(Clinical case and technique by Dr Daniel Machado, Dr Allan R. Alcantara, and Dr Jun Ho Kim)
In a contemporary and dynamic approach to dentistry, we can see a promising future in terms of the results of the treatments themselves in connection with many technological resources, the constant scientific advance, and the development of new techniques in dentistry [
Perhaps orthodontics can be considered the area of dentistry that has always sought to obtain more balanced facial profiles. Some important parameters about functional balance and proportionality of facial structures were developed based on facial analysis and definitions of ideal facial patterns
It is not by chance that orthodontics and, more recently, cosmetic dentistry have gained a prominent role in terms of facial restructuring and tissue balance. With the incessant search for knowledge, the evolution of materials currently available on the market, and the digital resources available for individualized planning, the development of new techniques has created new opportunities for treating and solving structural problems such as severe facial discrepancies.
The search for minimally invasive procedures has grown significantly in the last decade and surgical interventions have been gradually replaced by minimally invasive procedures. Cosmetic dentistry occupies a prominent place and its objective is the restructuring of the face, rebuilding what was lost in relation to various etiological factors such as the presence of facial discrepancies, habits, ethnicity considerations, gender considerations, and especially the physiology of aging
. The latter continues slowly, resulting in loss of skin support. In recent decades, several types of injectable devices have been tested in an attempt to restore facial volume . Mimicking tissue replacement has become more viable. Probably the most significant change related to facial restructuring and rejuvenation has been the introduction of nonsurgical treatments, either for muscle relaxation and wrinkle reduction or for recovery of volumes and contours lost. This has caused the evolution of materials, especially fillers, to advance quickly. In the past, materials such as paraffin or silicone were used to restore lost facial volumes, but there were concerns about biosafety of these materials. This has accelerated research and recently, new materials have been developed supported by studies on their safety and efficacy [ 4, 5].
The market revolution began with the introduction of hyaluronic acid in 2003 which paved the way for the development of other materials and techniques that, in combination, can promote major changes and restore balance and harmony to the face. According to the American Society for Plastic and Aesthetic Surgery, more than 1.2 million procedures for injectable dermal filler were performed in 2008, which represents a 200% increment since 1997 [
With orthodontic correction for the repositioning of the teeth and bone bases, the final result is not always satisfactory, from the point of view of balance and harmony of the facial structures. A gummy smile, a deficiency in the mandibular contour or even a projection of the chin may not translate the result of successful orthodontics, falling short of expectations on the part of both the professional and the patient. With a multidisciplinary digital treatment plan, cosmetic dentistry techniques can be used after orthodontic intervention for the correction of facial discrepancies and to promote satisfactory facial esthetics.
Facial Design™ is a digital tool developed to be a photographic protocol concept for digital face planning in cosmetic dentistry. Basically, the system uses digital masks that have different forms for each intervention and make it easier for the professional to identify the points to be worked on. With these masks, it is possible to digitally demarcate the patient’s face in the photograph and plan possible procedures to be performed
Every esthetic treatment requires good diagnosis and adequate planning that involves the patient’s function, esthetic, physical, and emotional health. It is worth remembering that technological resources and excellent technical execution do not guarantee satisfaction with the results at the end of treatment. It is important to create a rapport with the patient to understand their main complaints and meet their expectations, within the bounds of what is possible.
The planning stage will guide the execution of the treatment and will give greater predictability. Regarding cosmetic dentistry, planning and simulation software is still not very reliable and as we work with tissue mimicry related to several intrinsic and extrinsic factors and depend on the patient’s cooperation with regard to postoperative care, it is still very difficult to simulate treatments and predict outcomes. The main point of Facial Design is to add information, allowing a clearer and more direct communication with the patient. In addition, it enables a detailed facial analysis, digital planning of procedures, and interdisciplinary communication and strengthens the professional–patient relationship, increasing the predictability of results and optimizing treatment
Facial Design can be performed very simply through digital tools available in slideshow software such as Keynote
® (Apple) and PowerPoint ® (Microsoft). Digital masks can be added or removed according to the assessment, need, and intervention proposal for each case. With completion of digital face drawing, the facial photo without the masks is placed next to the same facial photo with the masks so that the patient can view all the proposed interventions.
According to de Maio et al.
, the lack of structural support related to significant bone deficiencies can result in changes in the pattern of muscle contraction and cause a superficial deformation; these deficits in facial structure can be remedied with injectable hyaluronic acid with the goal of restoring lost contours and volumes. It is noteworthy that the proper selection of each product, respecting its rheological characteristics, is essential for success of the treatment. As a result, the loss of facial contour, as well as facial asymmetries, can be corrected, always respecting the principles of balance and harmony to obtain positive results, thus achieving a more natural appearance of the facial profile [ 1, 5, 10].
Facial fillers using hyaluronic acid are considered the gold standard for nonsurgical and minimally invasive interventions, in the process of facial rejuvenation and to increase the volume and contour of facial tissues
. Studies have shown that the use of hyaluronic acid can promote safe solutions and provide excellent results in the treatment of facial discrepancies when associated with orthodontic treatment [ 7– 12].
With the increasing number of noninvasive injectable procedures, cosmetic dentistry is gaining more interest as an option for patients who do not wish to have surgical corrections of facial discrepancies.
A 44‐year‐old female patient, class III, presented with a protruding mandible. After completing the orthodontic treatment, she felt an esthetic need for correction of the facial discrepancy, but without having to undergo an orthognathic surgery for maxillary advancement. With the use of fillers with specific characteristics for each region, use of botulinum toxin, and mixtures for epidermal‐dermal rejuvenation, the following treatment was carried out to correct the facial discrepancies presented (
Figures 11.15– 11.24).
After a facial analysis using cephalometric points and complete exams, the entire treatment plan was carried out, trying to compensate for the missing maxilla and restructuring of the middle and upper third of the face, using fillers and botulinum toxin.
A full face treatment was performed in two stages, filling the following regions with the quantities mentioned in the images: temples, eyebrow arch, dark circles, malar and zygomatic arch, nasolabial sulcus, mandibular angle, lips and revitalization of the frontal and perioral region with Skinbooster
®. In addition, botulinum toxin applications were performed in the upper third. The treatment objective was achieved, bringing harmony to the face and reducing facial bone discrepancies and the facial aging process.
After completing the steps of facial restructuring, the patient still complained about the smile and teeth position, so digital planning of the smile was performed using Smilecloud
® planning software. This 2D design guided the diagnostic wax‐up.
The patient was then scanned, originating an STL model that was digitally waxed using open CAD software (Meshmixer
®) using a library of natural teeth. Diagnostic waxing was performed, with model printing for mock‐up and digital preparation of the dental guide.
The treatment was then performed in a minimally invasive way following the digital workflow, with the help of the preparation guide and an intraoral scanner model (TRIOS 3, 3Shape A/S). Digital models were printed on a die‐cast 3D printer and the laminate veneers were fabricated in lithium disilicate and cemented.
No posttreatment complications occurred within a 1‐year follow‐up.
Digital photographs following the Facial Design digital protocol – face evaluation in frontal and 22° photos. Figure 11.15
Digital photographs following the digital protocol Facial Design – face evaluation in frontal photos, 22° and 90° smiling. Figure 11.16
Face proportion analysis masks together with lateral cephalometric radiography to assess soft tissue position in relation to hard tissue. Figure 11.17
Facial filler masks, botulinum toxin in an integrated full face treatment. Figure 11.18
Step‐by‐step procedures of facial filling in the temple, malar and zygomatic arch, mandible angle, and dark circles. Use of needles and cannulas. Figure 11.19
Initial photographs of the teeth together with a mock‐up already in the mouth, models printed on a 3D printer and STL performed with an intraoral scanner. Figure 11.20
Intraoral scanning generating an STL file after dental preparation for making ceramic veneers. Figure 11.21
Models printed on a 3D printer die‐cast to try‐in the ceramic laminate veneers. Figure 11.22
Patient’s initial and final view in 22° and frontal view respectively, after the two stages of facial restructuring and installation of the CAD‐CAM ceramic laminate veneers. Figure 11.23
Final result of the patient after facial restructuring treatment and manufacture of ceramic laminate veneers for functional esthetic treatment of the smile with a full digital workflow in both treatments. Figure 11.24