Designing the Smile in Complete Denture Patient: An Ingenious Approach

ABSTRACT

Purpose:

This innovative technique determines the symmetry of anterior teeth arrangement discrepancies and ascertain the extension of the smile during the procedure of jaw relation procedure performed by prosthodontist.

Methods:

Smiling images of 20 patients were captured and analyzed using PicsArt© software. Facial midline, canine line, smile line, and other conventional factors were overlaid onto the photographs. Pre-designed smiles were extracted from previous designs and superimposed onto each patient’s photograph. The resulting images were systematically evaluated to enhance aesthetic outcomes, promoting attractiveness, encouraging patient satisfaction during jaw relation.

Results:

Patients were highly motivated on the day of jaw relation appointment. Prosthodontists were able to evaluate asymmetric smile, midline shift, extension of canines, and other discrepancies.

Conclusion:

Edentulous patients deserve a superior aesthetic and beautiful smile. Prosthodontist can now will be able to design smiles more easily and in less time before the appointment of try-in. At the same time, dentist will also be able to take approval from the patient regarding the appearance of the smile.

INTRODUCTION

Creating a natural and pleasant smile necessitates a well-informed, meticulously planned, disciplined approach to assess, diagnose, and rectify aesthetic imperfections. Achieving a compelling smile design involves effectively integrating aesthetic elements. Unlike fixed dental prosthesis, removable prosthesis are not given much consideration in smile designing, with complete dentures being the most common prosthesis given by a prosthodontist.[1] Determining the relationship between teeth, lips, and face of patient poses a challenge. This innovative technique allows the clinician not only to corelate with it but also to educate and motivate the patient by showcasing the final outcomes of proposed treatment solutions, thus enhancing patient acceptance.

Creating a smile solely based on mechanical parameters like facial shape and size results in a monotonous and stereotypical appearance. In contrast, personalizing it according to the individual’s attitudes and behaviors renders it more natural and lifelike. Upon reviewing literature, we noted a lack of publications assessing the effectiveness of these systems in complete denture treatment. Therefore, our study aimed to investigate the capabilities and constraints of digital smile simulation applications in context of edentulous patients receiving conventional complete dentures.[2]

MATERIAL AND METHODS

A study conducted between September 2022 and February 2023, involving 20 patients (8 women and 12 men), aged 45 to 80 years, who were edentulous and had not yet received conventional complete dentures.

Temporary denture bases and occlusal rims were fabricated, ensuring the plane of occlusion was parallel to the Frankfort Horizontal (FH) plane. The facial midline was marked on the occlusal rim, canine lines were marked by drawing the line from inner canthus of the eye to the lateral border of nose. A smiling photograph captured once the lines were marked, showing the full face of the patient from the front profile. Corroborating that photograph was high in quality, clear and in same plane with the patient’s face. Care was taken to ensure that the photograph was of high quality, clear, and in the same plane as the patient’s face, with sufficient light and no shadows. The photograph was then uploaded to the Pics Art© photo editing application [Figure 1a].

Figure 1.

(a-e) Patient’s facial midline match

This was followed by calibrating the frontal facial photo, identifying and positioning the incisal line along with lines corresponding to the distal surfaces of the maxillary central incisors. Next, the labial line of the smile and the smile arc were identified and the dimensions of the maxillary central incisors were recorded. Based on the patient’s facial typology and preference, the appropriate teeth template was selected. A smile frame was then generated according to the reference established in the previous steps, and the smile simulation commenced. This involved outlining the upper lip contour, applying stickers, and previewing the final outcome.

RESULTS

A photograph was captured of the patient, ensuring that the facial midline and Canine lines were prominently marked on the occlusal rim, with a clear smile line and buccal corridor.

The Photograph was then uploaded [Figure 1b]. The patient’s facial midline was matched, and the inter-pupillary line was drawn by tapping the Draw [Figure 1c] option below the screen. A horizontal straight line on photograph was added along with the smile line to determine the length of the anterior teeth [Figure 1d].

A template was added from the stickers; the suitable template for the patient added by clicking the “Add sticker” option below the screen.

Photographs of eight already designed smiles were cropped, and cutouts were made by selecting the “OUTLINE” tab below the screen. The smile was selected according to the Age, Sex, Personality (SPA) factors [Figure 1e]. The cutout was then dragged to align with the midline and canine lines for selection of shape, after which the size of the tooth was determined.

The extension of the sticker was matched with the photograph by reducing the opacity of sticker’s, extension of it was easily managed superiorly at lower border of upper lip, inferiorly along the smile line and laterally along the canine line (with the distal border of the canine is matched to the canine lines on both sides). Sticker lateral to the canine could be erased or kept accordingly to the buccal corridor and assessed.

If the smile is suitable at this point, it can be displayed to the patient. If not, another form or type of smile can be added by applying another sticker. Now the final result can be saved or shared with the patient directly.

DISCUSSIONS

Cigrande (1913), employed the contour of the fingernail to determine the outline of the upper central incisor tooth. This outline was then adjusted to suit the tooth space and other pertinent criteria, following Williams’ introduction of the “Typal Form Method” in 1914. Williams classified facial shapes as tapering, squarish, or ovoidal. Tooth selection thereafter adhered to the “Mould Guide Sample Teeth.”

Smile components: Smile arc, labial line of smile, buccal corridor, and upper lip curvature.[3]

In 1920, the ‘Wavrin Instrumental Guide Technique’ emerged, merging Berry’s Biometric Ratio Method with William’s typal form teeth. This concept led to the design of teeth in various shapes based on these principles.[4]

By using golden proportions to guide the size of each tooth in the template, achieving aesthetically pleasing results for our patients involves ensuring that each tooth adheres to these essential proportions, thereby utilizing the golden ratio effectively. Dr. Eddy Levin facilitated this process by developing the precise and user-friendly Golden Mean Gauge, which has significantly transformed the field of cosmetic dentistry.[1]

Patterns found in nature, spanning from seashells to flowers, frequently exhibit adherence to both the golden ratio and the Fibonacci sequence, highlighting their interconnectedness. The golden ratio, a mathematical constant denoted by an irrational number approximately equal to 1.618, exhibits a non-repeating decimal that extends infinitely without a discernible pattern.

Unlike another well-known irrational number, Pi, the golden ratio lacks nearby fractions that would disrupt its innate propensity for creating patterns in nature. When utilized in pattern formation, the irrational sequence of the golden ratio generates a striking golden spiral. Visualized through its number series of 0, 1, 1, 2, 3, 5, 8, 13, 21, 34, and so forth, the Fibonacci sequence similarly produces a golden spiral. This resulting golden spiral pattern has been leveraged in crafting aesthetically pleasing smiles and other designs.[5]

Curved facial features are typically linked with femininity, while square features are associated with masculinity.

The dynesthetic considerations are necessary for the production of dentogenic restorations.

The smiling line curves along the incisal edges of the central incisors, extending back to the incisal edges of the lateral incisors and continuing to cuspid tips. The contour of this arc is shaped by the patient’s age, progressively diminishing as time lapses.[6]

The smile line represents a secondary vertical alignment of the anterior teeth and is influenced by the distance between the incisors.

An embrasure allows for flexibility in dental composition and differs from diastemas or gaps by representing the divergence of the proximal surfaces of front teeth without actual separation. It serves a similar purpose as diastema. Taking this into consideration, embrasures were designed narrower anteriorly and wider posteriorly on the templates.[7]

This technique can also be used during the try-in appointment - By reducing the opacity of the template, the anterior teeth arrangement can be judged and corrected.

CONCLUSION

This technique is unique and has not been used so far. No studies or devices are working on designing the smile in completely edentulous patients. It is a simple, time-efficient, and effective technique, saving time and energy during the try-in appointment, where direct approval from the patient regarding the smile can be obtained, thereby motivating the patient during the jaw relation appointment.

There is scope for future studies to further explore this technique, including matching the shade of the teeth.

Conflicts of interest

There are no conflicts of interest.

Funding Statement

Nil.