Digitising the patient

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Leading aesthetic dentist Dr Jameel Gardee talks about Digital Smile Design during the Henry Schein Digital Symposium

“Digital design is now at the coalface of dentistry. It is a tool for everyday use.” Thus Dr Jameel Gardee began his talk about digitising the patient and Digital Smile Design (DSD) using the TRIOS intraoral scanner and software developed by 3Shape. He pointed out that, in the rest of the world, the uptake of digital dentistry has been “outstanding”. His observation that the UK is sadly lagging behind and that patient care could be suffering as a result is one that we’ve heard before, and will hear again, as is the warning that digital dentistry is just another tool, not a magic wand. In the right hands it will benefit both the practitioner and the patient, but bad dentistry remains bad.

The 3Shape software Dr Gardee was demonstrating has been developed around Dr Christian Coachman’s DSD philosophy and his Nemo DSD 3D system. Dr Gardee offered that a specific 3Shape digital workflow also exists for specialisms such as orthodontics and implant placement, but that smile design is at the heart of all dentistry and encompasses the entire face.
He explained that the idea of a facially driven treatment plan has existed for many years, and said that: “Its beauty does not lie in creating symmetry, it lies in finding harmony. It lies in the infinite algorithms of nature, perfect imperfections, lip dynamics and honest aesthetics.” He continued by explaining that adding digital workflow to everyday practice helps with managing patient’s expectations. Because dentists can visually demonstrate the eventual outcome they are able to better educate and motivate their patients to say yes to treatment that has clear benefits for them, and show why the dentistry they plan to do is in the patients’ best interests.

Who decides the smile design?

If a dentist supplies too little information to their lab the technician will take a stab at guessing what is really wanted in the restoration, which means they will be instrumental in creating the final smile design. And that may not be in the best interests of a patient, nor might it be what they were expecting.

Dr Gardee believes that smile design is subjective, and that although colour and texture of a restoration are important, they are just details. Getting the shape right is essential, understanding how the tooth works in 3D and fits in with other facial positions and shapes. Dentists who supply their technician with precise digital information will get the smile outcome they expect and a happy patient.
“A smile is as individual as a fingerprint, and everyone smiles in the same language, no matter what country they come from or what religion they pursue. That means that every smile design must be bespoke, and that begins with precise facial measurements.”

To get a correct portrait shot Dr Gardee says he needs to ensure that the patient’s ears are at the same level either side of the head. He positions his camera at the level of his patient’s eyes then tilts it down towards their mouth.
To ensure they are properly upright he then asks the patient to hold a box of gloves against the wall using the back of their head, a handy tip. The photograph is taken using a digital camera or smartphone mounted on a tripod, it is then sent directly into the software where the DSD frame is created by hitting the smile design icon and aligning the face using the pupils of the eyes, nasal wings and comisuras (corners of the mouth). Enter a precise measurement, i.e. the distance across one of the incisors, and the design will be ready to discuss with the patient in two minutes, something that used to take half a day in Photoshop. The design can then be tweaked for more realistic, asymmetric aesthetics. Dr Gardee charges £300 for DSD consultation, a charge he deducts from the final bill once the treatment plan goes ahead.

3Rs of smile design

Dr Gardee opines: “We are thinking about the benefits of our treatment plan, how digital dentistry can improve the life of the person in the chair. What is the patient thinking about? Something very different: pain, choking, blood, injections, and cost. We are providing them with a virtual product – and dentistry is not a priority. It comes way below buying a new car or booking a holiday. The goal in explaining and selling ethical dentistry is in showing our patient the end result − how the outcome actually looks – and then providing it in an accurate, predictable way.”

DSD works with Dr Coachman’s 3Rs of smile design:
• Relocate – orthodontics
• Reshape – dental planing
• Restore – composites or restorations
He prefers to intraorally scan the patient’s mouth to create an STL file he can send directly to the lab. Since investing in a TRIOS scanner, he says, he has never had to adjust an occlusion. There is also no need for retraction during the original DSD mock-up, all that happens once the patient has accepted the idea of treatment.

Dr Gardee concluded: “Before treatment planning begins, before discussing the options available, use DSD to get your patient’s agreement to treatment or you are wasting valuable surgery time. Once you have your patient’s consent get data. Accurate data is key to success. You can capture the data using a traditional impression, which can be scanned to create a virtual model but is more likely to have mistakes, or an intraoral scanner, which is more accurate. Impressions can be supplemented using images from a digital camera or video for smile design. Cone Beam Colour Tomography (CBCT) is perfect in the case of some orthodontic treatments or dental implantology. You want to know how much bone you have to use. Once you have the data you can create the smile with confidence.

“Some digital treatments are going to be super easy. Take a photovideo of your patient’s retracted mouth send it to your software for final design that goes to the lab for a virtual wax-up, and you’re done. Using the display you can show your patient precisely what you are going to do, the key words being ‘absolute precision’. In its simplest form you prep while the restoration is being manufactured using CAD/CAM and then you fit for a perfect result and a super happy patient.”

About Dr Gardee

Graduating from Glasgow University with commendation in 1995, Dr Jameel Gardee then went on to work in private practice and at the Glasgow Dental Hospital. His post doc was completed at Boston University’s renowned Goldman School of Dental Medicine, where he was a Resident in the Department of Restorative Dentistry for a few years. He has been taught by leaders in the field of restorative, cosmetic, and implant dentistry across the world and is currently Clinical Director and Partner at the Glasgow Smile Clinic.

Note: Photographs were taken during Dr Gardee's presentation during the Henry Schein Digital Symposium. Any mistakes in the text are the editor's.

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