico, DDS, for the orthodontic
when a ceramic material is employed. Fur- treatment, and José Flores, CDT, and RHB
thermore, the prepless technique is associ- Dental Laboratory for the dental laboratory
ated with the use of feldspar-based ceramic work.
306 | The International Journal of Esthetic Dentistry | Volume 17 | Number 3 | Autumn 2022
Henriques et al
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