DOI: 10.7860/JCDR/2023/61467.

17386
Review Article

Dentistry Section

Digital Smile Design- An Overview

of 3D Digital Workflow
Pooja Mohan Chitlange1, Priyanka Paul MaDhu2, aMit reChe3

ABSTRACT
Smile designing is a branch of cosmetic dental procedure that corrects imperfections of the teeth and restores dental health and
appearance of the person. Today Digital Smile Design (DSD) is changing the future of dental practice worldwide. It’s a unique
approach to modern dentistry is revolutionising smile designing clinics worldwide. DSD is a software which used worldwide, is based
on specific photographs and software analysis. DSD is a tool (software) that helps in easy communication and discussion between all
the smile designers, dental laboratory technician as well as with patients. DSD especially can be used in a multidisciplinary approach
and hence not only used in prosthetic rehabilitation but also used in other branches of dentistry like Orthodontic, Periodontics, etc.,
The concept of smile designing is not new. The need of aesthetic can be traced from the earliest civilisations of both the Phoenicians
(about 800 BC) and Etruscians (about 900 BC). They used to carve animal tusks to simulate the shape, form and hue of natural
teeth. Pierre Fauchard (1678-1761) from of France, together with several colleagues modernised and promoted dentistry and also
started aesthetic practices. There are many parameters such as dentofacial parameter, gingival parameter, ease of use,
documentation ability, cost, time required, systematic digital workflow and organisation, and compatibility of the program with
Computer-aided design/Computer-aided Manufacturing (CAD/CAM) or other parameters that may affect the user’s decision. DSD
helps both clinician and patient to improve treatment planning and stimulate the final results of the treatment. There are many
software available, and the clinicians can use any of the software according to their needs. Some software can be used easily as a
mobile app. This article reviews the basic principles of smile design, various parameters of smile design, comparison of various
software, uses, advantages and limitations of DSD.

Keywords: Aesthetic dentistry, Computer-aided design and computer-aided

manufacturing, Cosmetic dentistry, Intraoral scanner, Smile
INTRODUCTION quality and the ability to submit models to the laboratory via e-
Cosmetic dentistry has the ability to not only change but also mail, minimising money and time [1].
Journal of Clinical and Diagnostic Research. 2023 Jan, Vol-17(1): ZE01-
enhance once appearance. Smile designing is a branch of ZE04
cosmetic dentistry that corrects disturbances of the teeth and Background
restores dental problems and aesthetics of the person. Having The concept of designing a smile is evolving continuously. The
a smile you love increases your confidence as well as your demand for aesthetics can be traced back to the Phoenicians
self-esteem. Smile is the first to be noticed by someone when (around 800 BC) and Etruscians (around 900 BC). They used to
they look at you. Now, it is possible to achieve your dream carve animal tusks to mimic the form, shape and colour of real
smile with smile designing. Today DSD is changing the future teeth [2]. Pierre Fauchard (1678-1761) from France, together
of dental practice worldwide. It’s a unique approach to modern with several colleagues modernised and promoted dentistry and
dentistry is revolutionising smile designing clinics worldwide. also started aesthetic practices [3]. The concept of smile
Teeth have always been considered the most important factor designing developed rapidly during 18th century. During 18th
for beauty (smile) [1]. The main objective of a smile designing century the oral health was affected due to the wide spread of
is to fulfil patient’s requirements and the results of the caries, because of high intake of sweets, poisoning due to heavy
procedure should enhance patient’s facial aesthetics and metals and some systemic diseases. Therefore, over the time,
smile. Smile designing is an irreversible procedure, so it is the demand for aesthetics increased more among the high socio-
difficult to convince and educate through conventional smile economic groups before spreading among the population.
design technique but with DSD it is very easy to motivate and Modern dentistry attempted to satisfy the aesthetic and functional
educate patient by developing and showing the smile digitally needs by developing a variety of novel treatment alternatives [4].
and it helps them to visualise it prior to the treatment by In recent years, smile design has advanced from traditional
creating and presenting a virtual simulation of their new smile (manual) smile design to DSD, which has now improved from 2
design. Dimensional (2D) to 3 Dimensional (3D). Previously, manual
The DSD is a software which used worldwide, is based on drawings on printed photographs of the patient were used for the
particular photographs and software analysis [2,3]. DSD is a demonstration of the end results of therapy; however, this has
tool (software) that helps in easy communication and since been replaced with absolute automated drawing using DSD
discussion between all the smile designers, laboratory software on a computer. This is simple to operate, edit and
technician as well as with patients. DSD especially is a explain to patients [5]. In the year 2017, Christian Coachman has
multidisciplinary approach and hence, it is not only used in proposed the evolution of Digital Smile Design Software (DSDS)
prosthetic rehabilitation but also used in other branches of as six generations described in [Table/Fig-1] [6].
dentistry like Orthodontic, Periodontics etc., [4]. DSD workflow
needs an intraoral scanner and software programs,
photographs and videos. Intraoral scanners are dynamic
instruments that allow for instant evaluation of impression
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 Pooja Mohan Chitlange et al., Digital Smile Design-An Overview of 3D Digital Workflow www.jcdr.net

Components of Smile Aesthetics connecting lines of the gingival and incisal battlements and the
The components of smile aesthetics are divided into four main gingival zenith [5].
components which are facial aesthetics, gingival aesthetics, Some theories are used for the selection of ideal dimensions of
macroaesthetics and micro-aesthetics [7]. The components of teeth for ideal size of dental length to width ratio, Golden
smile aesthetics contain various parameters of analysis which proportion, Pound’s theory, Visagism, Dentogenic theory or
are listed in [Table/Fig-2]. recurring aesthetic dental proportion [10-15]. After all of the
preliminary work has been completed a digital ruler is used to
make the necessary modifications. The alterations can be
customised to the patient’s aesthetic preferences and unique
demands [16]. A fresh smile is displayed to a patient once all of
the modifications have been completed. This digital smile may be
used to prepare a final model that can be visually assessed in
the patient’s oral cavity. The model not only permits visualisation
of gingival architecture, lips and facial shape, but also speech
during the try-in phase before any permanent alterations occur
generation advancement Description
At that time, the treatment outcome was visualised by scribbling with a hand drawing on a printed
Analogue drawing over images and no link
First generation copy of a photograph, but that cannot be linked to the digital mock-up. Digital dentistry had not yet
to the analogue mock up
been developed at the time.
Some programmes, e.g., powerpoint, became familiar with the advent of the digital era, allowing for
Digital 2D drawing and visual link to the digital drawing. Although, it was limited to two-dimensional drawing and was not specific for
Second generation
analogue mock up dentistry, it was more appropriate and required less time than manual drawings. Although, the
artwork was aesthetically related to the study model, but there was no true relationship.
It was the start of digital-analogue conversion. The first dental specific digital drawing application was
Digital 2D drawing and analogue link to the launched, which linked two-dimensional Digital Smile Design (DSD) to three dimensional models.
Third generation
mock up Facial integration for smile design was also created at this time, but there was no link to the 3D
digital world.
Digital 2D drawing and digital link to the 3D Digital dentistry has moved from two dimensional to three-dimensional analysis at the time. A 3D
Fourth generation
mock up digital model was made with facial integration and current aesthetic requirements.
Now, it was the time when complete workflow is done digitally and a 3D workflow is done involving all
Fifth generation Complete 3D workflow
the facial and digital analysis parameters.
Sixth generation The 4D concept Including movement in the smile design process.
[Table/Fig-1]: Evolution of DSDS according to Christian Coachman (2017) [6].
Components Parameters [17]. The complete workflow of DSD is shown in [Table/Fig-3]
Facial aesthetics Height of face, shape of face, facial profile, gender, age [5,18].
Gingival aesthetics Gingival health, gingival architecture, gingival
symmetry
Lip analysis, lip morphology, lip mobility, smile line,
midline, balance, length of incisors, incisor angulation,
Macro-aesthetics
radiating symmetry, incisal embrasure form, buccal
corridor
Micro-aesthetics Specific tooth form and shade matching
[Table/Fig-2]: Various parameters of the components of smile aesthetics [7].
Digital Smile Designing Procedure
[Table/Fig-3]: Shows the complete workflow of Digital Smile Design (DSD) [5].
The cosmetic aspects in different DSD software vary, but the
core method of constructing a smile stays the similar. All of the Workflow of Digital Smile Design (DSD) the following
programmes allow you to build your own smile by drawing are the proportions used in smile designing; golden
reference lines and structures on intraoral and extraoral images. proportion: The golden proportion was initially stated by
The front image of the face is created using reference lines of Lombardi in dentistry and Levin subsequently developed it.
facial analysis. The horizontal guiding lines are intercommissural When a line is divided into two sections in the golden
lines and interpupillary lines which offer a perfect balance on the proportion, the ratio of the small segment to the large segment
horizontal parts of an aesthetically attractive face, while the is equal to the ratio of large section to overall line. The golden
vertical guiding lines are the glabella, nose, chin, dental midline proportion or divine proportion, ratio of following terms is about
and mandible [8,9]. DSD allows a relative analysis of the teeth 1:1.618 [19].
and face after determining horizontal and vertical proportion. Facial proportion: The rule of thirds separates the face
Dentogingival analysis is performed after face analysis. The vertically into about three equal portions in facial proportion.
gingiva shown is determined by the measurement of height of The lower 3rd of the face is then divided into three parts, with
the top lip at rest and during smiling. The smile curve is obtained the incisal plane ideally situated at the intersection of the top
by connecting the curvature of the incisal margins of the upper and middle third [19].
front teeth. The proportions of the lower lip and the
Dental proportion: The height of the ideal central incisor
anteriorposterior curve of the teeth establish the dental contour.
should be one-sixteenth of the height of the face from the ideal
This face image’s intraoral view is then cropped. On the teeth,
hairline to the chin and the width should be one-sixteenth of
three reference lines are drawn: a horizontal straight line from tip
the interzygomatic width [19].
of one canine to the tip of another canine, a vertical line crossing
the midline (passing from the interdental papillae) and a golden percentage: Snow analysed the individual apparent
horizontal line on the incisal margins of central incisors. This tooth width as a proportion of the overall apparent width of the
helps to reproduce the cross, i.e., the reference facial midline on six anterior teeth bilaterally. In order to generate an
the face and interpupillary line, onto the intraoral view. A few aesthetically attractive grin, he established the golden
other lines are drawn for a full dental study, such as the percentage, which states that the proportionate width of
individual tooth should be 25% central incisor, 15% lateral
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www.jcdr.net Pooja Mohan Chitlange et al., Digital Smile Design-An Overview of 3D Digital Workflow

incisor and 10% canine of the overall width of the anterior facial, dentogingival, dental analysis [31-33]. Similar to
section [19]. photoshop, keynote can analyse every parameter but was not
There are many DSD software developed by different able to change and create detailed ideal changes on the tooth
companies. The clinician can use any of the programmes structure [34,35]. Both keynote and photoshop are photo
according to the needs. The [Table/Fig-4] shows the list of the editing software hence, cannot be specific for dental use. It
DSD software available. cannot be operated by mobile phone and cannot be used with
CAD/CAM. The software is not developed for patient
Many aspects, including dentofacial parameter, gingival
documentation and dental use therefore, required special
parameter, documentation capability, cost, ease of use,
training to operate this software. Similarly, ADSD program
systematic digital workflow and organisation, time required and
scored 18 out of 20, but it contains limited facial analysis
application compatibility with CAD/CAM, may impact the user’s
parameters [36,37]. The software is specifically developed for
choice. Many aesthetic criteria, including the facial midline,
DSD and the workflow has been designed for dental use. This
dentofacial midline, gingival height and contour, facial profile,
software is also not used with CAD/CAM. It requires fewer
height and smile curve, as well as intra and interdental
operative skills to operate software effectively. However, the
proportions, influence smile evaluation and design [20-22].
functionalities are confined to those currently present in the
software [32].
DISCUSSION Planmeca Romexis Smile Design is a DSD software that may
In year 2017, Omar D and Duarte C, conducted a study
be used to simulate smiles, plan treatments and communicate
comparing eight DSD softwares (Photoshop CS6, Keynote,
effectively. It is compatible with both Mac and Windows. It
Planmeca Romexis Smile Design, Cerec SW 4.2, Aesthetic
doesn’t need any additional software to work. It’s quick and
Digital Smile Design (ÀDSD),
easy to use. Designing a smile with a 2D face shot and
Journal of Clinical and Diagnostic Research. 2023 Jan, Vol-17(1): ZE01-ZE04 accurate teeth selection takes only a few minutes. The
S. programme enables the operator to carefully alter the location,
no. Digital Smile Design Software (DSDS)
shape and size of each tooth in order to obtain perfect
1. Photoshop CS6 (Adobe Systems Incorporated) proportion and aesthetics [33,35].
2. Keynote (iWork, Apple, Cupertino, California, USA)
Journal of Clinical and Diagnostic Research. 2023 Jan, Vol-17(1): ZE01-ZE04
3. Aesthetic Digital Smile Design (ADSD- Dr. Valerio Bini)
Cerec SW 4.2, scored 13 out of 20 [38,39]. This software is not
4. Cerec SW 4.2 (Sirona Dental Systems Inc.) efficient as above-mentioned software in facial and dentogingival
5. Smile Designer Pro (SDP) (Tasty Tech Ltd.) parameter analysis. There are very few frontal facial parameters
6. Planmeca Romexis Smile Design (PRSD) (Planmeca Romexis®) and facial profile parameters incorporated in this software. This
software can be used with CAD/CAM but cannot be operated as
7. VisagiSMile (Web Motion Ltd.)
mobile app. Additionally, DSD App, SDP and VisagiSMile
8. DSS (EGSolution)
programs had similar scores, 10 out of 20 [34,40-42]. The most
9. Microsoft PowerPoint (Microsoft Office, Microsoft, Redmond, Washington, significant disadvantages of these programmes were discovered
USA)
in the analysis of facial component, which is typically employed
10. DSD App (DSDApp LLC by Coachman) for picture calibration in these systems. These programmes did
11. Guided Positioning System (GPS) not contain frontal face parameters or facial profile parameters.
12. NemoDSD (3D) Some of these programmes however, unable to change delicate
13 Exocad DentalCAD 2.3 natural aspects, which can result in a less convincing digital
replica of the smile. Later in 2017, the DSD app intended to
[Table/Fig-4]: List of Digital Smile Design Software (DSDS).
encompass every area of frontal and facial profile analysis, as
Smile Designer Pro, DSD App and VisagiSMile) [22]. With over
well as an orofacial surgical simulation extension [22,42].
25 parameters but the scoring was done based on 20
parameters. The [Table/Fig-5] shows the 12 face analysis Photoshop, keynote and ADSD has a greater number of
parameters, three dentogingival analysis parameters, five aesthetic analysis parameters. Other DSD softwares has a
parameters of dental analysis, and five additional parameters smaller number of aesthetic analysis parameters but
that were chosen from the examined literature [10-12,23-30]. incorporated comprehensive dentogingival and dental aesthetic
Despite the fact that the application was not designed functions. The PRSD, Cerec SW
particularly for dental use, it was found that keynote and 4.2 and DSD App all supported 3D processing moreover, Cerec
photoshop CS6 provide a more comprehensive smile design SW 4.2 and PRSD can be used in conjunction with CAD/CAM.
than other professional DSD programmes [23]. Both the smile designer pro and DSD app can be operated as
Dentogingival additional
mobile phone software [22,23].
Facial parameters parameters Dental parameter parameters In the year 2017, Santos FR et al., performed a periodontal
1. Facial midline surgery for gummy smile with the help of DSD. The results of the
2. Smile cant surgery were excellent and patient was happy with the end
3. Lower midline 1. Occlusal
4. Interpupillary line plane/Incisal results. He concluded that by the help of DSD it is very easy to
curve 1. Teeth grids
5. Dental midline shift 1. Lower demonstrate the end results of the treatment to the patients [43].
2. Teeth size 2. 3D design
6. Horizontal sections lipline Garcia PP et al., published a study report of a maxillary anterior
3. Teeth structural 3. CAD/CAM
7. Vertical sections 2. Buccal
8. Profile angle corridor
changes 4. Patient rehabilitation using the DSD system and a direct model
4. Teeth interface
9. E-plane 3. Gingival line
characterisatio 5. Mobile app
technique in 2018. He found that the use of DSD in association
10. H-plane n with mock-up for diagnostic and treatment planning yielded good
11. Nasolabial angle 5. Teeth colour
12. Intercommissural results in the cosmetic rehabilitation of the front teeth [44].
line Stanley M et al., conducted a case study in 2018. In this
[Table/Fig-5]: List of various parameters selected by Omar D and Duarte C, scenario, DSD software and CAD/CAM (monolithic lithium
(2017) for analysis of different software [22]. disilicate) ceramic veneers and crowns, were used to alleviate
According to Omar D and Duarte C, out of 20, photoshop vertical dimension loss, aesthetics, and temporomandibular joint
scored 20, followed by keynote which scored 19 out of 20 [22]. diseases (following a minimal tooth preparation technique) [14].
Photoshop has capability to fulfil all the parameters of the
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Pooja Mohan Chitlange et al., Digital Smile Design-An Overview of 3D Digital Workflow www.jcdr.net
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1. Intern, Department of Public Health Dentistry, Sharad Pawar Dental College and Hospital, Datta Meghe Institute of Medical Sciences (Deemed to be University),
Sawangi (Meghe), Wardha, Maharashtra, India.
2. Assistant Professor, Department of Public Health Dentistry, Sharad Pawar Dental College and Hospital, Datta Meghe Institute of Medical Sciences (Deemed to
be University), Sawangi (Meghe), Wardha, Maharashtra, India.
3. Associate Professor and Head, Department of Public Health Dentistry, Sharad Pawar Dental College and Hospital, Datta Meghe Institute of Medical Sciences
(Deemed to be University), Sawangi (Meghe), Wardha, Maharashtra, India.

naMe, aDDreSS, e-Mail iD oF the CorreSPonDing author: PlagiariSM CheCking MethoDS: [Jain H et al.] etyMology: Author Origin
Pooja Mohan Chitlange, • Plagiarism X-checker: Nov 22, 2022
Intern, Department of Public Health Dentistry, Sharad Pawar Dental College and • Manual Googling:
Nov 26, 2022 Hospital, Datta Meghe Institute of Medical Sciences (Deemed to be University), •
iThenticate Software: Dec 07, 2022 (9%) Sawangi (Meghe), Wardha-442001, Maharashtra,
India. E-mail: poojachitlange1999@gmail.com

author DeClaration:
• Financial or Other Competing Interests: None Date of Submission: nov 14, 2022 • Was Ethics Committee
Approval obtained for this study? Yes Date of Peer Review: Dec 05, 2022 • Was informed consent
obtained from the subjects involved in the study? NA Date of Acceptance: Dec 12, 2022
• For any images presented appropriateconsent has been obtained from the subjects. NA Date of
Publishing: jan 01, 2023

4 Journal of Clinical and Diagnostic Research. 2023 Jan, Vol-17(1): ZE01-ZE04