CLINICAL REPORT

Integrating a facial scan, virtual smile design, and 3D virtual

patient for treatment with CAD-CAM ceramic veneers:
A clinical report
Wei-Shao Lin, DDS,a Bryan T. Harris, DMD,b Kamolphob Phasuk, DDS, MS,c Daniel R. Llop, CDT,d and
Dean Morton, BDS, MSe

Smile design has used the ABSTRACT

patient’s diagnostic data, sci-
This clinical report describes a digital workflow using the virtual smile design approach augmented
entific principles, and artistic with a static 3-dimensional (3D) virtual patient with photorealistic appearance to restore maxillary
concepts of beauty to create central incisors by using computer-aided design and computer-aided manufacturing (CAD-CAM)
an esthetically pleasing smile.1 monolithic lithium disilicate ceramic veneers. (J Prosthet Dent 2017;-:---)
Both microesthetic elements2-5
and macroesthetic elements,6 such as facial esthetics,7 and surround soft tissue in the standard tessellation
oral esthetics,8 and dentogingival esthetics,1 are essen- language (STL) file format.19-21 Laser and optically based
9,10
tial in the smile design process. The concept of virtual extraoral surface imaging technologies have been pro-
smile design was introduced initially by using commer- posed to obtain digital data of extraoral soft tissue for the
cially available computer presentation software (Keynote; creation of a 3D virtual patient with photorealistic
Apple Inc or PowerPoint; Microsoft Corp) to edit the appearance.22-31
patient’s digital dentofacial photographs and simulate Because of their minimal invasiveness,32-34 esthetic
the desired esthetic outcome with a customized 2- properties,35 and favorable clinical outcomes,36,37
11,12
dimensional (2D) virtual smile design. The 2D vir- monolithic or layered lithium disilicate ceramic veneers
tual smile design in the presentation software could then have become a clinically acceptable option. This clinical
be converted into either a conventional or a virtual report describes a digital treatment workflow for
diagnostic waxing to facilitate subsequent clinical treat- restoring maxillary central incisors with CAD-CAM
ments, such as computer-aided design and computer- monolithic lithium disilicate ceramic veneers.
aided manufacturing (CAD-CAM) restorations.13-17
Although virtual diagnostic technology and treatment
CLINICAL REPORT
planning workflows have been evolving, the creation of a
3D virtual patient remains complex. To create a 3D virtual An endodontic specialist referred a 45-year-old white
patient, digital 3D diagnostic data, such as remaining woman whose main esthetic concern was chipped
dentition (including intraoral soft tissue), craniofacial maxillary central incisors due to an automobile accident.
hard tissue, and extraoral soft tissue must be accurately The patient wished to address the space between
integrated into a single entity.18 Intraoral scanning can be maxillary central incisors and consented to lithium dis-
used to acquire digital data of the remaining dentition ilicate ceramic veneers for both maxillary central incisors.

a
Associate Professor and Director, Division of Prosthodontics, Department of Oral Health and Rehabilitation, University of Louisville School of Dentistry, Louisville, Ky.
b
Associate Professor and Director, Advanced Education in Prosthodontics, Department of Oral Health and Rehabilitation, School of Dentistry, University of Louisville,
Louisville, Ky.
c
Assistant Professor, Department of Prosthodontics, Indiana University School of Dentistry, Indianapolis, Ind.
d
Consultant, NDX nSequence, Reno, Nev.
e
Professor and Chair, Department of Prosthodontics, Indiana University School of Dentistry, Indianapolis, Ind.

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patient’s 3D facial soft tissue profile was captured at the

full smile position with an inexpensive and portable
extraoral 3D scanner (Sense; 3D Systems Inc) (Fig. 2B).
All digital photographs were exported in the Joint
Photographic Experts Group (JPEG) file format, and 3D
facial scan data were exported in the STL file format. The
digital intraoral and extraoral photographs were imported
into presentation software (Keynote; Apple Inc), and a
customized 2D virtual smile design was drawn and
superimposed on the digital photographs (Fig. 3A, B).
The customized 2D virtual smile design was shown to the
patient for her initial approval of the esthetic outcome
and exported in the Keynote (KEY) file format.12,13 All
digital diagnostic data (JPEG, STL, and KEY files) were
forwarded to a dental laboratory (NDX nSequence).
In the dental laboratory, the JPEG files of the extraoral
digital photographs and the STL file of the extraoral facial
scan were imported in CAD software (Geomagic Free-
form; 3D Systems Inc). Constant soft tissue landmarks
were used to merge the 2D and 3D digital data with the
surface-based merging process.18,31 A virtual patient of
photorealistic appearance of facial soft tissue at full smile
was created (Fig. 4A). The STL file of 3D intraoral scan
was then registered to the virtual patient using remaining
teeth as merging landmarks (Fig. 4B). The customized 2D
virtual smile design was used by the dental laboratory
technician as a visual reference to create the virtual
diagnostic waxing (Fig. 4C). This 3D virtual patient with
desired virtual diagnostic waxing was demonstrated to
the patient and was modified according to the patient’s
feedback. A CAD-CAM diagnostic cast with diagnostic
waxing (which was approved by the patient, clinician,
and dental laboratory technician) was additively manu-
factured (Fig. 4D).
A preparation guide was fabricated with a vacuum
formed matrix (.020-inch Clear Tray Material; Buffalo
Dental Mfg) from the CAD-CAM diagnostic cast. The
abutment teeth were prepared, guided by the vacuum-
formed matrix (Fig. 5A, B). The single-cord technique38
was used for soft tissue management during the intrao-
ral scanning procedure (iTero; Align Technology Inc)
(Fig. 5C). Autopolymerizing composite resin (Integrity
Figure 1. Intraoral pretreatment condition. A, Digital intraoral Temporary C&B Material; Dentsply Intl) and the
photograph from retracted frontal view at maximum incuspation vacuum-formed matrix were used to fabricate the interim
position. B, Digital intraoral photograph made with black background.
veneers (Fig. 5D). The intraoral scan was transferred to
C, Digital intraoral scan.
the dental laboratory (Roy Dental Laboratory), and the
definitive veneers were fabricated with machinable
Digital intraoral photographs were made from a lithium disilicate ceramic block (IPS e.max CAD; Ivoclar
retracted frontal view and against black backgrounds Vivadent AG) (Fig. 6A, B).
(Anterior Classic Contraster; PhotoMed Intl) (Fig. 1A, B). After the trial insertion to confirm marginal fit and
A diagnostic impression was made with an intraoral optical properties, the abutment teeth were isolated with
scanner (iTero; Align Technology Inc) (Fig. 1C) and rubber dam (Non-Latex Dental Dam; Sanctuary Health),
exported in the STL file format. Digital extraoral photo- modified dental clamps (212 Satin Steel Rubber Dam
graphs were made at a full smile from the mid-facial and Clamp; Hu-Friedy Mfg), and dental isolation tape (Iso-
right and left 45-degree views (Fig. 2A). In addition, the Tape; TDV Dental Ltda). The isolated abutment teeth

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Figure 2. Extraoral pretreatment condition at full smile position from mid-facial, and right and left 45-degree views. A, Digital extraoral photographs.
B, Digital extraoral facial scan.

Figure 3. Customized 2D virtual smile design created and superimposed on digital photographs in presentation software. A, Intraoral view. B, Extraoral view.

and ceramic veneers were prepared by following the overcome this limitation. After the confirmation of
manufacturer’s recommendation, and the veneers were simulated esthetic outcome in the 3D virtual patient, a
adhesively luted to the abutments with light- CAD-CAM cast can be directly fabricated from an
polymerizing resin luting agent (RelyX Veneer Cement; approved virtual diagnostic waxing without the need of
3M ESPE). Excess luting agent was removed, and no further conversion. This CAD-CAM cast can be used to
complications were observed during the 6 months after fabricate a vacuum-formed matrix to increase the pre-
insertion (Fig. 7A, B). dictability from the virtual smile design to the actual
clinical esthetic outcome.
Creating a 3D virtual patient with the extraoral facial
DISCUSSION
and intraoral scan has some limitations. Although many
This clinical report describes a digital treatment workflow medical and dental 3D surface imaging scanners can be
using a virtual smile design principle in a 3D virtual pa- used to obtain the required extraoral facial scan, these
tient during the diagnostic and treatment planning scanners may be cost prohibitive for the dental clinicians.
phases to facilitate treatment with CAD-CAM ceramic In this clinical report, an economic and portable extraoral
veneers. The 2D virtual smile design approach is gaining 3D scanner (Sense; 3D Systems Inc) was used instead.
popularity as a conceptual tool to improve communica- However, the procedures for merging extraoral digital
tion among clinicians, patients, and dental technicians photographs, extraoral facial scans, and intraoral scans in
and to enhance treatment predictability.12-15 However, creating a 3D virtual patient would require additional
with the existing 2D virtual smile design approach, time, resources, and training for the dental laboratory
perspective distortion may cause inaccuracy or errors in technician and incur additional cost for the clinician and
the conversion process from 2D design to 3D diagnostic patient. The clinician should also verify that the patient’s
waxing,13,17 and the use of a 3D virtual patient can facial expression and head positioning are consistent

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Figure 4. A, Three-dimensional virtual patient of photorealistic appearance at full smile, shown from mid-facial and right and left 45-degree views. B,
Digital intraoral scan merged with 3D virtual patient. C, Virtual diagnostic waxing created in 3D virtual patient. D, CAD-CAM cast fabricated from
approved virtual diagnostic waxing.

when collecting extraoral digital photographs and facial 5. Goodlin R. Photographic-assisted diagnosis and treatment planning. Dent
Clin North Am 2011;55:211-27.
scans to improve the accuracy of the registration pro- 6. Morley J, Eubank J. Macroesthetic elements of smile design. J Am Dent Assoc
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The clinical report describes a digital workflow using a J Clin Orthod 2002;36:221-36.
static 3D virtual patient in conjunction with the virtual 12. Coachman C, Calamita MA. Digital smile design: a tool for treatment plan-
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Figure 5. A, Teeth prepared with vacuum-formed matrix guidance. B, Completed tooth preparations. C, Definitive impression made with intraoral
scanner. D, Interim veneers.

Figure 6. A, Design of CAD-CAM definitive lithium disilicate ceramic veneers. B, CAD-CAM definitive ceramic veneers after external characterization and
glazing.

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