INTRODUCTION
As technology becomes a more significant part of the modern dental practice, the question often raised is “What do I really need?” Face scanners hit the market a few years ago and have become more enhanced and accessible to the practitioner, but what is their role, and where do they shine? At this point in time, one can consider this technology a luxury rather than a necessity, but there have been quite a few scenarios where a face scanner has definitely helped enhance the outcomes, treatment planning, and communication necessary to provide exceptional results.
Coupling a face scanner with design software provides beneficial data that can be utilized to drive treatment to the finish line. But what does it take to simplify this process and utilize the technology to the best of your ability? This article will explore case studies that made a face scanner invaluable to the treatment rendered.
CASE REPORTS
Case 1
A 68-year-old patient came to my practice from a local oral surgeon after she had undergone numerous surgeries, including soft-tissue grafting and implant placement (Figures 1 and 2). Although the surgical outcomes were not favorable, the options were slim after numerous graft attempts. The patient had a high dentofacial risk due to her high smile-line and excessive gingival display. Pink porcelain was a necessity to help improve the aesthetics of this prosthesis. How did a face scanner (RAYFace [Ray America]) become beneficial in a setting such as this?
Figure 1. Preoperative smile, close up.
Figure 2. Pre-op full-face photo.
Knowing that porcelain would have to be fabricated over the soft-tissue void, it was beneficial to be able to view the tissue utilizing a face scan superimposed over the jaw scan to determine how much it could be bulked out with porcelain without impinging on the lips (Figures 3 to 5).
Figure 3. Pre-op face scan superimposed over jaw scan.
Figure 4. Pre-op face scan superimposed over jaw scan, close-up frontal view.
Figure 5. Pre-op face scan superimposed over jaw scan, close-up side view.
Figure 6. Virtual gingival and wax-up design, frontal view.
Figure 7. Virtual gingiva and wax-up design, side view.
Utilizing design software (exocad), virtual gingiva can be designed to communicate to the ceramist the placement and thickness of the pink porcelain needed to mask the defect (Figures 6 and 7). The desired wax-up can be done simultaneously to be a mirror image of the contralateral teeth Nos. 9 and 10. This virtual simulation provides enhanced communication to the patient and the lab technician on a template of how the final prosthesis will look, along with just how pink porcelain will be necessary to complete the case.
The same design software utilized to showcase the final outcome to the patient is also used to fabricate a definitive wax-up as well as a definitive prosthesis. The ceramist, if utilizing the same design software, can receive the entire design project through a portal and can begin to replicate the wax-up design into a full contour prosthesis or, as seen here (Figure 8), into a cutback design that he or she can mill and then layer by hand.
Figure 8. The cut back wax-up design to mill that was created by the ceramist.
While this helps solidify the shape and design, we must utilize enhanced technology to home in on not just the shade and value of the teeth but also the gingiva. Photos were taken utilizing an eLab gray card that allowed a ceramist to calibrate the shade in software to get to a perfect match (Figures 9 and 10).
Figure 9. An eLab shade tab photo.
Figure 10. Final ceramics on the printed model.
Figure 11. Final prosthesis inserted, close-up smile.
Figure 12. Final prosthesis inserted, magnified.
Figure 13. Final prosthesis inserted, full-face.
The final prosthesis was inserted (Figures 11 to 13) and approved by the patient all while reducing turnaround time, increasing patient and lab communication, and reducing the cost to the patient.
Case 2
This patient presented to our practice for a consult on failing upper anterior teeth Nos. 8 and 9, along with bulked-out implant crowns on Nos. 7 and 10 (Figures 14 to 16). Due to the mobility and extensive bone loss surrounding the upper centrals, they would have to be removed. The ideal treatment plan would have involved orthodontics to help facilitate repositioning of the dentition, especially the lowers, but the patient was deemed not a candidate due to over 50% bone loss in the areas of concern, along with existing implants.
Figure 14. Pre-op smile, close up.
Figure 15. Pre-op radiograph depicting hopeless teeth Nos. 8 and 9.
Figure 16. Pre-op photo, magnified.
Due to the extensive overbite, the patient’s lower anteriors were causing sore spots on the palate, so ultimately, the decision would be made to open the vertical to create space between the upper and lower arches (Figures 17 and 18). However, the first phase of treatment would be to dictate where the implants would be placed on the anterior teeth.
Figure 17. Intraoral scan showing the bite map.
Figure 18. Profile view of the intraoral scan to highlight the excessive overjet.
Figure 19. Pre-op full-face photo.
Figure 20. Full-face photo with digital design done on teeth Nos. 7 to 10.
In an attempt to design the teeth digitally without the use of a face scan but just a full-face photo, my results fell short of desirable (Figures 19 and 20). While the full-face photo was a great aid in designing the shape of the teeth and ensuring there was no cant in the new wax-up, it failed to account for the excessive overjet of the design even after I believed I had corrected it.
Without a profile view of the face, it was a difficult challenge to be able to know exactly how lingual the teeth could be positioned so that they were not protruding over the lip. When the temporaries for the anteriors were inserted, it was evident that the design would need to be redone (Figure 21).
Figure 21. Ill-designed temporaries were inserted.
Figure 22. Pre-op view of teeth with face scan highlighting the overjet.
Figure 23. Digital design, frontal view.
Figure 24. Digital design, profile view.
Figure 25. Pre-op photo of teeth with face scan, 12 o’clock view.
Figure 26. Digital design, 12 o’clock view.
At this point in the case, I utilized the CT scan with the face scan (RAYFace) superimposed on top of it to aid in the design from all directions and correct the errors made in the initial design. The software allowed us to keep the initial teeth to use as a reference while designing the new setup (Figures 22 to 26).
Figure 27. Digitally placed implants at site Nos. 8 and 9.
Once the new implants were virtually placed based on the restorative design (Figure 27), a surgical guide was fabricated to aid in clinical placement (Figure 28).
Figure 28. Surgical guide created from digital implant planning.
Figure 29. Postoperative full-face photo.
Figure 30. Smile photo, post-op side view.
Figure 31. Smile photo, post-op frontal view.
After the implants were placed and the sites healed, the patient wore a Kois deprogrammer to establish a new vertical dimension to provide space for the restorative work. The case was then completed utilizing 10 ceramics on the upper arch (Figures 29 to 31).
Case 3
This patient presented for a cosmetic consult unhappy with her bulky bondings on Nos. 8 and 9 (Figures 32 and 33). Recently, No. 8 had fractured, and the patient was looking for a long-term aesthetic solution. She was unsure how many teeth she wanted to incorporate into the treatment plan, but she was adamant that she did not want them to be too bulky or fake.
Figure 32. Pre-op smile photo.
Figure 33. Pre-op magnified view.
Utilizing a new mockup feature that is unique to the RAYFace face scanner, we were able to do a digital design inside the RAYFace software (Figure 34) that, in turn, let us export out shell temps.
Figure 34. RAYFace smile design studio (Ray America).
Since the patient was unsure if she wanted to do 2 or 4 veneers, we were able to seamlessly envision what both scenarios would look like utilizing the face scanner (Figures 35 and 36) as well as view the smile from the 12 o’clock view (Figure 37) to ensure the teeth were not bulked out over the lips.
Figure 35. Smile design with 4 anterior teeth (Nos. 7 to 10).
Figure 36. Smile design with 2 anterior teeth (Nos. 8 and 9).
Figure 37. Smile design, 12 o’clock view.
It was evident that 4 veneers would round out the smile much better than just 2. Next, utilizing the new Rayface mockup export, we were able to produce shell temps (Figures 38 and 39) to try in and assess for the most desired outcome (Figure 40).
Figure 38. Digital design of 4 anterior shell temps.
Figure 39. The 3D printed shell temps.
Figure 40. Shell temporaries inserted in smile.
Figure 41. Final ceramics for Nos. 7 to 10, magnified view.
Figure 42. Final ceramics for Nos. 7 to 10, close-up smile.
The mockup design created in RAYFace became the blueprint the ceramist utilized to create lithium disilicate veneers for teeth Nos. 7 to 10 (Figures 41 and 42).
CONCLUSION
While these challenging cases could have been executed through a digital workflow without the use of a face scanner, having the ability to view the smile from multiple angles while designing was a huge advantage for me over using traditional 2D images. When executed properly, it can provide huge wins for the patients, practitioners, and labs as it enhances the communication and predictability of the design and treatment plan.
ABOUT THE AUTHOR
Dr. Tadros owns a boutique, fee-for-service private practice in South Florida. She is a Kois Center graduate and an accredited member of the American Academy of Cosmetic Dentistry. She holds Fellowship status in the AGD as well as the International Congress of Oral Implantologists. She is a key opinion leader and lecturer for digital dentistry, including for exocad, SprintRay, and VHF. Outside of practice, she is the founder of Exocad Elite, a training continuum, where she teaches a series of workshops to other dentists and staff on digital designing and workflows. She will also be teaching 2 upcoming courses at the Kois Center on Digital Dentistry. She was selected as one of the Top 50 Global Digital Women of the Year (2022) as well as Digital Educator of the Year (2022). She can be reached at dianatadrosdds@gmail.com.
Disclosure: Dr. Tadros reports no disclosures.
