Journal of Oral Biology and Craniofacial Research 10 (2020) 194–198

Contents lists available at ScienceDirect

Journal of Oral Biology and Craniofacial Research

journal homepage: www.elsevier.com/locate/jobcr

Digital Smile Design-An innovative tool in aesthetic dentistry T

a,∗ b a a a
Zeba Jafri , Nafis Ahmad , Madhuri Sawai , Nishat Sultan , Ashu Bhardwaj
a
Department of Periodontology, Faculty of Dentistry, Jamia Millia Islamia University, Jamia Nagar, New Delhi, 110025, India
b
Department of Prosthodontics, Faculty of Dentistry, Jamia Millia Islamia University, Jamia Nagar, New Delhi, 110025, India

A R T I C LE I N FO A B S T R A C T

Keywords: A fundamental objective of an aesthetic treatment is the patient's satisfaction and that the outcome of the
Aesthetic treatment should meet the patient's expectation of enhancing his/her facial aesthetics and smile. A patient
Digital constantly doubting the end result of the treatment, which is an irreversible procedure, can be motivated and
Smile educated through Digital Smile Designing (DSD) technique. DSD is a technical tool which is used to design and
Design
modify the smile of patients digitally and help them to visualize it beforehand by creating and presenting a
digital mockup of their new smile design before the treatment physically starts. It helps in visual communication
and involvement of the patients in their own smile design process, thus ensuring predictable treatment outcome
and increasing case acceptance. This article reviews the aspects of digital smile designing in aesthetic dental
practice pertaining to its use, advantages, limitations and future prospects.

1. Introduction 2. Evolution of digital smile designing

A beautiful confident smile is desired by all. When a patient wishes In the last two decades smile designing has progressively evolved
to attain that smile but is skeptical to undertake the treatment proce- from physical analogue to digital designing which has advanced from
dure, for not being able to visualize his or her treatment outcome, is 2D to 3D. From the earlier times when hand drawing on printed photos
when, a clinician can use the Digital smile designing (DSD) tool. DSD of the patient were used to communicate and explain the patients of
concept aims to help clinician by improving the aesthetic visualization how the end result would look like, it has now progressed into complete
of the patient's concern, giving understanding of the possible solution digital drawing on DSD software on computer. This can be easily be
therefore educating and motivating them about the benefits of the edited and can be done and undone anytime to achieve the final design
treatment and increasing the case acceptance. Digital smile design is a balancing patients aesthetic and functional needs.
digital mode that help us to create and project the new smile design by Christian Coachman in 2017 has proposed this evolution in gen-
attaining a simulation and pre visualization of the ultimate result of the erations as:3
proposed treatment. A design created digitally involves participation of Generation 1. Analogue drawings over photos and no connec-
the patients on the designing process of their self-smile design, leading tion to the analogue model. It was the time when drawing with pen
to customization of smile design as per individual needs and desires was done on printed copy of photographs to visualize the treatment
that complements with the morpho psychological characteristics of the result but that could not be co-related with the study model. Digital
patient, relating patient to an emotional level, increasing their confi- dentistry by now was not introduced.
dence in the process and better acceptance of the anticipated treat- Generation 2. Digital 2D drawings and visual connection to the
ment.1 analogue model. With the advent of digital world, certain software
Coachman and Calamita described DSD as a multi-use conceptual like PowerPoint were familiarized which permitted digital drawing.
tool that can support diagnostic vision, improve communication, and Although not specific to dentistry and limited to drawing in two di-
enhance treatment predictability, by permitting careful analysis of the mension it was more accurate and less time consuming than hand
patient's facial and dental characteristics that may have gone unnoticed drawing. The drawing could be visually connected to the study model
by clinical, photographic or diagnostic cast based evaluation proce- but physical connection still lacked.
dures.2 Generation 3. Digital 2D drawings and analogue connection to

∗
Corresponding author.
E-mail addresses: zjafri@jmi.ac.in (Z. Jafri), nahmad7@jmi.ac.in (N. Ahmad), msawai@jmi.ac.in (M. Sawai), nsultan1@jmi.ac.in (N. Sultan),
abhardwaj@jmi.ac.in (A. Bhardwaj).

https://doi.org/10.1016/j.jobcr.2020.04.010
Received 10 March 2020; Received in revised form 9 April 2020; Accepted 11 April 2020
Available online 18 April 2020
2212-4268/ © 2020 Craniofacial Research Foundation. Published by Elsevier B.V. All rights reserved.
Z. Jafri, et al. Journal of Oral Biology and Craniofacial Research 10 (2020) 194–198

the model. This was the beginning of digital-analogue connection. The Four complementary videos should also be taken for facial, pho-
very first drawing software specific to digital dentistry was introduced netic, functional and structural analysis.
which linked 2D digital smile design to 3D wax-up. Facial integration to As it is, that a static photograph taken at a particular time cannot
smile design was also introduced at this stage, but connection to 3D guarantee the ideal moment captured at the idealistic rest position and
digital world was missing. a real maximum full smile position, videos are helpful to allow the
Generation 4. Digital 2D drawings and digital connection to the choice of capturing photo at the perfect moment. Videos can be paused
3D model. Now was the time when digital dentistry progressed from and transformed into a photo by making a screenshot of the best re-
2D to 3D analysis. 3D digital wax-up could be done involving facial corded moment at the desired angle. A study conducted by Tjan and
integration and predetermined dental aesthetic parameters. Miller on static photographs of a posed smile, reported that 11% of the
Generation 5. Complete 3D workflow. patients presented a high smile as opposed to the 21% of patients with
Generation 6. The 4D concept. Adding motion to the smile design an anterior high smile in a study with video recording.8 Tarantili et al.
process. also studied the smile on video and observed that the average duration
of a spontaneous smile was 500 ms, which emphasizes the difficulty of
3. Requirements for DSD recording this moment in photographs.9

DSD technique is carried out by digital equipment already pre- 3.3. Types of DSD software
vailing in current dental practice like a computer with one of the DSD
software, a digital SLR camera or even a smart phone.4 A digital intra- The clinician may follow any one of the given softwares-
oral scanner5 for digital impression, a 3D printer and CAD/CAM are
additional tools for complete digital 3D work flow. An accurate pho- 1. Photoshop CS6 (Adobe Systems Incorporated),
tographic documentation is essential as complete facial and dental 2. Microsoft PowerPoint (Microsoft Office, Microsoft, Redmond,
analysis rests on preliminary photographs on which changes and de- Washington, USA).
signing is formulated, a video documentation is required for dynamic 3. Smile Designer Pro (SDP) (Tasty Tech Ltd),
analysis of teeth, gingiva, lips and face during smiling, laughing and 4. Aaesthetic Digital Smile Design (ADSD - Dr. Valerio Bini),
talking in order to integrate facially guided principles to the smile de- 5. Cerec SW 4.2 (Sirona Dental Systems Inc.),
sign. 6. Planmeca Romexis Smile Design (PRSD) (Planmeca Romexis®),
7. VisagiSMile (Web Motion LTD),
3.1. Photography protocol 8. DSD App by Coachman (DSDApp LLC),
9. Keynote (iWork, Apple, Cupertino, California, USA)
To proceed with a correct digital planning it is crucial to follow a 10. Guided Positioning System (GPS)
photography protocol. Photographs taken should be of utmost quality 11. DSS (EGSolution)
and precision, with correct posture and standardized techniques, as 12. NemoDSD (3D)
facial reference lines like the commissural lines, lip line and inter-pu- 13. Exocad DentalCAD 2.3
pillary line which forms the basis of smile designing are established on
them. Poor photography misrepresents the reference image and may Factors such as dentofacial aesthetic parameters, ease of use, case
lead to an improper diagnosis and planning.6 documentation ability, cost, time efficiency, systematic digital work-
The following photographic views in fixed head position are ne- flow and organization, and compatibility of the program with CAD/
cessary: CAM or other digital systems may influence the user's decision.10
There are many aesthetic parameters that guide smile evaluation
1. Three frontal views: and design such as the midline, height, and the curve of the smile and
•Full face with a wide smile and the teeth apart, intra- and interdental proportion.11–13 A study conducted by Doya
•Full face at rest, and Omar et al.10 compared eight DSD softwares (Photoshop CS6, Keynote,
•Retracted view of the full maxillary and mandibular arch with Planmeca Romexis Smile Design, Cerec SW 4.2, Aesthetic Digital Smile
teeth apart. Design, Smile Designer Pro, DSD App and VisagiSMile in their cap-
2. Two profile views: ability to evaluate and digitally modify these aesthetic parameters i.e
•Side Profile at Rest facial, dento-gingival and dental parameter and concluded that Pho-
•Side Profile with a full Smile toshop, Keynote and Aesthetic Digital Smile Design included the largest
3. A 12 O, clock view with a wide smile and incisal edge of maxillary number of aesthetic analysis parameters. Apart from these the other
teeth visible and resting on lower lip. included DSD softwares were deficient in analyzing the facial aesthetic
4. An intra occlusal view of maxillary arch from second premolar to parameters although they had wide range of dentogingival and dental
second premolar. aesthetic features. According to the authors, “the DSD App, Planmeca
Romexis Smile Design, and Cerec SW 4.2 could execute 3D analysis;
3.2. Videography protocol moreover, Cerec SW 4.2 and PRSD worked together with CAD/CAM.
The DSD App and Smile Designer Pro were offered as mobile phone
According to Coachman7 during videography best framing and applications. SDP and ADSD were marketed as specialized digital de-
zoom should be adjusted with suitable exposure and focus adjusted to sign programs. Furthermore, VisagiSMile and DSD App shared the idea
mouth. For ideal development of the facially guided smile frame, four of visagism” which was first introduced by Braulio Paolucci14,15 that
videos from specific angles should be taken: suggests temperament can be used as a factor in smile design.
More recently, Exocad DentalCAD 2.3 was introduced which does
1. A facial frontal video with retractor and without retractor smiling, 3D analysis and could be incorporated with CAD/CAM.
2. A facial profile video with lips at rest and wide-E smile,
3. A 12 O'clock video above the head at the most coronal angle that 4. Procedure of carrying DSD
still allows visualization of the incisal edge,
4. An anterior occlusal video to record maxillary teeth from second Although the inclusion of aesthetic parameters in different DSD
premolar to second premolar with the palatine raphe as a straight software varies, basic procedure of smile designing remains the same.
line. All the DSD software allows for aesthetic designing through the

195
Z. Jafri, et al. Journal of Oral Biology and Craniofacial Research 10 (2020) 194–198

Fig. 1. 1a- Facial view with horizontal and vertical reference lines. 1b- Digital ruler.

drawing of reference lines and shapes on extra- and intraoral digital 5. Advantages
photographs. Facial analysis is done using reference lines from which
uniform parameters are developed for frontal view of the face. The Digital imaging and designing helps patients to visualize the ex-
horizontal reference lines consist of the inter-pupillary and inter-com- pected final result before the treatment itself starts which enhances the
missural lines that deliver a complete sense of balance and horizontal predictability of the treatment.29,30 The clinician can address patients
over view in the aesthetically pleasing face16,17 while the vertical re- concern by showing digitally the final outcome, motivating and edu-
ference line includes the facial midline, passing the glabella, nose, and cating them about the benefits of the treatment. It improves clinician
the chin (Fig. 1a). The horizontal and vertical lines are crossed against diagnosis and treatment plan by aesthetic visualization of patients
each other to measure symmetry and cant of the face.18 The facial problem through digital analysis of facial, gingival and dental para-
photograph with a wide smile and the teeth apart is moved behind this meters that will analyze the smile and the face in an objective and
cross to determine the ideal horizontal plane and vertical midline which standardized manner.
permits a comparative analysis of the teeth and face. DSD leads to customization of smile design by increasing the par-
After facial analysis, dento gingival analysis is done. The length of ticipation of patient in their own smile design which result in a more
the upper lip at rest and in a smile is checked to determine the gingival aesthetically driven, humanistic, emotional and confident smile.1 The
display. Smile curve is established by correlating the curvature of the patient may evaluate, provide opinion, and approve the final shape of
incisal edges of the maxillary anterior teeth. The dental contour is made the new smile before any treatment procedures are performed thus
according to the lower lip proportions and the anterior-posterior cur- enhancing patients satisfaction. It leaves no scope of regret post treat-
vature of the teeth. This facial photograph is then cropped to show only ment where the irreversible procedures once carried out cannot be
the intraoral view. Three reference lines are marked on the teeth, a undone. It also helps to evaluate and compare pre and post treatment
straight horizontal line drawn from canine tip to canine tip, one more changes. With the digital ruler, drawings, and reference lines, easy
horizontal line on the incisal edges of central incisors and another comparisons can be made between pre- and post-treatment photo-
vertical line passing through the dental midline (passing through the graphs.
interdental papillae). This supports in reproducing the cross, that is, the It not only improves communication between clinician and patient
reference inter-pupillary and facial midline on the face onto the in- but also between interdisciplinary team members, between clinicians,
traoral view. Few additional lines are drawn such as the gingival zenith, clinician and lab technician. All team members can access this in-
joining lines of the gingival and incisal battlements for complete dental formation whenever necessary to review, change, or add components
analysis. For adequate teeth dimension the ideal size of dental width to during the diagnostic and treatment phases, without being available in
length ratio can be incorporated by any one of the published theories the same place or at the same time. This enhances visual communica-
which includes Golden proportion,19 Pound's theory,20,21 Recurring tion, improves transparency, creates a better team work, and inter-
aesthetic dental proportion,21 Dentogenic theory,22,23 or Visagism.24 disciplinary treatment planning. The lab technician also receives feed-
Required changes are carried out with the help of a digital ruler back of patients expectation related to tooth shape, arrangement, and
(Fig. 1b) which can be calibrated on the photograph by measuring the color to enable any desired modifications. This persistent double-
width of the central incisors in the study model. Changes can be checking ensures the quality of the final result.
modified, decreased or adapted to different situations, depending on A study conducted by Gabriele Cervino et al.31 reviewed as much as
the aesthetic requirement25 and individual needs of the patient. Fig. 2 24 articles on DSD published up till the year 2018 with the purpose to
shows the procedure of digital smile designing on a DSD 3D software evaluate the effectiveness of the use of Digital Smile Design techniques
Exocad.26 and whether Digital Smile Design is bringing any improvements in the
After the new smile design is attained it can be digitally presented to comfort of patients and in their treatments. It took into consideration,
the patient to seek out appreciation and feedback. This digitally ap- the “communicative” utility of the software, the therapeutic planning,
proved smile design at this stage can be used to create physical mockup and, of aesthetic and functional rehabilitation of the patients. The au-
which can be tested aesthetically in the patient's mouth. The mock-up thors concluded from all of the articles present in the literature re-
allows for not only visualization of the shape integrated to the gingiva, garding Digital Smile Design, that, this tool provides important in-
lips, face, but also to phonetics during the evaluation period.27,28 As formation to the clinician and patient. Patients can view their
such, the patient may evaluate, provide opinion, and approve the final rehabilitations even before they start, and this can also have important
shape of the new smile before any irreversible procedures are per- medico-legal functions.
formed.

196
Z. Jafri, et al. Journal of Oral Biology and Craniofacial Research 10 (2020) 194–198

Fig. 2. Digital smile designing process on Exocad 3D software

2a & 2b shows drawing of facial and intraoral reference lines.
2c shows integration of facial with dental analysis.
2d represents incorporation of ideal dental contours in 3D.
2e shows digital designed smile compared with original smile.

6. Limitations further increases time and cost.32

1. As the diagnosis and treatment plan depends on photographic and

video documentation, inadequacy in them may distort the reference 7. Future prospects
image and may result in an incorrect diagnosis and planning.6
2. For complete 3D digital work flow, 3D softwares with updates, in- Complete 3D digital workflow is still not extensively used which in
traoral scanner, 3D printer and CAD/CAM are required which makes future may come into practice far and wide when more and more
it economically expensive. clinician will adopt digital scanner, 3D printers, CAD/CAM, then the
3. Training and handling for certain software are necessary which need for time-consuming impressions, plaster and wax will become far
less necessary. With the improvements in the software over the next few

197
Z. Jafri, et al. Journal of Oral Biology and Craniofacial Research 10 (2020) 194–198

years, it will be possible to address facial aesthetics in advanced cases by digital smile design programs: a review of literature. Saudi Dent J.
where implants need to be placed by superimposing the files coming 2018;30(1):7–11.
11. Fradeani M. Esthetic Rehabilitation in Fixed Prosthodontics. Chicago: Quintessence;
from a CT scan or a Cone Beam, along with 3D files of an oral im- 2004.
pression or a facial scan and a photo. There also is a possibility of in- 12. Davis NC. Smile design. Dent Clin North Am. 2007;51(2):299–318.
corporating 4D concept in which motion can be added to the smile 13. Dias NS, Tsingene F. SAEF–Smile's aesthetic evaluation form: a useful tool to improve
communication between clinicians and patients during multidisciplinary treatment.
design concept.3,33 With ever evolving fast paced technology a time, not Eur J Esthetic Dent. 2011;6(2):160–176.
so far, may come, when digitally designed smile can be projected to 14. Paolucci B. Visagismo e odontologia. In: Hallawell P, ed. Visagismo Integrado:
virtual reality glasses to foresee the desired smile in actual reality. Identidade, Estilo, Beleza. São Paulo: Senac; 2009:243–250.
15. Paolucci B, Calamita M, Coachman C, Gurel G, Shayder A, Hallawell P. Visagism: The
Art of Dental Composition. Quintessence of Dental Technology; 2012:1–14.
8. Conclusion 16. Chiche G, Pinault A. Diagnosis and treatment planning of aesthetic problems.
Aesthetics of Anterior Prosthodontics. Quintessence. 2004; 2004:13–25.
17. Cohen SE. Fundamentals of Dental Aesthetics: Analysis. Atlas of Cosmetic and
Digital smile design concept is a helpful tool in aesthetic visuali-
Reconstructive Periodontal Surgery. third ed. PMPH; 2007:217–238.
zation of patient's problem. It not only helps patients to envision their 18. Naini FB, Gill DS. Facial aesthetics: 2. Clinical assessment. Dent Update.
treatment outcome but also improves clinician's diagnosis and treat- 2008;35(3):159–170.
ment planning. 19. Priya K, Rahul DP, Varma S, Namitha R. Norms for crafting a beautiful smile. Amirta
J Med. 2013;2(9):4–9.
20. Vassantha Kumar M, Ahila SC, Suganya Devi S. The science of anterior teeth selection
Declaration of competing interest for a completely edentulous patient: a literature review. J Indian Prosthodont Soc.
2011;11(1):7–13.
21. Ward HD. Proportional smile design using: the recurring esthetic dental proportion
NIL. to correlate the widths and lengths of the maxillary anterior teeth with the size of the
face. Dent Clin North Am. 2015;59(3):623–638.
22. Farias FO, Ennes JP, Zorzatoo JR. Aesthetic value of the relationship between the
Acknowledgement shapes of the face and permanent upper central incisor. Int J Dent. 2010;1:1–6.
23. Pedrosa VO, Franca FM, Florio MF, Basting RT. Study of the morpho-dimensional
NIL. relationship between the maxillary central incisors and the face. Braz Oral Res.
2011;25(3):210–216.
24. Sharma A, Luthra R, Kaur P. A photographic study on Visagism. Indian J Oral Sci.
References 2015;6(3):122–127.
25. Ahmad N, Ahmed M, Jafri Z. Aesthetics considerations in the selection of teeth for
complete denture patients: a Review. Ann Dent Spec. 2013;1(1):4.
1. Coachman C, Yoshinaga L, Calamita M, Sesma N. Digital smile design concepts. The
26. GGmbH Exocad. Viewed March 2020 https://www.youtube.com/watch?v=
Technologist. 2014.
3GLXEweaXeM&t=648s; Nov 2019.
2. Coachman C, Calamita M. Digital smile design: a tool for treatment planning and
27. Neto AF, Bandeira AS, de Miranda BF, Sánchez-Ayala A. The use of mock-up in
communication in aesthetic dentistry. Quintessence Dent Technol. 2012;35:103–111.
dentistry: working with predictability. Full Dent Sci. 2015;6:256–260.
3. Evolution of Smile Design. (Accessed on 15th February 2020) Available online:.
28. Lin WS, Zandinejad A, Metz MJ, Harris BT, Morton D. Predictable restorative work
https://media.digitalsmiledesign.com/christian-coachman-thoughts/smile-design-
flow for computer-aided design/computer-aided manufacture–fabricated ceramic
evolution.
veneers utilizing a virtual smile design principle. Operat Dent. 2015;40(4):357–363.
4. Daher R, Ardu S, Vjero O, Krejci I. 3D digital smile design with a mobile phone and
29. Fan F, Li N, Huang S, Ma J. A multidisciplinary approach to the functional and
intraoral optical scanner. Comp Cont Educ Dent. 2018;39(6):e5–8.
aesthetic rehabilitation of dentinogenesis imperfecta type II: a clinical report. J
5. Aragón ML, Pontes L, Bichara L, Flores-Mir C, Normando D. Validity and reliability of
Prosthet Dent. 2019;122(2):95–103.
intraoral scanners compared to conventional gypsum models measurements: a sys-
30. Ahrberg D, Lauer HC, Ahrberg M, Weigl P. Evaluation of fit and efficiency of CAD/
tematic review. Eur J Orthod. 2016;38:429–434.
CAM fabricated all-ceramic restorations based on direct and indirect digitalization: a
6. Zanardi PR, Zanardi RL, Stegun RC, Sesma N, Costa BN, Laganá DC. The use of the
double-blinded, randomized clinical trial. Clin Oral Invest. 2016;20(2):291–300.
digital smile design concept as an auxiliary tool in aesthetic rehabilitation: a case
31. Cervino G, Fiorillo L, Arzukanyan AV, Spagnuolo G, Cicciù M. Dental restorative
report. Open Dent J. 2016;10:28.
digital workflow: digital smile design from aaesthetic to function. Dent J (Basel).
7. Coachman C, Calamita MA, Sesma N. Dynamic documentation of the smile and the
2019;7(2):30.
2D/3D digital smile design process. Int J Periodontics Restor Dent.
32. Meereis CT, De Souza GB, Albino LG, Ogliari FA, Piva E, Lima GS. Digital smile
2017;37(2):183–193.
design for computer-assisted aesthetic rehabilitation: two-year follow-up. Operat
8. Tjan AH, Miller GD. Some aesthetic factors in a smile. J Prosthet Dent.
Dent. 2016;41(1):E13–E22.
1984;51(1):24–28.
33. Halley E. The future—3D planning but with the face in motion. Br Dent J.
9. Tarantili VV, Halazonetis DJ, Spyropoulos MN. The spontaneous smile in dynamic
2015;218:326–327.
motion. Am J Orthod Dentofacial Orthop. 2005;128(1):8–15.
10. Omar D, Duarte C. The application of parameters for comprehensive smile aesthetics

198