What is the recommended approach for a patient seeking smile designing to achieve optimal oral health and aesthetics?

Smile Designing: Recommended Approach

For patients seeking smile designing, begin with a comprehensive esthetic evaluation using a structured smile evaluation form, followed by professional dental cleaning to establish optimal periodontal health, then proceed with digital smile design (DSD) technology to create a visual treatment plan that addresses facial, dentogingival, and dental esthetic parameters before any irreversible procedures. 1, 2

Initial Assessment and Documentation

Comprehensive Esthetic Evaluation

• Use a standardized Smile Evaluation Form to systematically document facial esthetics, dentogingival relationships, and dental parameters, allowing organized treatment planning and clear communication with the patient and interdisciplinary team 1, 2
• Assess the top 5 facial attractiveness features, with particular attention to smile and teeth appearance, as these are critical determinants of facial esthetics 3
• Evaluate facial "hot spot" areas including periorbital and perioral regions where aging signs are most visible, as these influence overall smile esthetics 3
• Document tooth shape, shade, gingival contours, and smile line relationships 4

Diagnostic Records

• Obtain 3D CBCT imaging to assess local anatomy and bone architecture when implant placement or complex reconstruction is anticipated 3
• Take comprehensive intraoral and extraoral photographs to document baseline esthetics and track treatment progress 3
• Create study casts and diagnostic wax-ups to visualize the expected endpoint before treatment 1
• Perform radiographic examination including panoramic radiograph and/or full mouth intraoral radiographs 3

Establishing Optimal Oral Health Foundation

Professional Periodontal Treatment

Professional scaling and root planing with polishing is mandatory as the first step, since calculus deposits cannot be removed by regular brushing alone and must be eliminated before esthetic procedures 5, 6

• Address any localized gingivitis presenting with bleeding during brushing, visible plaque and calculus 5
• Ensure complete resolution of periodontal inflammation before proceeding with irreversible esthetic procedures 3

Daily Home Oral Hygiene Protocol

Establish rigorous oral hygiene practices that patients must maintain throughout and after smile designing:

• Brush at least twice daily for minimum 2 minutes using a small, ultra-soft-headed, rounded-end bristle toothbrush 7
• Use prescription-strength fluoride toothpaste, spitting out foam without rinsing to maximize fluoride contact 7
• Ensure the gingival portion of the tooth and periodontal sulcus are included during brushing 7
• Floss at least once daily using waxed floss to minimize gingival trauma 7
• Rinse vigorously several times daily with a bland rinse (1 teaspoon salt, 1 teaspoon baking soda in 4 cups water) to maintain moisture and remove debris 3
• Consider 0.12-0.2% chlorhexidine gluconate twice daily for 60 seconds as adjunctive antimicrobial therapy 5

Digital Smile Design Implementation

Software Selection and Analysis

Use Photoshop CS6, Keynote, or Aesthetic Digital Smile Design programs as they include the largest number of esthetic analysis parameters compared to specialized DSD programs 8

• These programs provide comprehensive facial, dentogingival, and dental esthetic analysis capabilities 8
• For practices requiring CAD/CAM integration, Cerec SW 4.2 or Planmeca Romexis Smile Design offer 3D analysis with manufacturing capabilities 8
• Mobile applications (DSD App, Smile Designer Pro) provide accessibility for patient communication but have more limited analysis functions 8

Patient Communication and Visualization

Create a digital mockup of the proposed smile design before any physical treatment begins to ensure patient understanding and acceptance 9

• Present the digital visualization to educate patients about the expected outcome of irreversible procedures 9
• Use DSD as a visual communication tool to involve patients in their own smile design process, increasing case acceptance and ensuring predictable outcomes 9
• Modify the digital design based on patient feedback before finalizing the treatment plan 9

Treatment Planning Considerations

Mechanical and Biological Factors

Address the following parameters systematically:

• Tooth shape and shade principles using modern digital tools 4
• Facial bone wall thickness and soft tissue biotype, particularly in anterior maxilla where only 4.6% of central incisor sites have thick wall phenotype (>1 mm) 3
• Subcutaneous fat distribution and vascular supply, as decreased blood flow from aging causes deep fat atrophy affecting facial esthetics 3

Risk Assessment for Complex Reconstruction

Approach complex dental reconstruction with caution in elderly patients, those with cognitive impairment, limited manual dexterity, or multiple comorbidities (diabetes, osteoporosis, cancer history) 3

• Consider that complex reconstructions requiring significant maintenance may adversely affect quality of life when problems arise 3
• Evaluate patient's ability to perform adequate oral hygiene around difficult-to-clean prostheses 3
• Assess access to ongoing dental care and financial resources for long-term maintenance 3

Timing and Sequencing

Develop a logical treatment sequence with mutually agreed-upon endpoints:

• Complete all necessary periodontal therapy and allow initial healing before esthetic procedures 3
• For implant-based reconstruction, recognize that treatment often takes months to a year, during which patient circumstances may change 3
• Schedule regular follow-up appointments every 6 months minimum to monitor periodontal health and esthetic outcomes 7, 5

Interdisciplinary Collaboration

Incorporate perspectives from multiple dental disciplines (prosthodontics, periodontics, orthodontics, oral surgery) as modern esthetic cases cannot be restored to optimal standards by a single clinician 2

• Use the Smile Evaluation Form as a checklist for discussions with team members 1
• Establish clear communication protocols regarding treatment sequence and expected outcomes 2
• Leverage dentists' expertise in head and neck anatomy for comprehensive facial esthetic treatments 3

Common Pitfalls to Avoid

• Never proceed with irreversible esthetic procedures without first establishing optimal periodontal health, as underlying inflammation will compromise esthetic outcomes and longevity 3, 5
• Avoid immediate implant placement unless facial bone wall is fully intact with thick wall phenotype (>1 mm) and thick gingival biotype, conditions rarely present in anterior maxilla 3
• Do not perform complex reconstructions in patients with acute purulent infection at the treatment site 3
• Avoid petroleum-based lubricants for oral moisturization; use only plant- or animal-based oils (beeswax, cocoa butter, lanolin) 3
• Do not use commercial mouthwashes with alcohol base or astringent properties, as these can compromise oral tissues 7

Alternative Regenerative Approaches

For patients seeking natural, minimally invasive options:

• Consider autologous platelet concentrates (PRP/PRF) for facial rejuvenation, which offer safer and more natural-looking results than synthetic fillers 3
• Novel albumin gel preparations provide 4-6 months duration while simultaneously building collagen over time 3
• These regenerative approaches address underlying vascular degeneration and deep fat atrophy that contribute to facial aging 3